Limping child Flashcards
Differentials for limping child
Trauma
Child abuse
Osteomyelitis
Synovitis
Septic arthritis
Trauma
CH 683: TRAUMA
Pediatric tibial shaft fracture – 3rd MC long bone fracture in
children
- M>F
- Peak age 8yo (pedestrian/vehicle)
- Heals in 6-8 weeks
Toddler’s fracture – fracture unique to ambulatory infants and toddlers (1-4yo)
- torsional forces result in spiral or oblique fracture
pattern from low energy twisting or falls, tripping, stumbling
- Heals in 3-4 weeks
Clinical manifestations of trauma
CM
1. Pain, bruising
2. Limping or refusal to bear weight
3. Warmth, swelling, tender over fracture site
4. Pain on dorsiflexion
5. NV: compartment syndrome
o Emergency: required fasciotomy
Diagnostics
Dx
1. XR – AP and lateral view of tibia and fibula and of
ipsilateral knee and ankle: r/o concomitant injury
- Optional XR of contralateral leg
- May appear N in toddler’s fracture
2. CT – indications:
o Concern for physeal or intra-artcular
extension, pathologic lesion
o Distal 3rd tibia fractures may propagate to
physis or articular surface
3. MRI – indications:
o Suspicion for pathologic/ stress fracture
o r/o occult fracture
4. bone scan – r/o occult fracture
Management of trauma
Mgt
1. refer to orthosurgery
2. long leg casting – almost all Toddler’s fracture and
greenstick fractures
3. closed reduction and long leg casting – for most
traumatic fractures
4. external fixation
What is child abuse?
CH 40: CHILD ABUSE
Child Abuse – acts of commission. Any recent act or failure to act
on the part of a parent or caretaker, which results in death,
serious physical or emotional harm, sexual abuse or exploitation,
or an act or failure to act which presents an imminent risk of
serious harm
Neglect – acts of omission
Clinical manifestations of child abuse
CH 40: CHILD ABUSE
Child Abuse – acts of commission. Any recent act or failure to act
on the part of a parent or caretaker, which results in death,
serious physical or emotional harm, sexual abuse or exploitation,
or an act or failure to act which presents an imminent risk of
serious harm
Neglect – acts of omission
CM
- bruises – MC manifestation of physical abuse
- in preambulatory infant, in padded/less-exposed areas
(butt, cheeks, chin, genitalia), patterned, multiple and
clearly of different ages - fractures – 2nd MC manifestation.
- strongly suggest abuse: classical metaphyseal corner lesions, posterior rib fractures, and fractures of the scapula, sternum, and spinous process, especially in
young children, 1st rib fracture
- femoral and humeral fractures in non-ambulatory children suspicious
- multiple fractures in various stages of healing
- femoral fractures in children older than 2 yrs most
likely noninflicted UNLESS with signs of abuse
- infants: rib, metaphyseal, skull - Neuro-psych: sz, behavioral changes, dec sensorium,
retinal hemorrhages - Hematomas, hemangiomas
RED FLAGS FOR CHILD MALTREATMENT
RED FLAGS FOR CHILD MALTREATMENT
RA No 7610: Special Protection of Children Against Child Abuse,
Exploitation, and Discrimination Act
Risk factor for victimization
female sex
unaccompanied children
children in foster care, adopted children, stepchildren
physically or mentally handicapped
history of past abuse
poverty
children caught in the middle of armed confluict
single parent homes
social isolation
parent with mental illness or alcohol/drug dependency
SIGNS AND RED FLAGS
RED FLAGS FOR POSSIBLE CHILD ABUSE
-discrepancy between elicited hx and mechanism of injury
-story changes or varies
-there was unreasonable delay in seeking care
-the parent/caretaker seems to be hostile towards the child and denies there was injury
SIGNS SUGGESTIVE OF PHYSICAL ABUSE
Bruises over multiple areas (lower back, buttocks, thighs, cheeks, ear pinna, ankles and wrists and corners of mouth and lips)
SIGNS SUGGESTIVE OF VERBAL/EMOTIONAL ABUSE
-negative self-image; withdrawn or depressed
-self-destructive act: cutting oneself, reckless behavior
-antisocial behavior: physical aggression, delinquency, cruelty to animals, frequent quarrels with classmates
-delayed development: bedwetting, thumb sucking
RED FLAGS FOR INTENTIONAL BURN INJURIES
-dorsum of the hands or feet (glove and stocking burn pattern), anogenital area (donut sign in the buttocks)
-repeated burns
-symmetric burns
-symmetric or patterned burns
-uniform thickness with clear border
-delay in seeking care
RED FLAGS SPECIFIC FOR FRACTURES DUE TO ABUSE
-metaphyseal-epiphyseal (<3years old) or bucket handle or corner fractures
-thoracic cage (posterior ribs)
-shoulder (scapula, acromion)
-clavicle(medial or lateral)
-vertebral body (from lateral compression of spinous process)
-occipital fractures
RED FLAGS FOR SEXUAL ABUSE
Suspicious findings for sexual abuse
-focal erythema in the vestibule
-localized abrasions within the vestibule
-laceration of the posterior fourchette without history of straddle injury
-peaked notch in the post. hymen
-STDs like herpes or chlamydia
Definitive diagnosis of sexual abuse
-recent bleeding from a laceration or transection of the hymen
-presence of sperm
-recent anal laceration
-complete absence of hymenal tissue between 3 and 9 o’clock position
-pregnancy in a pubertal minor
-Syphilis or gonorrhea (non-neonatal)
