The limping child

Question 1

Common causes

Answer 1

osteomyelitis - septic arthritis - SUFE - toddler fracture - soft tissue injury

Question 2

Less common causes

Answer 2

NAI, tumour ,endocrinopathies

Question 3

0-3yrs

Answer 3

fractures
soft tissue injury 
septic arthritis 
osteomyelitis 
DDH 
NAI

Question 4

3-10yrs

Answer 4

trauma
septic arthritis
transient synovitis
perthes disease

Question 5

other causes of limping - age related pathologies

Answer 5

sickle cell
ST/spinal infection
metabolic, neoplasia, rheumatic, neuromuscular

Question 6

SUFE/SCFE stands for

Answer 6

slipped upper/capital femoral epiphysis

Question 7

What happens in SUFE

Answer 7

posteromedial displacement of proximal epiphysis in relation to the neck

Question 8

Where in the physis does SUFE occur?

Answer 8

through zone of hypertrophy

Question 9

Epidemiology of SUFE

Answer 9

age 9-16 (males 13.5, girls 12)
sex - 60% male
2-4/100 000

Question 10

Brief description of SUFE aetiology

Answer 10

increased load or weak physis or both

Question 11

idiopathic SUFE

Answer 11

adolescent, OBESITY, delayed bone age

Question 12

secondary SUFE

Answer 12

GH-1GF1 axis eg hypothyroid, hypogonadism, renal osteodystrophy, growth hormone therapy

Question 13

History - SUFE

Answer 13

pain in groin, thigh, knee
limp
trauma

Question 14

physical exam - SUFE

Answer 14

1. body habitus
2. externally rotated extremity
3. ROM limited by pain
4. obligatory external rotation in flexion
5. healing arthroscopy portals on ipsilateral knee

Question 15

Radiology - SUFE

Answer 15

• Trethowan/Klein’s line in lateral view
• widened physis
• knee x-rays normal
• obvious slip
• blanch sign of steel

Question 16

SUFE summary

Answer 16

older child 
hip/thigh/knee pain 
acute, acute on chronic
no infection 
limp 
external rotation gait 
knee flex into ER 
frog lateral x-ray 
percutaneous screw fixation

Question 17

4 infection and inflammations

Answer 17

septic arthritis
osteomyelitis
muscle abscess
transient synovitis

Question 18

History of infection and inflammation

Answer 18

limp - age, pain, temperature, malaise, loss of appetite, trauma, recent URTI/ear infection, pseudoparalysis

Question 19

Examination of infection/inflammation

Answer 19

look sick? limp? absolute refusal to weight bear?localise area, upper limb disuse

Question 20

ankle - infection/inflammation

Answer 20

distal tibia or joint line?

Question 21

knee - infection/inflammation

Answer 21

joint line or metaphyseal area

Question 22

hip - infection/inflammation

Answer 22

obligatory ER?

which movements hurt?

Question 23

Diff diagnosis - infection/inflammation

Answer 23

transient synovitis, osteomyelitis, septic arthritis

something else?…sarcoma, myositis, abscess, osteoma

Question 24

Initial investigations - infection/inflammation

Answer 24

temperature
x-ray
USS
bloods - CRP, ESR, WCC, CK, Cultures

Question 25

septic arthritis signs and symptoms

Answer 25

limping - pseudoparalysis - swollen, red joint - pain - temperature - refuse to move joint

Question 26

Most common location of septic arthritis

Answer 26

KNEE, then hip | ankle, shoulder, elbow, wrist, SI - rare

Question 27

5 routes of bacterial entry for septic arthritis

Answer 27

``` 1 - haematogenous 2 - dissemination from osteomyelitis 3 - soft tissue infection 4 - diagnostic/therapeutic measures 5 - penetrating trauma ```

Question 28

Investigations - septic arthritis

Answer 28

FBC, ESR, CRP, x-ray, blood cultures, USS, synovial fluid analysis eg WCC, gram stain and culture

Question 29

Presenting variables in septic arthritis

Answer 29

fever - ESR - CRP - ability to weight bear - serum WCC - joint space

Question 30

treatment of septic arthritis

Answer 30

aspiration arthroscopy arthrotomy antibiotics

Question 31

usual causative organism of septic arthritis

Answer 31

staph aureus

Question 32

osteomyelitis epidemiology

Answer 32

declining, 2-13/100 000 6 years old (10yrs pelvic) blunt trauma/recent infection

Question 33

3 factors for osteomyelitis pathogenesis

Answer 33

RARE IN ADULTS vascular anatomy - vascular loops and terminal branches cellular - inhibited phagocytosis trauma - 30%

Question 34

osteomyelitis symptoms

Answer 34

pain, fever, decreased ROM, decreased weight bearing

Question 35

investigations for osteomyelitis

Answer 35

ESR | CRP, WCC, Tc99 bone scan, MRI, CT, USS

Question 36

osteomyelitis surgery

Answer 36

``` aspiration for culture drain subperiosteal abscess drain joint sepsis debride dead tissue biopsy ```

Question 37

When is it transient synovitis?

Answer 37

limp, touch weight bear NOT THAT UNWELL joint infusion allow joint to be examined

Question 38

Concerning signs - neoplasm?

Answer 38

``` night pain stopping sports incidental trauma sweats and fatigue low Hb, atypical blood film and platelets ```