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Peds Final > The Limping Child -Warren > Flashcards

The Limping Child -Warren Flashcards

1
Q

What should you consider in a patient who limps worse in the morning but gets better as the day goes on?

A

Juvenile Idiopathic arthritis

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2
Q

What should you think of with a kiddo who limps worse at night/wakes up from sleep?

A

malignancy

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3
Q 
A 16 yo arroces to the office soon after beginning basketball season. He states that he has had progressive pain in his knees. PT reveals tenderness and a swollen prominent tibial tubercle. Which is the most likely diagnosis?
A. Popliteal cyst
B. traction apophysitis 
C. slipped capital femoral epiphysis
D. Legg-Calve-Perthes disease
E. Gonnococcal arthritis
A

B. traction apophysitis

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4
Q 
A 3 yo male presents with acute right leg pain and a limp. No hx of trauma but had a viral infection 1 week ago. He holds his right hip in external rotation and flexion and has mild restriction of range of motion. He appears otherwise well and is afebrile. His WBC is normal and his ESR is elevated. What is the best treatment option at this time?
A. IV antibiotics. 
B. surgical drainage of his hip
C. Anti-inflammatory drugs and bed rest 
D. Oral antibiotics 
E. immobilization with casting
A

C. Anti-inflammatory drugs and bed rest

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5
Q 
A 6 yo boy has developed a limp and limited mobility of the hip but denies fever and pain. What is the most likely diagnosis? 
A. Leg-Calve-Perthes disease
B. Slipped capital femoral epiphysis 
C. osteomyelitis 
D. septic arthritis of the hip
E. Transient synovitis
A

A. Leg-Calve-Perthes disease

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6
Q 
Differential diagnosis of limp in a toddler include all of the following except: 
A. spiral fracture 
B. slipped capital femoral epiphysis
C. osteomyelitis 
D. septic arthritis of the hip
E. Transient synovitis
A

B. slipped capital femoral epiphysis

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7
Q 
A 5 yo girl is referred to a peds rheumatologist with a 4 week history of milk swelling and decreased ROM of the left knee and right elbow. She is afebrile and otherwise well. Vision loss associated with JIA is most commonly associated with which of the following?
A. optic neuritis 
B. retinal artery thrombosis 
C. retinal detachment 
D. betacarotene malabsorption 
E. uveitis
A

E. uveitis

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8
Q

What are the most common causes of limping in a 1-3 yo?

A
  • Infection
  • Occult trauma
  • Neoplasia
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9
Q

What are the most common causes of limping in a 4-10 yo?

A
  • Infection
  • Transient synovitis
  • Legg-Calve Perthes
  • Rheumatologic disorder
  • Trauma
  • Neoplasm
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10
Q

What are the most common causes of limping in an 11+ yo?

A
  • Slipped Capital Femoral Epiphysis
  • Rheumatologic disorder
  • Trauma
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11
Q

Case 1:
18 month old with acute onset limp. Afebrile, otherwise no complaints. Happy and playful until stands up. Fussing, resists weight bearing on Right. Normal examination. What is your likely diagnosis? What is the management?

A

Toddler’s fracture

management=r/o child abuse. long leg cast for 3-4 weeks. heals completely in 6-8 weeks

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12
Q 
Which of the following types of fracture is most likely to suggest an etiology of child abuse?
A. Bowing fracture 
B. Buckle fracture 
C. Greenstick fracture 
D. spiral fracture
A

D. spiral fracture

fix and twist mechanism

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13
Q

A 4-year old is brought to the ER for concerns that she is unable to bear weight on her left leg and that she fell down on the stairs that morning. She was brought to the ER 2 other times in the past, each time with trauma after falling home. Her examination is mostly unremarkable except there are several bruises at various stages of healing. X-ray of the leg shows a spiral fracture of the left femur.

What is your appropriate course of action?
A. ask about Fmhx of brittle bones
B. consult opthalmology for an urgent retinal exam
C. contact child protective services
D. Require a private meeting with the family
E. Talk to the child about being more careful at home

A

c. . contact child protective services

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14
Q

Case:

  • 2yo male with 1 week of progressive limp and leg pain
  • X-ray at beginning of symptoms negative
  • Splinted for presumptive fracture
  • Low grade fever, increasing fussiness, now “dragging leg” and refusing to walk.
  • Exam: Fussy
  • Tender to palpation distal left leg
  • It is erythematous and warm to touch
  • CRP, ESR elevated
  • Blood samples for culture are drawn
  • X-rays and MRI done. What is the likely diagnosis? Which organism is likely to be isolated from this pts blood? What if the pt had sickle cell disease?
A
  • Osteomyelitis
  • Staph aureus* most common
  • if sickle cell==> salmonella species
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15
Q

What is the typical clinical presentation of osteomyelitis? What lab test is important to order?

