The limping child Flashcards
Common causes
osteomyelitis - septic arthritis - SUFE - toddler fracture - soft tissue injury
Less common causes
NAI, tumour ,endocrinopathies
0-3yrs
fractures soft tissue injury septic arthritis osteomyelitis DDH NAI
3-10yrs
trauma
septic arthritis
transient synovitis
perthes disease
other causes of limping - age related pathologies
sickle cell
ST/spinal infection
metabolic, neoplasia, rheumatic, neuromuscular
SUFE/SCFE stands for
slipped upper/capital femoral epiphysis
What happens in SUFE
posteromedial displacement of proximal epiphysis in relation to the neck
Where in the physis does SUFE occur?
through zone of hypertrophy
Epidemiology of SUFE
age 9-16 (males 13.5, girls 12)
sex - 60% male
2-4/100 000
Brief description of SUFE aetiology
increased load or weak physis or both
idiopathic SUFE
adolescent, OBESITY, delayed bone age
secondary SUFE
GH-1GF1 axis eg hypothyroid, hypogonadism, renal osteodystrophy, growth hormone therapy
History - SUFE
pain in groin, thigh, knee
limp
trauma
physical exam - SUFE
- body habitus
- externally rotated extremity
- ROM limited by pain
- obligatory external rotation in flexion
- healing arthroscopy portals on ipsilateral knee
Radiology - SUFE
- Trethowan/Klein’s line in lateral view
- widened physis
- knee x-rays normal
- obvious slip
- blanch sign of steel
SUFE summary
older child hip/thigh/knee pain acute, acute on chronic no infection limp external rotation gait knee flex into ER frog lateral x-ray percutaneous screw fixation
4 infection and inflammations
septic arthritis
osteomyelitis
muscle abscess
transient synovitis
History of infection and inflammation
limp - age, pain, temperature, malaise, loss of appetite, trauma, recent URTI/ear infection, pseudoparalysis
Examination of infection/inflammation
look sick? limp? absolute refusal to weight bear?localise area, upper limb disuse
ankle - infection/inflammation
distal tibia or joint line?
knee - infection/inflammation
joint line or metaphyseal area
hip - infection/inflammation
obligatory ER?
which movements hurt?
Diff diagnosis - infection/inflammation
transient synovitis, osteomyelitis, septic arthritis
something else?…sarcoma, myositis, abscess, osteoma
Initial investigations - infection/inflammation
temperature
x-ray
USS
bloods - CRP, ESR, WCC, CK, Cultures
septic arthritis signs and symptoms
limping - pseudoparalysis - swollen, red joint - pain - temperature - refuse to move joint
Most common location of septic arthritis
KNEE, then hip
ankle, shoulder, elbow, wrist, SI - rare
5 routes of bacterial entry for septic arthritis
1 - haematogenous 2 - dissemination from osteomyelitis 3 - soft tissue infection 4 - diagnostic/therapeutic measures 5 - penetrating trauma
Investigations - septic arthritis
FBC, ESR, CRP, x-ray, blood cultures, USS, synovial fluid analysis eg WCC, gram stain and culture
Presenting variables in septic arthritis
fever - ESR - CRP - ability to weight bear - serum WCC - joint space
treatment of septic arthritis
aspiration
arthroscopy
arthrotomy
antibiotics
usual causative organism of septic arthritis
staph aureus
osteomyelitis epidemiology
declining, 2-13/100 000
6 years old (10yrs pelvic)
blunt trauma/recent infection
3 factors for osteomyelitis pathogenesis
RARE IN ADULTS
vascular anatomy - vascular loops and terminal branches
cellular - inhibited phagocytosis
trauma - 30%
osteomyelitis symptoms
pain, fever, decreased ROM, decreased weight bearing
investigations for osteomyelitis
ESR
CRP, WCC, Tc99 bone scan, MRI, CT, USS
osteomyelitis surgery
aspiration for culture drain subperiosteal abscess drain joint sepsis debride dead tissue biopsy
When is it transient synovitis?
limp, touch weight bear
NOT THAT UNWELL
joint infusion
allow joint to be examined
Concerning signs - neoplasm?
night pain stopping sports incidental trauma sweats and fatigue low Hb, atypical blood film and platelets
