The limping child Flashcards by Callum Hill

Common causes of limp in a child?

Septic arthritis
Osteomyelitis
Perthes
SUFE
Toddlers fracture
Soft tissue injury

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Less common causes of limp in a child?

NAI
Tumour
Endocrinopathies

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Causes of limp in a child (0-3yrs)?

Septic arthritis
Osteomyelitis
DDH 
Toddlers fracture
Soft tissue injury
NAI

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Causes of limp in a child (3-10yrs)?

Trauma ( bone/ ST)
Septic arthritis
Transient synovitis
Perthes disease

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Causes of limp in a child (11-15yrs)?

Trauma (stress)
Septic arthritis
Osteomyelitis
SUFE 
Perthes

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What is SUFE/SCFE?

A slipped upper/capital femoral epiphysis

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Define SCFE/SUFE (Slipped upper/capital femoral epiphysis)?

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

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Epidemiology of SUFE/SCFE (Slipped upper/capital femoral epiphysis)?

> Age range: 9-16 yrs

males, mean = 13.5 yrs
females, mean = 12.0 yrs

> Sex: males 60% vs females 40%

> Incidence: 2-4/100,000
(up to 10/100,000 in USA)

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Aetiology of SUFE/SCFE (Slipped upper/capital femoral epiphysis)?

Increased load or 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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Obesity and SCFE?

Incidence increased 2.5 fold to 3.78 per 100,000

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SUFE/SCFE (Slipped upper/capital femoral epiphysis) - History?

Pain- groin/ thigh/ knee
Limp
Trauma
ER deformity

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SUFE/SCFE (Slipped upper/capital femoral epiphysis) - Physical exam?

> Body habitus
Externally rotated extremity
Obligatory external rotation in flexion
ROM limited by pain
Healing arthroscopy portals on ipsilateral knee

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SUFE/SCFE (Slipped upper/capital femoral epiphysis) - Radiology?

> 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
> Frog lateral x-ray

If x-ray positive should be referred for urgent review

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SUFE/SCFE (Slipped upper/capital femoral epiphysis) - general presentation?

> Older child (Rare <10yrs)
> Hip/thigh/knee pain 
> Can be either acute or chronic 
> Limp, external rotation gait 
> ROM limited by pain 
> No signs of infection

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Infective/inflammative causes of limping in a child?

Septic arthritis
Osteomyelitis
Transient synovitis
Muscle abscess

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Infective/inflammative causes of limping in a child - History?

> 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

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Infective/inflammative causes of limping in a child - Examination?

> 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 area?
> Upper limb disuse

Differential Diagnosis (pre-investigation)
What would make you put this at the top of your list in infective/inflammatory causes of limping in a child?

Most common:
> Transient synovitis
> Osteomyelitis
> Septic arthritis

Other:
> Sarcoma		
> Myositis
> Osteoid osteoma
> Abscess
> Inflammatory arthropathy

Infective/inflammative causes of limping in a child - Initial investigations?

> Temperature

> X-ray?

> USS (can indicate joint involvement but cannot separate infection from inflammation)

> Bloods:

WCC
CRP
ESR
CK
Cultures

Septic arthritis presentation in children?

Limping
Pseudoparalysis
Swollen, red joint
Refusal to move joint
Pain
Temperature

Most common site of septic arthritis in children?

> Knee = 37%
> Hip = 33%
> Ankle = 13%
> Shoulder = 8%
> Elbow = 5%
> Wrist = 3%
> Sacroiliac = 1%

Septic arthritis child - routes of entry?

1) Hematogenous
2) Dissemination from osteomyelitis
3) Soft tissue infection
4) Diagnostic or therapeutic procedure
5) Penetration damage from puncture or trauma

Septic arthritis child - Investigations?

> 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

Septic arthritis child - Investigations?

> FBC & differential

> Raised WCC >12,000/mm3

> ESR >50mm/hr

> CRP

> Blood cultures
+ve in 30-50%

> Xray

> ULTRASOUND- ALWAYS BE PRESENT**

> Synovial fluid (Best)

WCC >50,000/mm3
Gram stain
Culture

Septic arthritis child - Treatment?

> Typically staph aureus infection > Aspiration > Arthroscopy - Knee/ shoulder/ankle > Arthrotomy > ANTIBIOTICS: - IV for how long? Empirically 2 weeks - Continue orally for another 4 weeks

Osteomyelitis child - Epidemiology?

> 2-13/100,000 (up to 200/100,000 in developing countries) > Mean age 6 years (10yrs pelvic) > Risk factors (1/3): - Blunt trauma - Recent infection

Pathogenesis of osteomyelitis child?

3 factors: 1) Vascular anatomy - Vascular loops - Terminal branches 2) Cellular anatomy - Inhibited phagocytosis (low pO2) 3) Trauma A factor in 30%?

Osteomyelitis child - Symptoms?

``` > Pain > Localised sign/symptoms > Fever > Reduced ROM > Reduced weight-bearing ```

Indication for surgery in osteomyelitis child?

> Aspiration for culture > Drainage of subperiosteal abscess > Drainage of joint sepsis > Debridement of dead tissue > Biopsy in equivocal cases

Transient synovitis child- Presentation?

``` > Limping, often touch weight bearing > Slightly unwell > History of viral infection eg URTI/ ear > Apyrexial > Allowing joint to be examined > Low CRP, normal WCC > May have joint infusion > Not that unwell ```

Why are septic arthritis treated so aggressively with antibiotics?

If not infection can reoccur in the future e.g. a year later

What can indicate bone neoplasm in child?

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

Why is advantageous to use MRI in osetomyeltits?

X-Ray changes are late usually, 2-3 weeks after.

In osteomyelitis what does subperiosteal abscess usually indicate?

A worse outcome

How is osteomyelitis initially managed?

1) Try 48hrs of antibiotics | 2) No improvement drainage is required

What is the most likely organism involved in osteomyelitis, name a few more it could be?

1) S. aureus 2) S. epidermis 3) Strep. pneumoniae 4) S. pyogenes

Diagnositics in osteomyelitis?

1) Radiography: - Low sensitivity - High specificity - High positive predictive value 2) MRI: - High sensitivity - High specificity - High positive predictive value 3) Tc99 bone scan:

Diagnositics imaging in osteomyelitis?

1) Radiography: - Low sensitivity - High specificity - High positive predictive value 2) MRI: - High sensitivity - High specificity - High positive predictive value 3) Tc99 bone scan: - Medium-high sensitivity - medium-High specificity - medium-High positive predictive value 4) US: - Medium sensitivity - Medium specificity - High positive predictive value

Inflammatory markers in Osteomyelitis?

> ESR > CRP > WCC

What is the importance of growth plates having high vasculature in osteomyelitis?

Increases the risk