The Acute Limping Child

Question 1

Causes of limp in 0-3 years old

Answer 1

septic arthritis 
osteomyelitis
toddler's fracture
DDH
NAI
soft tissue injury

Question 2

What does NAI stand for?

Answer 2

Non-accidental injury

Question 3

Causes of limp in 3-10 years old

Answer 3

Trauma - bone/ST
Septic arthritis
Perthes disease
Transient synovitis

Question 4

Causes of limp in 11-15 years old

Answer 4

Trauma - stress
Septic arthritis 
osteomyelitis 
SUFE
Perthes

Question 5

Causes of limp in children

Answer 5

septic arthritis
osteomyelitis 
Perthes
SUFE
Toddler's fracture
Soft tissue injury 
NAI 
Tumour
endocrinopathies 
sickle cell 
ST/spine infection 
metabolic disease 
neoplastic 
anatomical 
rheumatological 
neuromuscular

Question 6

What does SCFE/SUFE stand for?

Answer 6

Slipped upper/capital femoral epiphysis

Question 7

Pathology of SCFE/SUFE

Answer 7

Posteriomedial displacement of the proximal femoral epiphysis in relation to the neck

Question 8

What age range can get SUFE/SCFE?

Answer 8

9-16 years; so older children

Question 9

What gender mostly gets SUFE/SCFE?

Answer 9

M > F, 60:40

Question 10

Causes of SUFE/SCFE

Answer 10

Idiopathic
- adolescence 
- delayed bone age
- increased weight 
Secondary to underlying disorder
- hypothyroidism 
- hypogonadism 
- renal osteodystrophy 
- growth hormone therapy

Question 11

What does SUFE/SCFE have a relation to?

Answer 11

Obesity

Question 12

Presentation of SUFE/SCFE

Answer 12

Pain - groin/thigh/knee
Limp 
Trauma
ER deformity + on flexion + on gait (externally rotated extremity)
ROM limited by pain

Question 13

Treatment of SUFE/SCFE

Answer 13

Percutaneous screw fixation

Question 14

Who is SUFE/SCFE most commonly seen in?

Answer 14

Adolescent obese males

Question 15

A presenting history which would flag a concern or would help to exclude it would include;

Answer 15

limp (age dependent)
pain 
general malaise/loss of apetite/listless 
Temperature 
Recent UTI/ear infections
trauma
pseudoparalysis

Question 16

Presentation of septic arthritis in children

Answer 16

Limping
ability to weight bear
pseudoparalysis
swollen, red joint
refusal to move joint 
pain 
temperature

Question 17

Routes of infection of septic arthritis

Answer 17

Haematogenous
Dissemination of osteomyelitis 
Spread from adjacent soft tissue infections
diagnostic or therapeutic measures
penetrating damage by puncture of trauma

Question 18

investigations of septic arthritis in children

Answer 18

FBC + differential - WCC > 12,000
ESR > 50 
CRP 
Blood cultures (+ve 30-50%)
Xray 
USS
Synovial fluid (WCC > 50,000, gram stain, culture)

Question 19

Treatment of septic arthritis

Answer 19

Aspiration
Arthroscopy
Arthrotomy
Antibiotics

Question 20

Mean age of osteomyelitis in children

Answer 20

6 y/o

10 y/o pelvis

Question 21

Risk factors for osteomyelitis

Answer 21

blunt trauma

recent infection

Question 22

Presentation of osteomyelitis

Answer 22

pain 
localised signs/symptoms
fever
reduced ROM
reduced weight bearing

Question 23

Investigations of osteomyelitis

Answer 23

radiography
Tc99 bone scan 
MRI
CT 
USS

Question 24

Most common site of osteomyelitis in children

Answer 24

femur

Question 25

Treatment of osteomyelitis

Answer 25

Antibiotics | Surgery

Question 26

Presentation of transient synovitis in children

Answer 26

``` NOT THAT UNWELL limping often touch weight bearing history of viral infection - UTI/ear Apyrexial - no fever low CRP Normal WCC May have joint effusion ```

Question 27

Definition of arthalgia

Answer 27

joint pain

Question 28

What is transient synovitis?

Answer 28

Transient inflammation of the synovium of the hip causing arthalgia and arthritis. Most common cause of acute hip pain in children aged 3-10 years

Question 29

3 factors of the pathogenesis of Albright osteodystrophy

Answer 29

1. vascular anatomy - vascular loops, terminal branches 2. cellular anatomy - inhibited phagocytosis (low PO2) 3. Trauma

Question 30

Features that raise concern of neoplasm

Answer 30

``` night pain often incidental trauma stop doing sport/going out sweats and fatigue Abnormal blood results - low Hb, atypical blood film, atypical platelets ```

Question 31

Where does Perthes Disease affect?

Answer 31

The hip

Question 32

Pathology of perthes disease

Answer 32

occurs when blood supply to the rounded head of the femur is temporarily disrupted and this leads to a vascular necrosis, where the bone cells die

Question 33

Presentation of perthes disease

Answer 33

``` Pain - in hip or groin - referred to thigh or knee - worsens with activity - relieved by rest painful muscle spasms ```

Question 34

Treatment of perthes disease

Answer 34

``` observation anti-inflammatory mediators limiting activity physio casting and bracing possibly surgery ```