Paed Ortho - Acute Limping Child

Question 1

Commonest Causes of limping kids?

Answer 1

• Septic Arthritis (1 or 2 a year)
• Osteomyelitis
• Perthes
• SUFE (slipped upper femoral epiphysis)
• Toddler’s Fracture
• Soft Tissue Injury
• Transient synovitis (irritable hip)

Less Common:

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

Question 2

Define SUFE?

Answer 2

Slipped upper femoral epiphysis - Femur Epiphysis is displaced, usually posteromedially/posteroinferiorly

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?

What are its features on examination?

Answer 5

Pain in groin +/- thigh/knee
Limp
May present acutely following trauma

ROM may be limited by pain
Leg is often rotated externally
Loss of internal rotation of leg in flexion

Question 6

How do we diagnose SUFE and treat?

Answer 6

X-ray, AP and Frog-Lateral, may be very subtle but can see the displaces head on top of the epiphysis

Pinning-in-situ

Question 7

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

Answer 7

• 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 8

Tests for Infection causing limp?

Answer 8

Blood cultures
WCC
CRP
ESR
Creatine Kinase

US and/or X-ray

Take Temp

Question 9

How do you tell SA apart from the other infections?

Answer 9

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 10

How does SA arise in kids?

Answer 10

Mostly haematogenous from another infection

Rarely its from a penetrating injury, injection into joint or spread from osteomyelitis

Question 11

How do we test for SA specifically?

Answer 11

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

Question 12

How do we treat SA?

Answer 12

IV abx

Aspiration

Question 13

How does OM present specifically?

Answer 13

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

Question 14

Testing for OM?

Answer 14

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

Question 15

How do we treat OM?

Answer 15

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

• Debriding dead shit

Question 16

What transient condition can cause a limp

Answer 16

Transient synovitis

Question 17

What would suggest transient synovitis

Answer 17

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

In essence - acute hip pain in kid whos recently had an infection but is all good now