Limping_Child_Flashcards
What are common causes of a limping child with acute onset?
Transient synovitis - usually accompanies viral infections, but the child is well or has a mild fever. More common in boys, aged 2-12 years.
What are the key features of septic arthritis/osteomyelitis in a limping child?
Unwell child, high fever.
What is a characteristic of juvenile idiopathic arthritis in a limping child?
Limp may be painless.
How is trauma typically diagnosed in a limping child?
History is usually diagnostic.
What are the key features of developmental dysplasia of the hip?
Usually detected in neonates. 6 times more common in girls.
What age group is more commonly affected by Perthes disease and what is the cause?
More common at 4-8 years. Due to avascular necrosis of the femoral head.
What age group is more commonly affected by slipped upper femoral epiphysis and what is the condition?
10-15 years. Displacement of the femoral head epiphysis postero-inferiorly.
summarise limping child
An 18-month-old boy is brought to the emergency department by his mother due to pain in his right hip and a new limp. He has no past medical history except for a viral upper respiratory tract infection he had 1 week ago, from which he has recovered. There is no trauma to the hip. His development to date has been normal.
On examination, he is afebrile. Slight movement of his right hip is tolerated but excess motion causes him to cry.
Investigations show:
Hb 123 g/L Male: (110-140)
Platelets 200 * 109/L (150 - 400)
WBC 10.0 * 109/L (4.0 - 11.0)
What is the most appropriate next step in his management?
Recommend rest and analgesia
Refer for urgent MRI of the hip
Refer for urgent X-ray of the hip
Refer for urgent paediatric assessment
Refer for urgent ultrasound of the hip
Refer for urgent paediatric assessment
Urgent assessment should be arranged for a child < 3 years presenting with an acute limp
Refer for urgent paediatric assessment is correct. Although this child has features that are suggestive of transient synovitis, due to their mild symptoms and recent history of an upper respiratory tract infection, NICE recommends that all children <3 years old should have an urgent assessment when presenting with a limp. This is because transient synovitis is rare in this age group and septic arthritis is much more common. Further investigations need to be considered by paediatricians before diagnosis and management. The normal investigations cannot definitely rule out septic arthritis in this scenario and further investigations are needed, which may involve an ultrasound or synovial fluid aspirate.
Recommend rest and analgesia is incorrect. Although this would be appropriate advice for a patient with transient synovitis, this infant must have an urgent assessment by paediatrics as transient synovitis is rare in this age group and septic arthritis is much more common. The normal investigations cannot definitely rule out septic arthritis in this scenario and further investigations are needed, which may involve an ultrasound or synovial fluid aspirate.
Refer for urgent MRI of the hip is incorrect. Although this may be considered to assess for other potential underlying causes, this investigation would be considered by a paediatrician after an initial urgent assessment. An MRI may be used for cases of unexplained complaints (e.g. in Perthes’ disease if an x-ray is normal).
Refer for urgent X-ray of the hip is incorrect. Although this may be considered to assess for other potential underlying causes, this investigation would be considered by a paediatrician after an initial urgent assessment. An X-ray may be useful in cases such as fractures.
Refer for urgent ultrasound of the hip is incorrect. Although this may be considered to assess for other potential underlying causes, this investigation would be considered by a paediatrician after an initial urgent assessment. Ultrasound is mainly used for soft tissues to assess for joint effusion, such as in septic arthritis. It may be used once a paediatrician has assessed them and performed by a professional trained in its use for children.
A father brings his 2-year-old daughter to see the GP as her walk has changed.
He explains that she started walking shortly after 12 months old. He has noticed that, over the last 2 days, her walking has been different. There is no history of trauma.
The GP assesses her and notices an asymmetric gait. She appears well otherwise and basic observations are within normal limits. She is up-to-date with her immunisations and is developing normally.
What is the most appropriate next step?
Full blood count including inflammatory markers
Refer for routine hip x-ray
Refer for urgent hip ultrasound
Refer for urgent hip x-ray
Refer for urgent paediatric assessment
Refer for urgent paediatric assessment
Urgent assessment should be arranged for a child < 3 years presenting with an acute limp
Important for meLess important
Refer for urgent paediatric assessment is correct. This 2-year-old patient has presented with an acute limp. All acute limps in patients under 3 years should be urgently assessed by secondary care paediatric teams to rule out septic arthritis or traumatic injury. Note that septic arthritis can present in patients who are otherwise well so normal observations are not necessarily reassuring in this patient.
Full blood count including inflammatory markers is incorrect. While this will likely form part of the patient’s management in secondary care, this patient has a medical emergency (acute limp) and thus the first step is to refer to urgent assessment.
Refer for routine hip x-ray is incorrect. A hip x-ray may be useful in determining the cause of the limp, for example, trauma, but acute limp in a patient <3 years old is a medical emergency and thus this patient requires urgent assessment.
Refer for urgent hip ultrasound is incorrect. Hip ultrasound is useful for investigating developmental dysplasia of the hip in newborns and in suspected transient synovitis where there are questions about the diagnosis. However, hip ultrasound does not form part of the immediate management of patients with acute limps.
Refer for urgent hip x-ray is incorrect. This patient requires urgent secondary care assessment to rule out and manage potential emergencies such as septic arthritis. An urgent hip x-ray is not indicated at this stage, though it may be ordered by secondary care specialists to investigate the cause of this patient’s limp.
