Paed Ortho - Acute Limping Child

Question 1

Commonest Causes of limping kids?

Answer 1

In all: 0-15

• Septic Arthritis (1 or 2 a year)
• Osteomyelitis
• Trauma

In 0-5

• DDH
• JIA
• Transient synovitis
• Normal variant

In 5-10

• Transient synovitis
• Perthes disease

In 10-15

• SUFE (slipped upper femoral epiphysis)
• Chondromalacia

Less Common:

• NAI (non-accidental injury(
• Tumour
• Endocrinopathies

Question 2

Define SUFE?

Answer 2

Femur Epiphysis is displaced, usually posteromedially due to disruption to the growth plate

Question 3

When do kids get SUFE?

Answer 3

60:40 more often in males
ranges from 9-16yrs with most males at 13/14 and most girls at 12

Associated with kids who are overweight or have delayed bone age.

Question 4

What causes SUFE?

Answer 4

Associated with growth spurts of adolescense who are overweight or have delayed bone age.

Also caused by certain endocrinopathies like hypothyroidism.

Question 5

how does SUFE present?

Answer 5

Pain in groin/thigh/knee
Limp
Trauma (most children have a trauma history)
Deformity

ROM may be limited by pain.
Leg is often rotated externally and have obligatory external rotation in flexion

Question 6

What history would suggest an infection such as OM, SA or Transient Synovitis?

Answer 6

• Limp
• Pain
• Generally unwell (malaise, appetite loss or listless)
• Temperature
• Recent infection e.g. URTI or ear infection.
• Trauma (most kids have one)
• Pseudoparalysis (usually too much pain to move or WB)

Question 7

Tests for Infection causing limp?

Answer 7

Blood cultures
WCC
CRP
ESR
Creatine Kinase

US and/or X-ray

Take Temp

Question 8

How do you tell SA apart from the other infections?

Answer 8

SA will be so painful they may have pseudoparalysis and not be able to walk/WB at all.
Joint will be visibly swollen and red.

Question 9

How does SA arise in kids?

Answer 9

-Mostly haematogenous from another infection
Rarely its from:
-a penetrating injury
-injection into joint   
-spread from osteomyelitis
- Soft tissue infection

Question 10

How do we test for SA specifically?

Answer 10

FBC & Differential WCC
ESR & CRP
Blood cultures
X-ray
US!!
Synovial fluid aspiration - WCC, gram stain & culture

Question 11

How do we treat SA?

Answer 11

IV abx
Aspiration

Surgery:

• Arthroscopy
• Arthroplasty

Question 12

How does OM present specifically?

Answer 12

Pain
~ROM reduced
~weight bearing reduced
~fever
~localised signs/symptoms

Question 13

Testing for OM?

Answer 13

WCC
ESR & CRP
X-ray –> MRI/CT/Biopsy/Bone scan
Blood cultures or bone cultures

Question 14

How do we treat OM?

Answer 14

IV Abx
Surgery if:
- aspirating for culture
- Draining abscess

• Debriding dead shit

Question 15

What transient condition can cause a limp

Answer 15

Transient synovitis

Question 16

What would suggest transient synovitis

Answer 16

Limp
Not that unwell
H/o viral inf e.g. URTI/ear
Apyrexial
Low CRP & normal WCC

Question 17

Indications for surgery in Om

Answer 17

• aspiration for culture
• drainage of subperiosteal abscess
• Drainage of joint sepsis
• Debridement of dead tissue
• Failure to improve
• Biopsy in equivocal cases

Question 18

what classification do we use to confirm SA?

Answer 18

Kocher

• ESR>40,000
• WCC>12,000
• Fever> 38
• No weight bearing