Limping

Question 1

Antalgic

Answer 1

• Painful
• Involved leg is shorter

Question 2

Trendelenburg

Answer 2

• Normal standing
• Imbalance (front and back)

Question 3

Duck gait

Answer 3

Bilateral gluteus weakness

Question 4

Toe walking

Answer 4

• Kids that recently started walking
• Habit, Neuromuscular, Short achilles
• Checked in older than 3yr olds

Question 5

Approach (Sudden or chronic)

Answer 5

Sudden:
- Infection
- Trauma
- Better prognosis
Chronic:
- Neuromuscular, Metabolic
- Malignancy, Leukemia, Neuroblastoma

Question 6

Common in kids

Answer 6

• Trauma
• Immune complex arthritis after infection (Henoch, Rheumatic Fever, EBV)
• Transient Synovitis of hip
• Arthritis, Arthralgia, Serum sickness (after cephalosporines) are mostly systemic

Question 7

Other complaints

Answer 7

• Fever & weight loss: Malignancy, infection
  Osteomyelitis & Septic arthritis are emergencies
• Long fevers: Malignancy
• Specific lesions: Dermatomyositis, JRA, Lupus

Question 8

Limping secondary to pain

Answer 8

Pain is in:
Organs, stomach, hip, hip joint

Question 9

Painful limping (1-3yr old)

Answer 9

• Septic arthritis
• Osteomyelitis
• Transient Synovitis
• Hidden trauma
• Disc inflammation
• Malignancy

Question 10

Painless limping (1-3yrs)

Answer 10

• Hip dysplasia (DDH)
• Neuromuscular disorder
• Cerebral palsy
• Short steps (pressure off the involved leg)

Question 11

Painful limping (3-10yrs)

Answer 11

1-3yrs
+
- Myositis
- Rheumatic disorders
- JRA

Question 12

Painless limping (3-10yrs)

Answer 12

1-3yrs
+
- Legg-Calvé-Perthes (Avascular femur head necrosis)
- Duchenne muscular dystrophy

Question 13

Painful (>11)

Answer 13

• Septic arthritis
• Osteomyelitis
• Myositis
• Trauma
• Malignancy
• Rheumatic disorders
• Slipped capital femoral epiphysis (SCFE)
  _{acute & unstable}

Question 14

Painless (>11)

Answer 14

• Slipped capital femoral epiphysis (SCFE)
  _{chronic & stable}
• Hip dysplasia (DDH)
• Acetabulum dysplasia
• Short steps

Question 15

DDx

Answer 15

• Infectious
• Orthopedic
• Inflammatory
• Neoplasm
• Neuromuscular
• Other

Question 16

Infectious ddx

Answer 16

• Disc inflammation
• Osteomyelitis, Septic arthritis
• Myositis
• Cellulitis, arthralgia or arthritis after infection

Question 17

Orthopedic ddx

Answer 17

• SCFE
• DDH
• Avascular necrosis

Question 18

Inflammatory ddx

Answer 18

• Transient Myositis
• SLE, JRA, Dermatomyositis, Henoch

Question 19

Neoplasm ddx

Answer 19

• Benign Osteochondroma, Osteoma
• Osteogenic sarcoma
• Leukemia, Neuroblastoma (Fatigue, weight loss, fever)
• Metastasis

Question 20

Neuromuscular ddx

Answer 20

• Duchenne (Gowers’s sign)
• Guillain-barré
• Tick borne paralysis
• Weak cerebral palsy

Question 21

Reactive arthritis

Answer 21

• Aseptic
• Infection in another place
• Acute Polyarthritis/Tenosynovitis
• Immune complex

Question 22

Causes of reactive arthritis

Answer 22

• Meningococcemia
• Gonococcemia
• Hepatitis
  Immune-complex-causing infections:
  Yersinia, Salmonella, Campylobacter, Shigella, Ureoplasma, Mycoplasma, Chlamydia

Question 23

Reiter syndrome triad

Answer 23

1- Non-gonococcal Urethritis
2- Conjunctivitis
3- Reactive arthritis

Question 24

Joint swelling

Answer 24

• Hematogen: 3 days, microbial
• Immune reaction: 1w, no microbes
• Hip IAP: Avascular epiphysis & femor head necrosis, EMERGENCY

Question 25

Gonococcal Septic arthritis

Answer 25

- With DGI, most common cause of poly/single arthritis in teens - Following bacteremia (Fever, chills, Migrating Polyarthritis) - DGI women 4×, period, 2nd&3rd trimester - Reiter can mimic DGI - **Reiter doesn't respond to antibiotics**

Question 26

Septic arthritis treatment duration

Answer 26

- S. Aureus: **4-6w** - H. Influenza B, Strep A, Pneumococcus: **2-3w, 10-14d** - Gonococcus: **7-10d** - Joint Aspiration beginning or 3-5d later

Question 27

Septic arthritis surgery indications

Answer 27

1- Fluid more than 7d 2- Any hip septic arthritis 3- Most shoulder arthritis

Question 28

Good prognosis (Septic arthritis)

Answer 28

- Systemic Ab against Staph & Haemophilus - Rest, Immobilization, Not putting weight - Recovery after 72h if quick diagnosis

Question 29

Bad prognosis

Answer 29

- Under 6m old - S. Aureus, Gr -, Fungus - Hip involvement - Osteomyelitis & Epiphysis destruction - Late treatment (5-7d) - If fast diagnosis no disability

Question 30

Other limping ddx

Answer 30

1- Stomach, substernal, testicular pain 2- Sickle cell 3- Femur head avascular necrosis 4- Hemophilia (Hemarthrosis)