Limping child Flashcards
What is the differential for a limping child?
DDH (Developmental Dysplasia of the Hip) Septic arthritis Perthes disease Transient synovitis (Irritable hip) SUFE - Slipped Upper Femoral Epiphyses Still's disease
What is DDH?
Developmental Dysplasia of the Hip
Congenital hip joint deformity in which the acetabulum is shallow which can cause the femoral head to partially or completely dislocate
What are some of the risk factors for DDH?
Female
FH
Breach presentation at birth
Oligohydramnios (Deficiency of amniotic fluid)
What is the typical presentation of DDH?
Screening at 6 week check (Barlow Vs Ortolani tests)
Asymmetrical skin folds
Limping child/abnormal gait
What investigations can be done for DDH?
USS
What is the treatment of DDH?
Dependent on the severity Need to maintain abduction Pavlik harness Plaster hip spica Open reduction
What is Transient synovitis (Irritable hip)?
Self limiting condition in which there is inflammation of synovium of the capsule of the hip joint. Syndrome of hip pain, joint stiffness and a limp/non weight bearing gait.
How does transient synovitis present?
Usually 2-12 y/o
Sudden onset of hip pain/limp
Often associated with a viral infection
Systemically well
What investigations can be done for a patient with transient synovitis?
Polymorphonuclear leukocytes and CRP normal
-ive blood cultures
May need joint aspiration and culture
What is the treatment of transient synovitis?
Rest
Analgesia
Should start to settle in 2-3 days
What is Perthes’ disease?
Inadequate blood supply to the epiphysis of the femur causing avascular necosis of the femoral head
Osteochondritis occurs due to AVN (Inflammation of bone/cartilage)
What is the presentation of Perthes’ disease?
Usually males
4-10 y/o
Insidious onset of hip/groin pain that becomes painless over time
What investigations can be done in a patient with suspected Perthes’ disease?
X rays can be normal initially
Becomes increased density of the femoral head whihc becomes fragmented and irregular, flattened and sclerosed.
A bone scan can be useful
What is the managment of Perthes’ disease?
If detected early and less than half femoral head - rest and traction
If severe, plaster to maintain abduction and possibly osteotomy
What is SUFE?
Slipped Upper Femoral Epiphysis
Mainly overweight 10-15 y/o males, especially those underdeveloped sexually
Epiphyseal pate is weak so femoral head slips inferior and posterior
3 types - Acute, Chronic, Acute on Chronic
What is the presentation of a SUFE?
Chronic - slowly developing groin/hip/knee pain over several months with a limp, limited movement and slight shortening of effected leg
Acute - Groin pain with a shortened, externally rotated leg. All movements painful
Acute on Chronic
What are the investigations for a suspected SUFE?
X-ray - Diagnostic
What is the management of SUFE?
Acute - reduce and pin epiphysis
Chronic - In situ pinning - epiphyseal reduction reduces the risk of AVN
What are some of the complications of SUFE?
AVN
Chondrolysis - breakdown of articular cartilage (Risk increases with surgery)
What is Still’s disease (Juvenile Rheumatoid arthritis)?
Usually in 5-10 y/o
Maladaptive immune response triggered by stress or infections
How does Still’s disease present?
Fever Salmon pink rash Joint pain Joint swelling Can be insidious over several months
What investigations can be done for suspected Still’s disease?
FBC - low Hb, high WCC, high CRP
X-ray
What are some of the treatments for Still’s disease?
NSAIDs
Corticosteroids
Physiotherapy
What is septic arthritis?
Infection of a joint causing inflammation and arthritis
What organisms commonly cause septic arthritis?
Staphylococcus aureus - 60% Steptococcus viridans/pneumoniae Gonococcus Gram -ive bacilli eg Escherichia coli, Salmonella *Can be local or haematogenous*
What are risk factors for septic arthritis?
Previous joint disease
Chronic renal failure
Immunosuppressants
Prosthetic joints
What are the symptoms of septic arthritis?
Hot swollen joint that is tender to touch
Decreased ROM
Acute
Systemically unwell
What investigations can be done for suspected septic arthritis?
Joint aspiration for microscopy, increased WCC
Increased CRP, WCC, may have +ive blood cultures
X-ray - joint effusion, cartilage destruction, narrowing of joint space in acute phase with destruction of subchondral bone and sclerosis chronically
Purulent synovial fluid
What is the management of septic arthritis?
IV Vancomycin & Cefotaxime
Consider joint wash out
Splint joint
Physiotherapy post infection
What are some of the complications of septic arthritis?
Osteomyelitis
Arthritis
Ankylosis (Stiffness of joint due to adhesion post disease/injury - fusion)
Whats the differential for septic arthritis?
Crystal arthropathy eg Gout, Pseudogout
Reactive arthritis eg Reiters syndrome
What is acute osetomyelitis?
Inflammation of bone/bone marrow due to infection
What organisms commonly cause osteomyelitis?
Staphylococcus aureus Steptococcus viridans/pneumoniae Escherichia coli Pseudomonas Salmonella (Especially sickle cell disease)
What are some of the risk factors for osteomyelitis?
Vascular disease
Trauma
Sickle cell disease (Especially children)
Immunosuppression
Children have a rich blood supply to the growth plate so can effect metaphysis
What is the presentation of osteomyelitis?
Pain Tenderness Decreased ROM Increased local temperature Erythematous Systemically unwell May have effusions in neighbouring joints
What investigations can be done for osteomyelitis?
Increased CRP, WCC, +ive blood cultures (In 60%)
On x-ray - Haziness + ↓ bone density, Sub-periosteal reaction, Involucrum (layer of new bone growth outside existing bone)
MRI can be very sensitive
What is the treatment of osteomyelitis?
IV Vancomycin & Cefotaxime
Drain abscess and remove sequestra
Analgesia
