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Year 3 - Musculoskeletal > The limping child > Flashcards

The limping child Flashcards

1
Q

Common causes of limp in a child?

A 
Septic arthritis
Osteomyelitis
Perthes
SUFE
Toddlers fracture
Soft tissue injury
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2
Q

Less common causes of limp in a child?

A

NAI
Tumour
Endocrinopathies

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3
Q

Causes of limp in a child (0-3yrs)?

A 
Septic arthritis
Osteomyelitis
DDH 
Toddlers fracture
Soft tissue injury
NAI
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4
Q

Causes of limp in a child (3-10yrs)?

A

Trauma ( bone/ ST)
Septic arthritis
Transient synovitis
Perthes disease

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5
Q

Causes of limp in a child (11-15yrs)?

A 
Trauma (stress)
Septic arthritis
Osteomyelitis
SUFE 
Perthes
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6
Q

What is SUFE/SCFE?

A

A slipped upper/capital femoral epiphysis

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7
Q

Define SCFE/SUFE (Slipped upper/capital femoral epiphysis)?

A

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

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8
Q

Epidemiology of SUFE/SCFE (Slipped upper/capital femoral epiphysis)?

A

> Age range: 9-16 yrs

  • males, mean = 13.5 yrs
  • females, mean = 12.0 yrs

> Sex: males 60% vs females 40%

> Incidence: 2-4/100,000
(up to 10/100,000 in USA)

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9
Q

Aetiology of SUFE/SCFE (Slipped upper/capital femoral epiphysis)?

A

Increased load or weak physis or both:

> Idiopathic:

  • Adolescence
  • Delayed bone age
  • Increased weight

> Secondary to underlying disorder (GH-IGF axis):

  • hypothyroidism
  • hypogonadism
  • renal osteodystrophy
  • growth hormone therapy
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10
Q

Obesity and SCFE?

A

Incidence increased 2.5 fold to 3.78 per 100,000

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11
Q

SUFE/SCFE (Slipped upper/capital femoral epiphysis) - History?

A

Pain- groin/ thigh/ knee
Limp
Trauma
ER deformity

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12
Q

SUFE/SCFE (Slipped upper/capital femoral epiphysis) - Physical exam?

A

> Body habitus
Externally rotated extremity
Obligatory external rotation in flexion
ROM limited by pain
Healing arthroscopy portals on ipsilateral knee

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13
Q

SUFE/SCFE (Slipped upper/capital femoral epiphysis) - Radiology?

A 
> Trethowan’s / Klein’s line
> More obvious on lateral view
> Widened physis
> Horizontal physis (flexion contracture)
> Knee x-rays are usually normal!
> Blanch sign of Steel
> Or just an obvious slip
> Frog lateral x-ray

If x-ray positive should be referred for urgent review

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14
Q

SUFE/SCFE (Slipped upper/capital femoral epiphysis) - general presentation?

A 
> Older child (Rare <10yrs)
> Hip/thigh/knee pain 
> Can be either acute or chronic 
> Limp, external rotation gait 
> ROM limited by pain 
> No signs of infection
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15
Q

Infective/inflammative causes of limping in a child?

A

Septic arthritis
Osteomyelitis
Transient synovitis
Muscle abscess

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16
Q

Infective/inflammative causes of limping in a child - History?

A 
> Limp (age dependent)
> Pain
> General malaise/ loss of appetite/ listless
> Temperature
> Recent URTI/ ear infections
> Trauma
> Pseudoparalysis
> Listen to the parent, they are usually right
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17
Q

Infective/inflammative causes of limping in a child - Examination?

A 
> Do they look sick?
> Limp?
> Absolute refusal to weight bear?
> Localising area- ankle/ tibia/ knee/ thigh/ hip
> Hip - obligatory ER?
- which movements hurt?
> Ankle- distal tibia or joint line?
> Knee- joint line or metaphyseal area?
> Upper limb disuse
18
Q 
Differential Diagnosis (pre-investigation)
What would make you put this at the top of your list in infective/inflammatory causes of limping in a child?
A

Most common:
> Transient synovitis
> Osteomyelitis
> Septic arthritis

Other:
> Sarcoma		
> Myositis
> Osteoid osteoma
> Abscess
> Inflammatory arthropathy
19
Q

Infective/inflammative causes of limping in a child - Initial investigations?

A

> Temperature

> X-ray?

> USS (can indicate joint involvement but cannot separate infection from inflammation)

> Bloods:

  • WCC
  • CRP
  • ESR
  • CK
  • Cultures
20
Q

Septic arthritis presentation in children?

