What are the common causes of acute limping child?
- Septic arthritis
- Toddlers fracture
- Soft tissue injury
Less common are:
What does SUFE stand for?
Slipped upper / capital femoral epiphysis
What is the definition of SUFE?
Posteromedial displacement of the proximal femoral epiphysis in relation to the neck
Where in the physis does the SUFE occur in the physis?
–Through the (widened) zone of hypertrophy in the physis
What is the epidaemiology of the disease?
Males mean is 13/5 years
Females is 12 years
What are the causes of SUFE?
Increased load, weak physis or both
- Delayed bone age
- Increased weight
–Secondary to underlying disorder (GH-IGF axis)
- renal osteodystrophy
- growth hormone therapy
What are the findings on physical examination of SUFE?
External rotation of extremity
ROM limited by pain
What are the findings of SUFE on radiology?
- Trethowan’s / Klein’s line - line parallel to the upper edge of the femoral neck
- More obvious on lateral view
- Widened physis
- Horizontal physis (flexion contracture)
- Knee x-rays are usually normal!
- Blanch sign of Steel - this is when there is a crescentic shaped area of increased density overlying the metaphysis adjacent to the physis - Increased density is caused by overlapping of the femoral neck and the posteriorly displaced capital epiphysis
Or just an obvious slip
(Klein’s line and the physis is widened and horizontal)
What type of X-ray is necessary for SUFE?
Frog lateral X-ray
- Older child (rare but occasionally <10 yrs)
- Hip / thigh/ knee pain
- Acute, acute on chronic
- No clinical indicators of infection
- Limp, external rotation gait, knee flex into ER
- Frog lateral x-ray
- If x-ray positive should be referred for urgent review
What are the infections that can cause a limp in a child?
What presenting history might suggest infection?
- Limp (age dependent)
- General malaise/ loss of appetite/ listless
- Recent URTI/ ear infections
- Listen to the parent, they are usually right
On examination the child may look sick, limp, refusal to weight bear, localising area, movements that hurt more than others
What are the initial investigations for a limping child?
What tests can you use CK for?
Acute kidney injury
What is the presenation for septic arthritis?
- Swollen, red joint
- Refusal to move joint
What are the most common places for septic arthritis?
Most commonly in the hip and the knee
What are the routes by which bacteria can enter the joint?
Dissemination from osteomyelitis
Spread from adjacent soft tissue infection
Diagostic or therapeutic measures
Penetrating damage by punture or trauma
What is the investigation for septic arthritis?
•FBC & differential
–Raised WCC >12,000/mm3
- ESR >50mm/hr
- Blood cultures
– +ve in 30-50%
- ULTRASOUND- ALWAYS BE PRESENT
- Synovial fluid
What organism is typically responsible for septic arthritis?
What is the treatment for septic arthritis?
- Typically staph aureus infection
What is the mean age for osteomyelitis?
What are the risk factors for osteomyelitis?
What are the most common places for osteomyelitis?
What are the presenting features of osteomyelitis?
Reduced range of movement
Reduced weight bearing
What are the blood investigations for osteomyelitis?
What are the imaging modalities for osteomyelitis?
Radiography (poor sensitivity)
Tc99 bone scan
What is the most likely causative organism for osteomyelitis?
What are indications for surgery in osteomyelitis?
- Aspiration for culture
- Drainage of subperiosteal abscess
- Drainage of joint sepsis
- Debridement of dead tissue
- Biopsy in equivocal cases
What is the clinical presentation of transient synovitis?
- Limping, often touch weight bearing
- Slightly unwell
- History of viral infection eg URTI/ ear
- Allowing joint to be examined
What are the blood values of CRP and WCC for transient synovitis?