A

Pain

  • Neonate pseudoparalysis
  • Not weight bearing
  • Failure to use limb
  • Fever
  • Lethargy
  • Anorexia
  • Swelling (neonates / older kids)

*blood culture

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16
Q

Which radiologic study is most sensitive and specific for finding osteomyelitis?

A

MRI> x-ray

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17
Q

What is the treatment for osteomyelitis?

A
  • Surgery to improve local environment
  • Remove infected devitalized bone
  • Decompress abscess cavity
  • Antibiotic treatment 3-6 weeks

**Early antibiotic before necrosis / pus then surgery less likely to be needed

18
Q

What age group normally gets transient synovitis? What are the common presentations?

A
  • age 3-8
  • non-infectious, inflammatory condition (MAY BE VIRAL)
  • mild fever, limp, fussiness
  • minimal ROM
19
Q

What is the treatment for transient synovitis?

A

conservative treatment-NSAIDS

follow up in the next day–> if not improving=aspirate

20
Q

**What differential should be considered with a suspected transient synovitis? How can you differentiate these?

A

Septic arthritis (progressive worsening symptoms)

transient synovitis will have a hx of preceding viral illness

21
Q

What normally causes septic arthritis? What is the pathophysiology?

A

S. aureus –> osteomyelitis extension or direct inoculation from penetrating trauma

-bacteria deposited in subsynovial capillary network–>
Immune response –>
Inflammatory cascade initiated with release of proteolytic enzymes and toxins –>
Articular cartilage degradation–>
Increased fluid and pus –> inc pressure and ischemia from compression

22
Q

What position do patients with septic arthritis prefer their hip to be in ? Why?

A

slightly flexed and externally rotated to maximize the joint space and decrease pressure

23
Q

What is the gold standard for diagnosis of septic arthritis?

A

aspiration of fluid for cell count, gram stain, culture and sensitivity

24
Q 
Case:
A 4-year-old female presents with her parents to their PCP with concerns of limping with swelling of her right knee for several months. She cannot fully extend her right knee. She sometimes does not want to walk in the morning, but seems fine later in the morning and the rest of the day. Her past medical history is unremarkable. Physical examination demonstrates swelling (effusion) of her right knee, flexion contracture of 10 degrees and flexion to 120 degrees. No increased heat or pain upon range of motion is present. 
She appears unconcerned about her limp and swelling. 
What is her likely diagnosis?
A. Septic arthritis
B. Reactive arthritis
C. Juvenille idiopathic arthritis 
D. Osteomyelitis 
E. Patellar fracture
A

C. Juvenille idiopathic arthritis

25
Q 
A 6 yo boy has developed a limp and limited mobility of the hip but denies fever and pain. What is the most likely diagnosis? 
A. Leg-Calve-Perthes disease
B. Slipped capital femoral epiphysis 
C. osteomyelitis 
D. septic arthritis of the hip
E. Transient synovitis
A

A. Leg-Calve-Perthes disease

26
Q

What is the most appropriate treatment for a pt with Juvenille idiopathic arthritis?

A

NSAIDS

27
Q

What is Pauciarticular arthritis? What age group is this normally seen in? What are the positive lab findings?

A
  • 4 or less large joints (NOT hip)
  • 2-6 yo
  • Positive ANA
28
Q

What is the main morbidity of JIA?

A

Asymptomatic anterior Uveitis. can lead to blindness

–> associated with +ANA

29
Q 
Case:
-4 yo male with 3d h/o limp and thigh pain
-No fever
-Some improvement with ibuprofen 
-Active and playful
-Uncomfortable with palpation over the entire right hip region and internal rotation and hip abduction causes significant pain.  
-Decreased range of motion compared to the other side. 
-"moth eaten" x-ray of hip
What is your likely diagnosis?
A. Leg-Calve-Perthes disease
B. Slipped capital femoral epiphysis 
C. osteomyelitis 
D. septic arthritis of the hip
E. Transient synovitis
A

A. Leg-Calve-Perthes disease

30
Q 
Case:
-4 yo male with 3d h/o limp and thigh pain
-No fever
-Some improvement with ibuprofen 
-Active and playful
-Uncomfortable with palpation over the entire right hip region and internal rotation and hip abduction causes significant pain.  
-Decreased range of motion compared to the other side. 
-"moth eaten" x-ray of hip
What is your likely diagnosis?
A. Leg-Calve-Perthes disease
B. Slipped capital femoral epiphysis 
C. osteomyelitis 
D. septic arthritis of the hip
E. Transient synovitis
A

A. Leg-Calve-Perthes disease (avascular necrosis of the femoral head)

31
Q

What are some PE findings consistent with Legg-Calve-Perthes disease?