A 
Limping
Pseudoparalysis
Swollen, red joint
Refusal to move joint
Pain
Temperature
21
Q

Most common site of septic arthritis in children?

A 
> Knee = 37%
> Hip = 33%
> Ankle = 13%
> Shoulder = 8%
> Elbow = 5%
> Wrist = 3%
> Sacroiliac = 1%
22
Q

Septic arthritis child - routes of entry?

A

1) Hematogenous
2) Dissemination from osteomyelitis
3) Soft tissue infection
4) Diagnostic or therapeutic procedure
5) Penetration damage from puncture or trauma

23
Q

Septic arthritis child - Investigations?

A

> FBC & differential

> Raised WCC >12,000/mm3

> ESR >50mm/hr

> CRP

> Blood cultures
+ve in 30-50%

> Xray

> ULTRASOUND- ALWAYS BE PRESENT**

> Synovial fluid

  • WCC >50,000/mm3
  • Gram stain
  • Culture
24
Q

Septic arthritis child - Investigations?

A

> FBC & differential

> Raised WCC >12,000/mm3

> ESR >50mm/hr

> CRP

> Blood cultures
+ve in 30-50%

> Xray

> ULTRASOUND- ALWAYS BE PRESENT**

> Synovial fluid (Best)

  • WCC >50,000/mm3
  • Gram stain
  • Culture
25
Q

Septic arthritis child - Treatment?

A

> Typically staph aureus infection

> Aspiration

> Arthroscopy - Knee/ shoulder/ankle

> Arthrotomy

> ANTIBIOTICS:

  • IV for how long? Empirically 2 weeks
  • Continue orally for another 4 weeks
26
Q

Osteomyelitis child - Epidemiology?

A

> 2-13/100,000 (up to 200/100,000 in developing countries)

> Mean age 6 years (10yrs pelvic)

> Risk factors (1/3):

  • Blunt trauma
  • Recent infection
27
Q

Pathogenesis of osteomyelitis child?

A

3 factors:

1) Vascular anatomy
- Vascular loops
- Terminal branches

2) Cellular anatomy
- Inhibited phagocytosis (low pO2)

3) Trauma
A factor in 30%?

28
Q

Osteomyelitis child - Symptoms?

A 
> Pain
> Localised sign/symptoms
> Fever
> Reduced ROM
> Reduced weight-bearing
29
Q

Indication for surgery in osteomyelitis child?

A

> Aspiration for culture
Drainage of subperiosteal abscess
Drainage of joint sepsis
Debridement of dead tissue

> Biopsy in equivocal cases

30
Q

Transient synovitis child- Presentation?

A 
> Limping, often touch weight bearing
> Slightly unwell
> History of viral infection eg URTI/ ear
> Apyrexial
> Allowing joint to be examined
> Low CRP, normal WCC
> May have joint infusion
> Not that unwell
31
Q

Why are septic arthritis treated so aggressively with antibiotics?

A

If not infection can reoccur in the future e.g. a year later

32
Q

What can indicate bone neoplasm in child?

A 
> Night pain
> Often incidental trauma
> Stops doing sport/ going out
> Sweats and fatigue
> Abnormal blood results- low Hb, atypical blood film, atypical platelets
33
Q

Why is advantageous to use MRI in osetomyeltits?

A

X-Ray changes are late usually, 2-3 weeks after.

34
Q

In osteomyelitis what does subperiosteal abscess usually indicate?

A

A worse outcome

35
Q

How is osteomyelitis initially managed?

A

1) Try 48hrs of antibiotics

2) No improvement drainage is required

36
Q

What is the most likely organism involved in osteomyelitis, name a few more it could be?

A

1) S. aureus
2) S. epidermis
3) Strep. pneumoniae
4) S. pyogenes

37
Q

Diagnositics in osteomyelitis?

A

1) Radiography:
- Low sensitivity
- High specificity
- High positive predictive value

2) MRI:
- High sensitivity
- High specificity
- High positive predictive value

3) Tc99 bone scan:

38
Q

Diagnositics imaging in osteomyelitis?

A

1) Radiography:
- Low sensitivity
- High specificity
- High positive predictive value

2) MRI:
- High sensitivity
- High specificity
- High positive predictive value

3) Tc99 bone scan:
- Medium-high sensitivity
- medium-High specificity
- medium-High positive predictive value

4) US:
- Medium sensitivity
- Medium specificity
- High positive predictive value

39
Q

Inflammatory markers in Osteomyelitis?

A

> ESR
CRP
WCC

40
Q

What is the importance of growth plates having high vasculature in osteomyelitis?

A

Increases the risk

Year 3 - Musculoskeletal (30 decks)

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