The Child With a Limp

Transcription

1 KID WITH A LIMP

2 Common in ED, common in Exams Differential diagnosis is very wide Most causes benign, but mustn't miss Septic arthritis Osteomyelitis Fractures / NAI SUFE (older, heavier children) The Child With a Limp Key is history and examination -Age of the child -Is the limp acute or chronic? -Is there fever or a history of fever? -Is there a history of trauma? -Examine the abdomen and lower limbs right to the toes Acute causes (all ages) - Contusion, Foot foreign body, fracture, osteomyelitis, septic arthritis, poor shoe fit, reactive arthritis, transient synovitis Chronic causes- Rheumatoid disease Preschool (1-5 years) Acute NAI Hand-foot-mouth disease Haemarthrosis (haemophillia) Henoch-schonlein purpura Fracture (Salter Harris I, Toddler's fracture) Septic Hip Chronic Cerebral palsy Dysplastic hip Discitis Leg length discrepancy Vertical Talus School age (5-12) Acute Fracture Myositis Chronic Perthe's disease Baker cyst Kohler disease Leukaemia Tethered cord Tarsal coalition

3 Adolescent (13-19) Acute Injury Tendonitis Chronic Chondromalacia of patella Gonococcal arthritis Herniated disc Overuse syndromes Scoliosis Slipped capital epiphysis Tethered cord Tumour Investigations WCC- Not particularly sensitive or specific CRP- Temperature of 38.5 or greater and elevated CRP 100% sensitive for septic arthritis, 87% specific in children with arthritis ESR- Reasonably sensitive, CRP probably better Blood Cultures Ultrasound -useful for finding an effusion and guiding aspiration Joint aspiration Radiology Plain Xrays- Indicated in most children with a limp Stress fractures, Perthe's disease, SCFE, Osteomyelitis, congenital abnormalities, bone tumours MRI- Avascular necrosis Nuclear medicine scans- Osteomyelitis, Perthe's disease Approach -Careful history and examination- abdomen to feet, examine gait -Xray area of concern -If febrile or history of fever, Investigate for septic arthritis -Bloods- if raised CRP or WCC --> Ultrasound and aspirate - If history of trauma, consider NAI

4 2. APPROACHES..

5 What s the BAD Stuff? Tumour Brain Bone Ewings Tumour Osteogenic Sarcoma Severe Infection Septic Arthritis Osteomyelitis Discitis Appendicitis Joint problem SCFE Referred pain Child Abuse

6 What if you miss a fracture, or something else?? EARLY FOLLOW-UP IS THE KEY

7 The Limping Child DIFFERENT APPROACHES

8 Think in terms of Age Groups In all ages - Trauma, infection(septic arthritis, OM), tumour, serum sickness 1-3 yo 4-10 yo yo Transient synovitis NAI Hip dysplasia Juvenile arthritis Neuromuscular disease Haemophilia Henoch-Schonlein purpura Transient synovitis Juvenile arthritis Perthe s disease Leg length Rheumatic fever Haemophilia Henoch-Shonlein purpura Slipped femoral epiphysis osteochondritis dessicans Gauchers disease Regional pain syndrome Dunn

9 Think in terms of Painful vs Painless PAINFULL Septic Arthritis Synovitis Malignancy Osteochondritis Trauma Referred pain NAI PAINLESS Things they re born with Hip dysplasias Unequal leg lengths Perthes Neuromuscular disorder

10 HERE S MY APPROACH

11 Where does it hurt? If they localise and it makes sense Is it? Traumatic Inflammatory Neoplastic Vascular Is it INFLAMMATION, FRACTURE/ DISLOCATION, NECROSIS, SEPTIC ARTHRITIS or a TUMOUR

12 When it doesn t make sense Is it central? Is it referred pain ie appendicitis? Is it coming from the back ie discitis?

13 There are so many things it can be Avascular necrosis hip, navicular, metatarsal head Apophysitis inflammation of the apophysis where tendons insert» calcaneal, tibial tuberosity Tendonitis infrapatella Discitis Growing pains

14 Is it in the back? Exclude Discitis! Pain in back! Radiation down legs! May develop abscess! Require antibiotics!

15 Is it localised to the foot? Avascular Necrosis NAVICULAR (Kohler s Disease) May be bilateral males 4-7 yo METATARSAL HEAD (Freiberg s Disease) usually 2nd metatarsal head

16 Is the pain in the hip? SCFE Legg Calves Perthes (avascular necrosis) Septic Arthritis

17 Slipped Capital Femoral Epiphysis! Ipsilateral many cases are bilateral! Older, heavier children! widening and irregular growth plate! pain on weight bearing, rotation, abduction, flexion!

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21 Slipped Capital Femoral Epiphysis! Klein s Line! If Xray normal, investigate further! bone scan! MRI!

22 Klein Line

23 Avascular Necrosis Idiopathic - Legg Calve Perthes 3-12 yo sepsis/trauma Limited movement

24 Avascular Necrosis

25 Septic Hip! Hip Flexed, externally rotated! Minimal movement! Inflammatory markers up! Xray may be normal, need ultrasound!

26 OK, so the pain is coming from the hip and its not SCFE or Avascular Necrosis SEPTIC HIP VS SYNOVITIS HOW TO TELL THEM APART

27 Septic arthritis vs synovitis Children with septic arthritis Higher fever Look sicker Severe pain CPR and ESR >20 Children with transient synovitis Children aren t as sick Post viral, trauma or allergic reaction

28 Who to ultrasound? My approach- Well child Child is well and Short Hx of the disease Treat with anti-inflammatories and watch. If doesn t get better then Ultrasound Ultrasound: >95% sensitive for fluid in the joint In the low risk patient, use it like a D-dimer if it s negative, the patient can go home. if it s positive, tap the joint.

29 Who to ultrasound? My approach- Unwell child If you think the child has a high chance of a septic hip, then ultrasound. If the ultrasound is positive- tap it. If negative, consider admission for 12 hours then re-scan.

30 ALWAYS CONSIDER NAI

31 KID WITH A LIMP