A
  • Antalgic gait
  • Short stature – children with LCPD often have delayed bone age
  • +Galeazzi test (difference in knee height)
  • Decrease range of motion with internal rotation and abduction
  • +Log Roll test
32
Q

What is the treatment for Legg-Calve-Perthes disease? What is the most important factor in preventing long term complications?

A
  • Symptomatic – rest, pain meds

- Observation for children

33
Q

What should you think of with “moth eaten” destruction of the femoral head?

A

Legg-Calve-Perthes disease

34
Q 
Case:
-4 yo male with 3d h/o limp and thigh pain
-No fever
-Some improvement with ibuprofen 
-Active and playful
-Uncomfortable with palpation over the entire right hip region and internal rotation and hip abduction causes significant pain.  
-Decreased range of motion compared to the other side. 
-"moth eaten" x-ray of hip
What is your likely diagnosis?
A. Leg-Calve-Perthes disease
B. Slipped capital femoral epiphysis 
C. osteomyelitis 
D. septic arthritis of the hip
E. Transient synovitis
A

A. Leg-Calve-Perthes disease (avascular necrosis of the femoral head)

35
Q 
Case:
-12yo obese male with chief complaint of knee pain
-Present for a couple weeks, acutely worsened after playing basketball
-No fever, no other symptoms
-Exam: walks with limp
-Knee – no swelling, no tenderness, normal range of motion
What is the most likely diagnosis?
A. Leg-Calve-Perthes disease
B. Slipped capital femoral epiphysis 
C. osteomyelitis 
D. septic arthritis of the hip
E. Transient synovitis
A

B. Slipped capital femoral epiphysis

36
Q

What is the most common adolescent hip disorder? How will this present?

A
  • Slipped capital femoral epiphysis
  • May present with chronic limp, acute pain or combination
  • Hold leg in slight external rotation and have limited internal rotation
37
Q

What test should be ordered for a suspected SCFE? What is the earliest sign? What is the treatment?

A
  • x-ray of both hips
  • frog-leg radiograph
  • early sign=widening of the epiphysis
  • treatment: pin fixation
  • complications: avascular necrosis and chondrolysis
38
Q

case:
-15 yo male brought in by EMS for sudden onset severe hip and leg pain
-Was running 40 yard dash for football tryouts when developed severe pain and difficulty ambulating
-Exam: very uncomfortable, pelvis stable but painful to palpation, pain with hip movement, especially hip flexion
-x-ray is normal
What is the most likely diagnosis?

A

avulsion

39
Q

What is Osgood-Schlatter Disease?

A
  • Painful enlargement of tibial tuberosity at patellar tendon insertion
  • A “traction apophysitis” due to excessive tension on the site
  • Most prevalent in pre-adolescent and early adolescent boys (5:1)
40
Q

What are the PE findings associated with Osgood-Schlatter Disease? What is the treatment?

A
  • Soft tissue swelling about the patellar tendon
  • Thickened patellar tendon
  • Loss of infrapatellar fat pad
  • Irregularity of the tibial tuberosity

NSAIDs rest

41
Q

case:
-15yo male with several days of limping, back pain, decreased appetite and activity and weight loss
-Patient is alert, thin, ill and uncomfortable appearing. -Cries with manipulation of hips/legs.
-Firmness to palpation in upper abdomen
-CBC, chemistry normal
What is the likely diagnosis?

A

Osteosarcome

42
Q

case:
-15yo male with several days of limping, back pain, decreased appetite and activity and weight loss
-Patient is alert, thin, ill and uncomfortable appearing. -Cries with manipulation of hips/legs.
-Firmness to palpation in upper abdomen
-CBC, chemistry normal
What is the likely diagnosis?

A

Osteosarcoma (or other malignancy)

Peds Final (21 decks)

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