CCP: limping child

Question 1

normal gait

Answer 1

Walk without support by 12-15 months

Coordination with reciprocal arm swing by 2 years

Adult gait pattern attained by 8-10 years of age

Question 2

antalgic gait

Answer 2

from pain, less time in stance phase

Question 3

trendelenburg limp

Answer 3

stance phase body sway away from the weak hip abductor and swing phase droop on the weak side

Question 4

waddling gait

Answer 4

seen in b/l hip involvement or neuro problem

Question 5

stiff legged gait

Answer 5

knee extension and circumduction w/ pelvic elevation on affected side

Question 6

toe walking

Answer 6

habitual or due to muscle contractures, spasticity or (puncture wound on heel)

Question 7

steappage

Answer 7

difficulties w/ dorsiflexion of foot usu. Assoc. w/ peroneal neuropathies

Question 8

stooped gait

Answer 8

might indicate abdominal pathology

Question 9

developmental hip dysplasia

Answer 9

do Barlow: push back to move the femoral head out of the acetabulum

ortolani: Abduct the thigh, see if there is a substantial clunk back into the joint space

Age: 0-4 yrs.

Abnormal formation of hip joint

Cause: unknown - femoral head unstable w/in acetabulum

Incidence: 3-4 per 1,000

5-9X more common in females

-risk factors-genetic component, anything causing crowding of the fetus—large birth, oligohydraminos; female, first born, breech (esp. feet up)

Question 10

Toddler’s fracture

Answer 10

Def: Spiral fracture of tibia under age of 5 years

Common childhood fx

Sudden twisting of tibia

Often difficult to visualize on x-ray

Sx: pain, refusal to walk, minor swelling/warmth over site, pain with palpation

Tx: long-leg cast; heal within 3-4 wks

Question 11

Physeal fracture

Answer 11

“growth plate injury”

Age: 0-16 yrs girls; 0-18 yrs boys

Weakest area of growing bone

15% of all childhood fractures

Boys>girls

Salter-Harris classification: II is most common!

Question 12

stress fractures

Answer 12

Small crack in bone

Often from overuse, high impact sports

Weight bearing bones

2nd/3rd metatarsal most common

Age: 10-18 years

Sx: pain that increases with weight bearing activities, reduced with rest, tenderness to touch

Tx: rest, possible surgery depending on site

Question 13

which salter harris needs ORIF?

Answer 13

3-5

Question 14

osteomyelitis

Answer 14

Inflammation of bone marrow & adjacent bone

Age: all

Children: hematogenous spread

Location: metaphysis of long bones

Sx: local inflammation & fever, irritability, lethargy, bone tenderness & dec. ROM

Adults: subacute/chronic forms, secondary to open wounds

Tx: IV antibiotics (4-6 wks min.)

NOTE: staph aureus implicated in most pts. w/ hematogenous spread

Question 15

septic arthritis

Answer 15

Infection with the joint space (long bones don’t give you the swollen red joint, this will give you a swollen red joint)

Age: all

Bacterial, viral, (fungi or parasite)

Intense synovitis is the result of the inflammatory response

pathology: pathogen enters joint space through hematogenous spread or cut in the skin - leukocytes are released causing cytokine infiltration and destruction of cartilage –> acute monoarticular joint swelling

Sx: monoarticular, erythema, swelling, pain, dec. ROM

Knee most common
- however Septic arthritis of hip associated with highest risk of avascular necrosis

Ddx: aspiration and culture of synovial fluid

Tx: IV/PO antibiotics (4-6 wks) - Cefotaxamine

Question 16

transient/toxic synovitis

Answer 16

Sx: “irritable hip syndrome”: acute hip pain, dec. ROM

Hip in flexion/abduction & ext. rotation (relieves pressure on the capsule)

Age 0-10 yrs

Dx of exclusion

Cause: ? Infectious - no firm cause, findings of preceding URI

• about 30% of all non-traumatic childhood limps
• often post viral and goes to the hip

Tx: self limited (5-7 days), NSAIDS

Question 17

Legg-Calve-Perthes disease - LCPD

Answer 17

• insidious onset, happens more often in thin, active boys

aka Perthes disease or idiopathic osteonecrosis of the femoral head

Age 4-10 years

Lack of blood flow to femoral head=necrosis

Bone collapses—flattens

Blood supply returns after several months

New bone replaces old

Sx: slight limp, pain in knee, thigh or groin, limited ROM, leg length discrepancy

Tx: meds/reduce activity to dec. pain (children under 6); splinting or surgery to keep hip stable

Question 18

slipped capital femoral epiphysis - SCFE

Answer 18

Noninflammatory condition; femoral head displaced from femoral neck

presents w/ pain and inability to walk

Initially bilateral 20-40%, if unilateral, the other side slips in 30-60%

Age: 10-14 years

** Typically overweight boys: shear stress

***Association with endocrine disorders, 1° hypothyroid and HGH deficiency

Sx: insidious, complaint of pain in hip and limp

Tx: surgical stabilization w/ cntral screw or bone graft

Question 19

juvenile idiopathic arthritis - JIA

Answer 19

its hot red swollen joint

Chronic joint pain for min. of 6 wks & age onset t look sick

Question 20

lyme arthritis

Answer 20

2nd most frequent presenting sx (rash #1; erythema migrans)

May occur months or years after infection

Sx: Episodic initially
- 2/3 monoarthritis of knee

Age: 10-18 yrs.

Cause: Borrelia burgdorferi transmitted by tick

Prevalence: US–northeast, midwest, south & west costal areas

Boys=girls

Tx: IV/PO antibiotics, NSAIDs

GIVES clue of something you need to pay att’n to outside of the joint

Question 21

Gonococcal arthritis

Answer 21

Septic arthritis of the joint caused by gonococcus

Age: 10-18 yrs (sexually active) – only shows up if they are sexually active!!!! not that common, though will be on bugs

Sx: same as septic arthritis

Dx/Tx: aspiration of joint fluid; IV/PO antibiotics (at least 1 week)

Question 22

Growing pains

Answer 22

Intermittent nonarticular pains in childhood

Diagnosis of exclusion

Sx: Typically pain at night & limited to calf, thigh or shin

• pain is short-lived and resolved with heat, massage, or mild analgesics
• Pain free during the day

Cause: unknown

Tx: reassurance to parents/child

Question 23

organisms involved in septic arthritis

Answer 23

The most common causative organism is Staphylococcus aureus then nongroup A beta-hemolytic streptococci

Neonate
Group B Streptococcus, Staphlococcus aureus, gram-negative bacilli

Infant (1-3 m.o.)
Streptococcus sp., Staphlococcus sp., Haemophilius influenza

Child
S. aureus, S. pneumoniae, group A Streptococcus

Adolescent
As above plus Neisseria gonorrhoeae

Sickle cell disease
As above plus Salmonella

Puncture wound
As above plus Pseudomonas