Case 9 - acute onset limp Flashcards
(26 cards)
Essential areas to examine in a child with leg pain
- Abdomen -?appendicits, hepatosplenomegaly -?malig
- Axilla and groin - lympahdenoapthy - ?malig
- Hips - referred pain
- Scrotum - testicular torsion
- Spine - referred pain
Cause of acute painful limp in 1-3 years
- Developmental dysplasia of hip
- Septic arthiritis or osteomyelitis
- Fracture or soft tissue injury
- Malignancy - leukaemia or neuroblastoma
Cause of acute painful limp in aged 3-10
- Transient synovitis/irritable hip
- Septic arthiritis/osteomyelitis
- Perthes disease
- Fracture or soft tissue injury
- Rheum disease eg Juvenile idiopathic arthritis
- Malignancy - leukaemia
Causes of acute painful hip aged 10-15
- Slipped under femoral epiphysis
- Septic arthritis or osteomyelitis
- Perthes disease
- Fracture/soft tissue injury
- Rheum disease eg JIA
- Malignancy - bone tumours
Imaging for acutely painful limp
- Hip x-ray - AP and frog leg lateral
- Kleins line drawn from superior border of femoral neck and should intersect growth plate
Criteria for septic arthirtis - name
Kocher
Kocher criteria
- Fever greater than 38.5
- Inability to weight bear
- CRP more than 20
- WCC more than 12
Presence of number of factors influence risk of septic arthritis
Invetsigations for septic arthiritis
- Blood culture
- CRP
Imaging:
* US hip - joint effusion
* X-ray hip - baseline, can sometimes see soft tissue swelling
Common bacteral cause of septic arthirits
- Staph aureus
Management of septic arthiritis
- Aspirate joint - send for gram stain, crystal microscopy, culture and sensitivity
- Emperical IV abx - usually for 3-6 weels
- Surgical drainage and washout - if needed, insert PICC line for abx whilst asleep
When do children have mature, reproducible rhytmic gait?
Not until after 7 years of age
Other causes of limp based on system
- Haem: sickle cell
- Infective - osteomyelitis
- Metabolic - rickets
- Neurmusc - cerebral palsy, muscular dystrophy
- Primary anatmical - limb length discrepency
- Ortho - osteochondritis dessicans, Osgood Schlatter
- Lower abdo - appendicitis, torsion
Transient synovitis cause
- Recent viral URTI
- –> inflammation synovial membrane
- Typically no fever (if yes think septic)
Management of transient synovitis
- Symptomatic
- Analgesia
- Ensure ruled out septic
- Can be managed in primary care if aged 3-9 and present for <48hrs and well - safety net
- Usually resolves within 1-2 weeks
Perthes disease - what is it
- Avascular necrosis of femoral head
- Affects epiphysis
- Often idiopathic cause - unknown
- Over time there is revascularisation or neo –> healing
Main complication of perthes
- Soft and deformed femoral head –> early OA needing total hip replacement
Management of perthes disease
If young and less severe:
Conservative -
* Bed rest
* Traction
* Crutches
* Analgesia
Physiotherapy
Regular x-rays to assess healing
Surgery - if severe, older or those not healing
Slipped under femoral epiphysis - what is it
- Head of femur displaced along growth plate
- More common in obese children and boys
- History of minor trauma - disproportionate to pain
- Undergoing growth spurt
Examination of SUFE
- Prefer to keep hip in external rotation
- Limited movement of hip, esp internal rotation
Management of SUFE
- Surgery - return femoral head to correct position and fix into place to prevent slip
Developmental dysplasia of hip - what is it?
- Structural abnormality - abnormal developmet of fetal bones
- = subluxation and dislocation
- Usually picked up in newborn screen or later with hip assymetry, reduced RM or limp
RF for DDH
- First degree FH
- Breech from 36 onwards
- Breech at birth if 28 weeks onwards
- Multiple pregnancy
NIPE findings suggestive of DDH
- Different leg lengths
- Restricted hip abduction
- Significant bilatral restricted abduction
- Difference in knee level when hips flexed
- Clunking of hips on Ortolani and Barlow
Inv DDH
US hips
