Limping Child

21 April, 2011 by: colinparker

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Watchful waiting or invasive investigations?  A limping child may have transient synovitis, or something more serious such as septic arthritis, osteomyelitis, or Perthes Disease.


Tests can be falsely reassuring in the early stages… Join us for a tour of clinical discovery in evaluating the child with a limp.



Outline: Limping Child PEMcast

[cp] Hello, welcome, introductions, disclaimer

[cp] Background / incidence / importance of ED role

[cp] Limping Child: non-ED setting

Roberts 2009 –
[cp] quick overview
[RR] Gait abnormalities (in brief)
[KB] Major differential diagnoses

[cp] ED setting: Limp associated with pain / discomfort:
Differentials: hip / limb / other:
[KB] Limb: foot / toe / shin / knee/ thigh / hip (“pebble in the shoe”)
[cp] Other: referred from spine / abdomen (appendicitis) / genitalia (torsion) / retroperitoneal
[RR] Hip (most common subset):
SA
OM
TS
Reactive arthritis
JIA = JRA = JCA
Perthes Disease
SCFE
Trauma (including NAI)
Neoplasia

[cp] Don’t be a Boob…

•Trauma
•Infection
•Tumour

History of recent trauma always present & often blamed, think of other causes…

Assessment:

[KB] History:
Trauma (&context) vs gradual onset
Recent illness
Fever
Systemic symptoms
Rash (Still’s Disease = SOJIAHSP)
Mobility (weight-bearing/crawling)

[RR] Examination:
Observation, Fever, General appearance
Gait
Back & pelvis
Genitalia
Limb starting at foot
Heel Percussion (or even push & twist)
Joints (look, feel, move)
Hip flexion, external  & INTERNAL rotation

Specific conditions:

[KB] Perthe’s Disease
•Avascular necrosis of femoral head
•Cause is not known
•4-10 years age, boys > girls
•Uncommon but potentially BAD
•Diagnosed on X-ray
•Refer to Orthopaedics
•May need operation

[cp] SCFE
•Slipped Capital Femoral Epiphysis
= Slipped Upper Femoral Epiphysis (SUFE)
•Stress fracture through femoral growth plate
•10-15 years age group
•especially chubby boys
•Diagnosed on X-ray
•Refer to Orthopaedics
•Cannulated screw

[RR] Septic Arthritis
= pus in the hip joint
•Rare but BAD
•Difficult to exclude / confirm
May have:
•Fever (up to 80%), Rigors (20%), ‘toxic’ looking, unwell
•Muscle spasm / pseudoparalysis / decreased ROM
­WCC, ­ESR, ­CRP
U/S-guided aspiration of hip joint (in theatre):
•invasive, GA risks
•50-75% of clinically diagnosed SA have positive culture
•?Unlikely in well child if ultrasound shows effusion < 5 mm
•Treatment = washout in theatre, IV AB’s (after ortho ‘approval’***),
?IV dexamethasone (shorter recovery, fewer complications)

*** treating ‘blind’ without an organism diagnosis results in more complications, more procedures, longer duration of treatment, more frustration & anxiety for orthopaedic surgeons

[cp] Osteomyelitis
= pus in the bone
•Commonest around knee joint
•Distal femur > proximal tibia
•Can occur anywhere, including proximal femur
•Similar to septic arthritis in presentation
•Diagnosed on bone scan
•X-Ray changes take weeks to develop
•Treatment = IV AB’s for weeks

[KB] Transient Synovitis
•Inflammation ± fluid in joint capsule
•3-8 years peak age group (±recent viral infection)
•Commonest cause of limp in a young child
•Clinical diagnosis
“Capsular Pattern” = Limited internal rotation compared to the other side
[cp] (anatomy of hip joint)
•May need to do some tests to ‘risk stratify’ for other causes (Septic Arthritis)
eg Xray, U/S, FBC/ESR/CRP
Treatment:
•Self-limiting condition, 1-3 days
•Ibuprofen (quicker recovery than placebo) & paracetamol (acetaminophen)
GP review (or return to ED if worse)
•Follow-up
? Repeat Ultrasound in 3-4 weeks (Perthes 10%)

[RR]>> Challenges for us in ED:
•not to ‘miss’ Septic Arthritis
•not to over-investigate those with benign condition of Transient Synovitis (“what’s the next test?”)
•not to close the door on other possibilities (open mind)

[cp] Risk stratifying SA vs TS is difficult, requires good thorough clinical assessment, collaboration with caregivers.
Tests have limited utility (especially blood tests in first day or two – can be falsely reassuring)

Protocols and flowcharts:
eg septic vs trauma vs other causes
Lower threshold for tests in younger children?

[all] Goodbye… send us a comment (or a tweet)

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