Paediatric Orthopaedics - The Limping Child Flashcards
What can the different gaits be for limping child?
Pain - antalgic gait
Weakness - Trendelenburg gait
Short limb - toe walk
Stiff joint - adducted and loss of rotation
What is the definition of a limp?
Abnormal gait commonly due to pain, weakness or deformity
Is often but not always due to pain
Shorter stance stage of affected limb
What are the causes for limping child?
Trauma, infective/ inflammatory, neoplastic, endocrine, neuro, degenerative, vascular, idiopathic, congenital, metabolic and occupational
What are causes for limping in a child aged 0-5 years?
Normal variant, trauma, transient synovitis, osteomyelitis, SA, DDH and JIA
What are some causes of limping in 5-10 year olds?
Trauma, transient synovitis, osteomyelitis, SA and Perthes disease
What are some causes of limping in a child aged 10-15 years old?
Trauma, osteomyelitis, SA< SUFE, chondromalacia and neoplasm
What should be asked in history?
Acute or chronic
Localise pain
Constant/ intermittent
Morning pain
Uni/ bilateral
Systemic illness
How is the limping child examined?
Sole feet, is child ill, is child splinting/ protecting, gait, look at spine, Gower’s manoeuvre (test of muscular dystrophy), comfort position and rash + swelling
What test is done if Gower’s manoeuvre is positive?
Creatinine kinase - elevated in muscular dystrophy
What are important infection and inflammation diseases?
Septic arthritis - drainage and antibiotics
Osteomyelitis - IV antibiotics
Transient synovitis
What are symptoms and signs of infection and inflammatory disease?
Limp, pain, general malaise, temp., recent URTI/ ear infection, trauma and pseudo paralysis
What does refusion to weight bear suggest?
Infection, tumour or fracture
What are some differential diagnosis for infection and inflammatory disease?
Sarcoma, myositis, osteoid osteoma, abscess and inflammatory arthropathy
What investigations are looked for in infection and inflammation?
Bloods - WCC, CRP, ESR, CK, and cultures
Temp.
X-ray and US - better for seeing bone and not infection
What is the Kocher criteria for septic arthritis?
Pyrexia >38 degrees
No weight bearing
WBC >12000/ml
ESR >40mm/hr
If 1 positive then 3% of SA
If 4 positive then 99%
What is the presentation of septic arthritis?
Limping, pseudo-paralysis, swollen, red joint, refusal to move joint, pain, and temp.
What is the distribution of septic arthritis?
Knee - 37%
Hip - 33%
Ankle - 13%
Sacroiliac - 1%
More common in lower limb
What is the route of entry of septic arthritis?
Hematogenous spread
Dissemination from osteomyelitis
Spread from adjacent soft tissue infection
Diagnostic or therapeutic measures
Penetrating trauma
What is the treatment for septic arthritis?
Typically staph. aureus infection
Aspiration
Arthroscopy and arthrotomy
Antibiotics - IV 2 weeks and 4 weeks oral
What is the incidence of osteomyelitis?
3/1000000 per year
Mean age is 6 years
Risk factors - blunt trauma and recent infection
What are the 3 factors for acute haematogenous osteomyelitis?
Vascular anatomy - vascular loops and terminal branches
Cellular anatomy - inhibited phagocytosis (low PO2)
Trauma
What is the presenting features of osteomyelitis?
Pain, localised signs/ symptoms, fever, reduced range of movement and reduced weight bearing
What is the most common organism causing osteomyelitis?
Staph. aureus
What are the indications for surgery in osteomyelitis?
Aspiration for culture
Drainage of subperiosteal abscess
Drainage of joint sepsis
Debridement of dead tissue
Failure to improve
Biopsy in equivocal cases
What is the presentation of transient synovitis?
Limping, often touch weight bearing, slightly unwell, history of viral infection, apyrexial, allowing joint to be examined, low CRP and normal WCC, may have joint effusion and not that unwell
What is the presentation of juvenile idiopathic arthritis?
Limping, swollen joints, stiffness in morning which gets better
3 groups - polyarticular (seronegative or positive), pauciarticular (early or late onset) and systemic onset
What is the definition of juvenile idiopathic arthritis?
Persistent arthritis of at least 6 weeks duration in one or more joints where forms of arthritis have been excluded
More common in girls
When is juvenile idiopathic arthritis refered?
Refer pauci-articular to eyes as can lead to blindness
What are some features which raise concern of neoplasm?
Night pain, often incidence trauma, stops doing sports, sweats and fatigue, and abnormal blood results (low Hb, atypical blood film, and atypical platelets)
