The Acute Limping Child Flashcards by Aimee Love

What are common cause of an acute limping child?

Septic arthritis 
Osteomyelitis
Perthes
SUFE
Toddler's fracture 
Soft tissue injury

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What are less common cause of an acute limping child?

NAI
Tumours
Endocrinopathies

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What is the most common cause of limping in a 0-3yo?

Septic arthritis

Followed by: OM, DDH, Toddler’s fracture, soft tissue injury, NAI

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What is the most common cause of limping in a 3-10yo?

Trauma (bone or soft tissue)

Followed by: SA, transient synovitis, Perthes disease

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What is the most common cause of limping in a 11-15yo?

Trauma (stress)

Followed by: SA, OM, SUFE, perthes

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What are other rarer causes of an acute limping child?

Sickle cell 
Soft tissue/spine infection 
Metabolic disorder
Neoplastic
Anatomical 
Rheumatological 
Neuromuscular

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Why do you need a really good reason to do an MRI scan on someone under age 8?

Under 8 age MRI scan req. anaesthesia

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What is SUFE?

Slipped upper femoral epiphysis

Fracture through the widened part (where fattest and therefore weakest cells are) of the hypertrophic zone of the growth plate that leads to posteriomedial displacement of the proximal femoral epiphysis in relation to the neck

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At what age does SUFE tend to happen?

9-16 years old
In males, mean 13.5 years
In females, mean 12 years

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What is the aetiology of SUFE?

Increased load or weak epiphysis:
Adolescence
Delayed bone age 
Increased weight 
V. active --> extra stress on growth plate

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What are some rarer aetiologies of SUFE?

Secondary to underlying disorders (DH-IGF axis):
Hypothyroidism
Hypogonadism 
Renal osteodystrophy 
GH therapy

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What is a typical history for a SUFE?

Pain in groin/knee/thigh
Limp
Trauma (coincidental)
ER deformity

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What are typical examination findings in SUFE?

Obese/overweight child
ER extremity 
Obligatory external rotation in flexion 
RoM limited by pain 
Healing arthroscopy portals on ipsilateral knee (wrong op!) 
No indicators of infection

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What are typical radiological findings for SUFE?

Trethowan's sign 
Widened physis
Horizontal physis 
Blanch sign of steel 
Knee XRay normal 
Obvious slip

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What is the best XRay to do for SUFE?

Lateral frog X-Ray

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What is Trethowan’s sign?

Used for diagnosis of SUFE

Normally line from superior femoral neck intersects a small part of the upper capital epiphyseal (Klein’s line), but in SUFE it does not

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What is Blanch sign of steel?

Crescent shaped increased density lies over metaphysis of femur neck adjacent to physis

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How do you treat SUFE?

Pinning to allow fusion

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What is the most common cause of non-traumatic limp?

Infection or inflammation

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What are possible infections or inflammation that may lead to a limp?

Muscle abscesses, transient synovitis, septic arthritis, osteomyelitis
Watch out - could be sarcoma, myositis, osteoid osteoma etc.

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What history is typical of infection/inflammation?

Limp 
Pain 
Malaise/loss of appetite
Temperature/fever
Recurrent URTI/ear infections
Trauma 
Pseudoparalysis (voluntary restriction of movement)

What is important in examination when you suspect infection for the cause of a limp?

Limping? Refusal to wt bear? Localise the area!

Hip - obligatory ER?
Ankle - joint line or distal tibia? Knee - joint line or metaphyseal area?

What are your initial investigations when you suspect infection?

Temperature XRay
USS
Bloods: CRP, ESR, culture, WCC, CK

What is septic arthritis?

Bacterial infection of the joint space

What tends to cause SA?

Staph aureus

What are the different routes by which SA can occur?

Haematogenous spread from distant site (e.g. wound infection) - most common Dissemination from OM Spread from adjacent soft tissue infection Diagnostic/therapeutic measures Penetrating trauma

What is a typical history for SA?

Limping Pseudoparalysis Swollen, red, effused joint Knee > hip > ankle Won't let you Ex!!

What are typical investigation findings in SA?

WCC raised, ESR and CRP raised | 30-50% blood cultures +ve

After XRay what investigation must you do if you suspect SA?

USS - this is the best imaging for SA | Allows you to see effusion, oedema surrounding tissue

What investigations, apart from the initial ones, Xray and USS might you do in SA?

Testing the synovial fluid for WCC, gram stain and culture

How do you manage SA?

Aspirate joint Arthroscopy/arthrotomy (drainage and washing out of joint) IV followed by oral antibiotics

What is osteomyelitis?

Infection of the bone/bone marrow

What is the mean age to get OM?

6 years old

What are risk factors for OM?

Blunt trauma, recent infection

What are the three contributing factors to getting OM?

Vascular anatomy - happens most freq. at end of bones as BS best here as this is where growth plate is Cellular anatomy (e.g. inhibited phagocytes in low pO2) trauma - in 30%

What bacteria most commonly causes OM?

Staph aureus

What is a typical history of OM?

Pain at site of infection, tenderness over affected area Fever (less common than SA) Reduced RoM Reduced wt bearing

What are typical investigation findings in OM?

Raised ESR, CRP | Less likely to have raised WCC

What is the best imaging for OM?

XRay not very good as bone changes take weeks | MRI best

What should be your investigation plan if you suspect OM?

Serum CRP, ESR, blood culture, plain XRay, if abnormal --> MRI, bone scan, CT if +ve --> Rx, if neg --> bone and blood culture --> if +ve Rx

When should you take blood cultures?

Before antibiotics are given

What is the treatment for OM?

``` Surgery if: Aspiration needed for culture Drainage of subperiosteal abscess/joint sepsis Debridement of dead tissue Biopsy IV antibiotics 4-6wks ```

What is transient synovitis?

Non-specific inflammation and hypertrophy of the synovium

What is a typical history of transient synovitis?

``` Limping Often touch wt bearing Slightly unwell Hx of viral infection (URTI, ear infection) Aprexial Allowing joint to the Ex Low CRP, normal WCC May have joint effusion Not that unwell!! ```

What are typical imaging findings for transient synovitis?

Normal XRay | Effusion on USS

How do you manage transient synovitis?

Conservative, e.g. NSAIDs

How can you distinguish between SA and transient synovitis?

Fever - present in SA, not in TS

What is a muscle abscess?

Collection of pus in muscle

What does a muscle abscess present like?

Similar to OM | Tenderness over muscle

How do you treat muscle abscesses?

IV antibiotic, 4-6wks oral after

What features may raise concern of a neoplasm?

``` Night pain Often incidental trauma Stops doing sport/going out Sweats/fatigue Abnormal blood results - low Hb, atypical blood film, atypical platelets ```