The Acute Limping Child Flashcards
What are common causes of limp?
- Septic arthritis
- Osteomyelitis
- Perthes
- SUFE
- Toddlers fracture
- Soft tissue injury
What are less common causes of limp?
- NAI
- Tumour
- Endocrinopathies
What pathologies are common in the 0-3 years?
- Septic arthritis
- Osteomyelitis
- DDH
- Toddlers fracture
- Soft tissue injury
- NAI
What pathologies are common in the 3-10 years?
- Trauma ( bone/ ST)
- Septic arthritis
- Transient synovitis
- Perthes disease
What pathologies are common in the 11-15 years?
- Trauma (stress)
- Septic arthritis
- Osteomyelities
- SUFE
- Perthes
What other types of pathology can impact the MSK system of children?
- Sickle cell
- ST/ spine infection
- Metabolic disease-
- Neoplastic
- Anatomical
- Rheumatological
- Neuromuscular
What does SUFE stand for?
Slipped upper femoral epiphysis
How is SUFE defined?
Posteromedial displacement of the proximal femoral epiphysis in relation to the neck
Where in the physis foes SUFE occur?
Through the (widened) zone of hypertrophy in the physis
What is the epidemiology of SUFE?
- Age range 9-16 years
- Males mean=13.5 years
- Female mean= 12 years
- M:F 3:2
- Incidence 2-4/100,000
What is SUFE due to?
Increased load, weak physis or both
What is the aetiology of SUFE?
Idiopathic
- Adolescence
- Delayed bone age
- Increased weight
Secondary to underlying disorder (GH-IGF axis)
- Hypothyroidism
- Hypogonadism
- Renal osteodystrophy
- Growth hormone therapy
What history dies SUFE present with?
- Pain- groin/ thigh/ knee
- Limp
- Trauma
- ER deformity
What may be found on physical exam of SUFE?
- Body habitus
- Externally rotated extremity
- Obligatory external rotation in flexion
- ROM limited by pain
- Healing arthroscopy portals on ipsilateral knee
What may be seen on radiology of SUFE/
- Trethowan’s / Klein’s line
- More obvious on lateral view
- Widened physis
- Horizontal physis (flexion contracture)
- Knee x-rays are usually normal!
- Blanch sign of Steel
- Or just an obvious slip
What are the key summary points for SUFE?
- 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
How is SUFE treated?
Percutaneous screw fixation
What history is associated with infection?
- 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
What examination should be carried out for suspected infection?
- Do they look sick?
- Limp?
- Absolute refusal to weight bear?
- Localising area: ankle/tibia/knee/thigh/hip
- Hip: obligatory ER?, Which movements hurt
- Ankle: distal tibia or joint line?
- Knee: joint line or metaphyseal are
- Upper limb diffuse
What is the differential diagnosis for suspected infection?
- Transient synovitis
- Osteomyelitis
- Septic arthritis
- Sarcoma
- Mysoitis
- Osteoid osteoma
- Abscess
- Inflammatory arthropathy
What initial investigations should be done for suspected infection?
- Temperature
- X-ray
- USS
Bloods
- WCC
- CRP
- ESR
- CK
- Cultures
How does septic arthritis present?
- Limping
- Pseudoparalysis
- Swollen, red joint
- Refusal to move joint
- Pain
- Temperature
What is the distribution of septic arthritis?
- Knee: 37%
- Hip: 33%
- Ankle: 13%
- Shoulder: 8%
- Elbow: 5%
- Wrist: 3%
- Sacroiliac 1%
What are the possible routes of entry for septic arthritis?
- Haematogenous spread
- Dissemination from osteomyelitis
- Spread from adjacent soft tissue infection
- Consequence of diagnostic or therapeutic measures (injections)
- Penetrating damage by puncture or trauma
What investigations should be done for septic arthritis?
- FBC and differential (Raised WCC >12,000mm^3)
- ESR (>50 mm/hr)
- CRP
- Blood Cultures (+ve in 30-50%)
- Ultrasound (always be present)
- Synovial fluid (WCC>50,000mm^3, Gram stain, culture)
What presenting variables help to direct in diagnosis?
- Fever
- Ability to weight bear
- ESR
- CRP
- Serum WCC
- Joint space
How is septic arthritis treated?
- Aspiration
- Arthroscopy
- Arthrotomy
- IV antibiotics
What organism is the typical cause of septic arthritis?
Staph aureus
What is the epidemiology of osteomyelitis?
- Declining
- 2-13/100,000 incidence
- Mean age 6 years (10 years for pelvic)
What risk factors are there for osteomyelitis?
- Blunt trauma
- Recent infection
What is the pathogenesis of acute haematogenous osteomyelitis?
Vascular anatomy
- Vascular loops
- Terminal branches
Cellular anatomy
-Inhibited phagocytosis (low pO2)
Trauma
-A factor in 30%
How does osteomyelitis present?
- Pain
- Localised symptoms
- Fever
- Reduced ROM
- Reduced weight bearing
What is the most common organism involved in 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
- Biopsy in equivocal cases
How does transient synovitis present?
- Limping, often touch weight bearing
- History of viral infection eg URTI/ ear
- Apyrexial
- Allowing joint to be examined
- Low CRP, normal WCC
- May have joint infusion
- NOT THAT UNWELL
What features raise concerns about neoplasms?
- Night pain
- Often incidental trauma
- Stops doing sport/ going out
- Sweats and fatigue
- Abnormal blood results- low Hb, atypical blood film, atypical platelets
- Get a paediatricians/ oncology opinion
