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Musculoskeletal > The Acute Limping Child > Flashcards

The Acute Limping Child Flashcards

1
Q

What are the common causes of acute limping child?

A
  • Septic arthritis
  • Osteomyelitis
  • Perthes
  • SUFE
  • Toddlers fracture
  • Soft tissue injury

Less common are:

  • NAI
  • Tumour
  • Endocrinopathies
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2
Q

What does SUFE stand for?

A

Slipped upper / capital femoral epiphysis

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3
Q

What is the definition of SUFE?

A

Posteromedial displacement of the proximal femoral epiphysis in relation to the neck

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4
Q

Where in the physis does the SUFE occur in the physis?

A

–Through the (widened) zone of hypertrophy in the physis

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5
Q

What is the epidaemiology of the disease?

A

Males mean is 13/5 years

Females is 12 years

Males 60%

Females 40%

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6
Q

What are the causes of SUFE?

A

Increased load, weak physis or both

–Idiopathic

  • Adolescence
  • Delayed bone age
  • Increased weight

–Secondary to underlying disorder (GH-IGF axis)

  • hypothyroidism
  • hypogonadism
  • renal osteodystrophy
  • growth hormone therapy
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7
Q
A
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8
Q

What are the findings on physical examination of SUFE?

A

External rotation of extremity

ROM limited by pain

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9
Q

What are the findings of SUFE on radiology?

A
  • Trethowan’s / Klein’s line - line parallel to the upper edge of the femoral neck
  • More obvious on lateral view
  • Widened physis
  • Horizontal physis (flexion contracture)
  • Knee x-rays are usually normal!
  • Blanch sign of Steel - this is when there is a crescentic shaped area of increased density overlying the metaphysis adjacent to the physis - Increased density is caused by overlapping of the femoral neck and the posteriorly displaced capital epiphysis

Or just an obvious slip

(Klein’s line and the physis is widened and horizontal)

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10
Q

What type of X-ray is necessary for SUFE?

A

Frog lateral X-ray

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11
Q

SUFE summary

A
  • Older child (rare but occasionally <10 yrs)
  • Hip / thigh/ knee pain
  • Acute, acute on chronic
  • No clinical indicators of infection
  • Limp, external rotation gait, knee flex into ER
  • Frog lateral x-ray
  • If x-ray positive should be referred for urgent review
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12
Q
A
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13
Q

What are the infections that can cause a limp in a child?

A

Septic arthritis

Osteomyelitis

Transient synovitis

Muscle abscess

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14
Q

What presenting history might suggest infection?

A
  • Limp (age dependent)
  • Pain
  • General malaise/ loss of appetite/ listless
  • Temperature
  • Recent URTI/ ear infections
  • Trauma
  • Pseudoparalysis
  • Listen to the parent, they are usually right

On examination the child may look sick, limp, refusal to weight bear, localising area, movements that hurt more than others

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15
Q

What are the initial investigations for a limping child?

A

WCC

CRP ESR

CK

Cultures

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16
Q

What tests can you use CK for?

A

Heart attack

Rhabdomyolysis

Acute kidney injury

17
Q

What is the presenation for septic arthritis?

A
  • Limping
  • Pseudoparalysis
  • Swollen, red joint
  • Refusal to move joint
  • Pain
  • Temperature
18
Q

What are the most common places for septic arthritis?

A

Most commonly in the hip and the knee

19
Q

What are the routes by which bacteria can enter the joint?

A

Haematogenous route

Dissemination from osteomyelitis

Spread from adjacent soft tissue infection

Diagostic or therapeutic measures

Penetrating damage by punture or trauma

20
Q

What is the investigation for septic arthritis?

A

•FBC & differential

–Raised WCC >12,000/mm3

  • ESR >50mm/hr
  • CRP
  • Blood cultures

– +ve in 30-50%

  • Xray
  • ULTRASOUND- ALWAYS BE PRESENT
  • Synovial fluid

–WCC >50,000/mm3

–Gram stain

–Culture

21
Q

What organism is typically responsible for septic arthritis?

A

Staph aureus

22
Q

What is the treatment for septic arthritis?

A
  • Typically staph aureus infection
  • Aspiration
  • Arthroscopy

–Knee/shoulder/ankle

  • Arthrotomy
  • ANTIBIOTICS
23
Q

What is the mean age for osteomyelitis?

24
Q

What are the risk factors for osteomyelitis?

A

Blunt trauma

Recent infection

25
Q

What are the most common places for osteomyelitis?

A

Femur

Tibia

26
Q

What are the presenting features of osteomyelitis?

A

Pain

Localised signs/symptoms

Fever

Reduced range of movement

Reduced weight bearing

27
Q

What are the blood investigations for osteomyelitis?

A

WCC

ESR

CRP

Blood culture

28
Q

What are the imaging modalities for osteomyelitis?

A

Radiography (poor sensitivity)

Tc99 bone scan

MRi

CT

Ultrasoound scan

29
Q

What is the most likely causative organism for osteomyelitis?

A

Staph aureus

30
Q

What are indications for surgery in osteomyelitis?

A
  • Aspiration for culture
  • Drainage of subperiosteal abscess
  • Drainage of joint sepsis
  • Debridement of dead tissue
  • Biopsy in equivocal cases
31
Q

What is the clinical presentation of transient synovitis?

A
  • Limping, often touch weight bearing
  • Slightly unwell
  • History of viral infection eg URTI/ ear
  • Apyrexial
  • Allowing joint to be examined
32
Q

What are the blood values of CRP and WCC for transient synovitis?

A

Low CRP

Normal WCC

Musculoskeletal (28 decks)

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