The Acute Limping Child Flashcards
What are common cause of an acute limping child?
Septic arthritis Osteomyelitis Perthes SUFE Toddler's fracture Soft tissue injury
What are less common cause of an acute limping child?
NAI
Tumours
Endocrinopathies
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
What is the most common cause of limping in a 3-10yo?
Trauma (bone or soft tissue)
Followed by: SA, transient synovitis, Perthes disease
What is the most common cause of limping in a 11-15yo?
Trauma (stress)
Followed by: SA, OM, SUFE, perthes
What are other rarer causes of an acute limping child?
Sickle cell Soft tissue/spine infection Metabolic disorder Neoplastic Anatomical Rheumatological Neuromuscular
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
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
At what age does SUFE tend to happen?
9-16 years old
In males, mean 13.5 years
In females, mean 12 years
What is the aetiology of SUFE?
Increased load or weak epiphysis: Adolescence Delayed bone age Increased weight V. active --> extra stress on growth plate
What are some rarer aetiologies of SUFE?
Secondary to underlying disorders (DH-IGF axis): Hypothyroidism Hypogonadism Renal osteodystrophy GH therapy
What is a typical history for a SUFE?
Pain in groin/knee/thigh
Limp
Trauma (coincidental)
ER deformity
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
What are typical radiological findings for SUFE?
Trethowan's sign Widened physis Horizontal physis Blanch sign of steel Knee XRay normal Obvious slip
What is the best XRay to do for SUFE?
Lateral frog X-Ray
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
What is Blanch sign of steel?
Crescent shaped increased density lies over metaphysis of femur neck adjacent to physis
How do you treat SUFE?
Pinning to allow fusion
What is the most common cause of non-traumatic limp?
Infection or inflammation
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.
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