The limping child Flashcards
Common causes of limp in a child?
Septic arthritis Osteomyelitis Perthes SUFE Toddlers fracture Soft tissue injury
Less common causes of limp in a child?
NAI
Tumour
Endocrinopathies
Causes of limp in a child (0-3yrs)?
Septic arthritis Osteomyelitis DDH Toddlers fracture Soft tissue injury NAI
Causes of limp in a child (3-10yrs)?
Trauma ( bone/ ST)
Septic arthritis
Transient synovitis
Perthes disease
Causes of limp in a child (11-15yrs)?
Trauma (stress) Septic arthritis Osteomyelitis SUFE Perthes
What is SUFE/SCFE?
A slipped upper/capital femoral epiphysis
Define SCFE/SUFE (Slipped upper/capital femoral epiphysis)?
Posteromedial displacement of the proximal femoral epiphysis in relation to the neck
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)
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
Obesity and SCFE?
Incidence increased 2.5 fold to 3.78 per 100,000
SUFE/SCFE (Slipped upper/capital femoral epiphysis) - History?
Pain- groin/ thigh/ knee
Limp
Trauma
ER deformity
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
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
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
Infective/inflammative causes of limping in a child?
Septic arthritis
Osteomyelitis
Transient synovitis
Muscle abscess
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
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