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)
What is shaken baby syndrome?
Shaken Baby Syndrome
- Responsible for at least 50% of the deaths of children
caused by non-accidental trauma
- Involves forceful, intentional, repetitive, and violent
shaking of the baby (usually <2yo)
- Leads to traumatic brain injury (subdural hematoma)
Diagnosis of child abuse
- skeletal survey – in children <2yo
AP and lateral of skull (Townes view optional)
lateral spine
AP, right post. oblique, left post oblique of chest- rib technique
AP pelvis
AP of each femur
AP of each leg
AP of each humerus
AP of each forearm
PA of each hand
AP (dorsoventral) of each foot
- CBC, PT, PTT – r/o hema d/o. should be N.
- Cranial UTZ/ CT – r/o cerebral edema, hemorrhage
Management of child abuse
Mgt
1. Priority: help ensure the child’s safety
2. Report to proper channels
3. Interdisciplinary assessment and Mgt
4. Refer to ortho if with fracture
What is osteomyelitis?
CH 684: OSTEOMYELITIS
Etiology
- 0-4mos: S.aureus, gram (-) bacilli, GBS, Enterobacteriaceae
- > 4mos: S.aureus, GABHS, Enterobacteriaceae
- Puncture wound: P.aeruginosa, S.aureus,
Streptococcus, anaerobes
Epid
- Median age 6yo, M>F
- Majority of cases in previously healthy children are
hematogenous
- Minor closed trauma: common preceding event
Patho
- anatomy and circulation of long bones – localization of
blood borne bacteria
- metaphysis – sluggish blood flow bacterial focus,
spreads through haversian system and Volkmann
canals in subperiosteal space
Clinical manifestations of Osteomyelitis
CM
The earliest s/sx of OM are often subtle and nonspecific
1. infants – pseudoparalysis or pain with movt of the
affected extremity
2. pain, fever, localizing signs (edema, erythema, warmth)
3. limp or refusal to walk
4. focal tenderness over a long bone – impt finding long bones (femur and tibia) – MC ***
Diagnostics for osteomyelitis
Dx
- clinical
1. BCS – all suspected cases before abx
2. XR of suspected part – with comparison to opposite
extremity
- (+)=displacement of deep muscle planes from the
adjacent metaphysis caused by deep-tissue edema
- Lytic bone changes if with >30-50% bony matrix
destruction, infection >7-14d
3. Bone/ subperiosteal abscess biopsy with GS/CS and
histology – confirmatory
4. CBC, ESR, CRP – elev. Monitor response to tx
- CRP N within 7d after tx
- ESR decreases after 10-14d
5. CT – demo osseus and soft-tissue abnormalities, gas in
soft tissue
6. MRI – more sn than CT or XR for acute OM. Best for ID
abscess and for differentiating between bone and softtissue
infection
7. 3 phase bone scan (99mTC scan) – increased uptake,
can detect early (24-48h) OM
Management for osteomyelitis
Mgt
1. ABX –
a. Infants <4m: oxacillin + ceftazidime
b. >4m: oxacillin
c. Puncture wound: oxacillin + amikacin or
ceftazidime
d. Invasive/MRSA: vancomycin 60mkd q6h IV
e. Clindamycin – child not severely ill, BCS (-)
f. NAGCOM: 1st line: Vancomycin 100-200mkd
q6 + Cefotaxime 100-200 mkd q12/24 or
Ceftriaxone 100-200 mkd q12/24
2nd line: Clindamycin 25-40 mkd q6-8 +
Cefotaxime/Ceftriaxone
195
Option 2: vancomycin + Ciprofloxacin 20-
30mkd q8-12
Option 3: Linezolid 30mkd q8 (<12yo)/
1.2g/d q12 (>12yo) + Ciprofloxacin
Option 4: Co-trimoxazole 8-12 mkd q12 +
Ciprofloxacin
2. Surgical drainage – for frank pus
3. Physical tx
What is synovitis? what are the clinical manifestations?
CH ?: SYNOVITIS
-reactive arthritis that affects the hip, one of the most common
causes of hip pain in young children
-etiology unknown
-nonspecific inflammatory condition
- postviral immunologic synovitis
-prevalent in 3-8 years old (but present in all age groups)
CM
-70% with recent URTI 7-14 days before symptoms
1. pain in groin, anterior thigh or knee, which may be referred
from the hip
2. usually ambulatory, with painful limping gait
3. afebrile or with low grade fever
Diagnostics
Dx
- clinical
1. CRP and WBC normal
2. may have mild elevation of ESR
3. XRAY – frog leg lateral radiographs of pelvis, usually
normal
4. UTZ of hip preferred to xrays, demonstrates joint
effusion
-r/o Septic arthritis!! – usually appear more systematically ill,
more severe pain, and child refuses to walk or move their hip at
all, with high fever, refusal to walk, elevation of CRP or ESR
Mgt
-symptomatic
-activity limitation and relief of weight bearing
-anti inflammatory agents and analgesics can shorten duration of
pain recovery usually within 3 weeks
