Andrea Marmor, MD Associate Clinical Professor, Pediatrics UCSF San Francisco General Hospital

Size: px

Start display at page:

Download "Andrea Marmor, MD Associate Clinical Professor, Pediatrics UCSF San Francisco General Hospital"

Opal Pierce
6 years ago
Views:

1 Andrea Marmor, MD Associate Clinical Professor, Pediatrics UCSF San Francisco General Hospital

2 Carambola is a 16 mo old girl brought to the ED for crying nonstop She has been not herself for about a week, refusing to walk, always wants to be held, screams with diaper changes, and trouble sleeping This evening, unable to fall asleep, so brought to ED

3 T= 38, P 160 (crying), R 32, BP 100/60 Well-appearing, consolable when held, nontoxic, supple neck Full rotation at knee, ankle, hip No tenderness or swelling of joints or bones Screams when put on back on table, and when manipulating legs;? tenderness over middle of spine Normal neuro exam

4 A. CBC, CRP, ESR B. AP and frog-leg view of hips C. Aspiration of hip D. Plain films and MRI of spine E. Lumbar puncture

5 MRI lumbar spine: diffuse bony edema of L4 and L5, with enhancement of the disc. T1 +contrast (left) and T2 (right). (from Arthurs et al, 2009)

6 Inflammatory/infectious etiology Dx commonly delayed Refusal to walk/sit/limp/crying > back pain Recent 18 year series (Fernandez, 2000) Mean age: 2.8 years Only 28% febrile Mean days of symptoms = 22 Fernandez, Pediatrics, 2000

7 Diagnostic pearls: Inflammatory markers poor predictors (may be normal) MRI best sensitivity/specificity 76% seen on plain film (narrowing of 2-4 wks) Consider scintigraphy sensitive but non-specific Management Blood cultures rarely positive Parenteral antibiotics (vanco, clinda) recommended In some series, patients did well without antibiotics Follow ESR/CRP

8 Jujube is a 4 week old boy brought in for crying nonstop Seen by PCP yesterday, told it was colic Not feeding well, and seems to cry more with the 5 S s. PMH: ex- 32 weeker, got a few days of antibiotics after birth, no other illnesses

9 T= 36.0, P 160 (crying), R 50, BP 90/50 Very fussy, inconsolable Flat fontanelle, well-perfused, no rash Slight erythema/warmth/swelling of left calf

10 NEXT STEPS? You obtain blood cultures, a CRP/ESR and an LP Plain film of left leg: Osteomyelitis of the tibia

11 A. Clindamycin B. Nafcillin C. Vancomycin D. Ampicillin+cefotaxime E. Vancomycin+cefotaxime

12 Hematogenous most likely cause in pediatrics Multifocal disease > in neonates/s. aureus Diagnosis: CBC: most helpful to R/O other conditions ESR/CRP: variable sensitivity (normal reassuring if low suspicion) Blood cultures: poor sensitivity, but helpful if + Plain films: may show findings earlier in neonates MRI: 97% sensitive/92% specific

13 Neonatal: S. aureus (MRSA), E, Coli, GBS (late-onset) Vancomycin and cefotaxime Infants/kids: S. aureus (MRSA), GAS: vancomycin Kingella? Add cefazolin Sickle cell? Add ceftriaxone

14 Cherimoya is a 6 mo old girl, brought in for crying nonstop Usually consolable when held, but that seems to make her cry more Dad notes that she seems to be breathing fast, but otherwise has been afebrile, eating well, and no other symptoms No PCP identified, but has been healthy

15 T 37.3, P 130, R 45, O2 sat 99% Well-nourished, comfortably tachypneic, no rashes/bruises, smiles and coos when sitting in dad s lap Screams when you pick her up, and will not lie on her back You are able to range all of the limbs without difficulty, the rest of the exam is normal

16 A. CBC, CRP and ESR B. MRI of the spine C. Chest Xray D. Lumbar puncture

18 Virtually pathognomonic for abuse Can be missed on plain films Let radiologist know what you are looking for

19 Thoracic cage, sternum, scapula, spine Metaphyseal corner lesions (MCL)/bucket handle fractures

$symptoms Imaging: Multiple views may be necessary Consider child abuse if: Multiple fractures, < 12 mo, midshaft$

20 TODDLERS FRACTURE Consider in infant/toddler with limp May be due to unrecognized trauma When stable, minimal symptoms Imaging: Multiple views may be necessary Consider child abuse if: Multiple fractures, < 12 mo, midshaft fracture

21 13 yo Rambutan has been limping for 3 mo Complaining of L knee pain 4 months ago, but able to play soccer Exam: Well-appearing, mildly obese male, Tanner IV, VS WNL for age

22 Lies with L leg flexed and externally rotated Obligate external rotation on flexion of L hip Internal rotation of L hip severely limited Knee exam normal

25 Presents insidiously: groin, thigh, knee pain or limp Usually idiopathic, 20% bilateral Average age 11.2 in girls/12.7 in boys decreasing? More common in Boys (60%) Obesity Black/Hispanic/Asian (4x/2.5x/1.6x) > Caucasian Diagnosis: AP and frog-leg views, bilateral Management: surgical Stable (90%) = able to weight bear -> urgent referral Unstable = NWB immediately (20-50% risk of osteonecrosis)

26 AP view Frog s Leg view

27 Avascular necrosis of the femoral head Ischemia -> collapse -> remodeling More common in boys, age 4-8 at onset Etiology: unknown (trauma, radiation, steroids may also cause ANFH) Treatment: Immediate orthopedic referral 75% of cases resolve spontaneously with remodeling of femoral head

28 Pitaya is a 15 yo girl complaining of R knee pain for 2 months Pain is intermittent, improves at night Told she has growing pains No specific trauma, but has been unable to play basketball Exam: tender mass distal R thigh, otherwise normal

29 A. Age 15 B. Improves at night C. Unable to play basketball D. Mass/tenderness on exam E. All of the above

30 A. Age 15 B. Improves at night C. Unable to play basketball D. Mass/tenderness on exam E. All of the above Growing pains occur in younger kids, ONLY at night, and do not interfere with activity

31 Codman s triangle Calcified soft tissue mass Osteosarcoma

32 Osteosarcoma > Ewing s Peak age: 13-16, boys:girls = 1.5:1 Clinical: Intermittent pain, improves at night Mass in 30-40% Long bones most frequently involved Constitutional symptoms are rare Delay in dx common: average 2-3 mo

33 Osteosarcoma: sunburst reaction Ewing s Sarcoma: Onion-skinning Pelvis> long bones

34 Kiwano is a 5 year old boy with 1 week of knee pain and limp Maybe fell playing soccer last week: not getting better, knee seems swollen No previous bone/joint problems

35 T38.4, non-toxic, pain with weight on R leg R leg: knee is mildly erythemetous, warm, with decreased extension/flexion Full ROM hip and ankle Labs: WBC =12,000, ESR = 25, CRP =1 mg/dl

36 A. Yes B. No

TS = Self-limited inflammation of hip/knee Differentiation from septic arthritis? Kocher criteria: WBC > 12, ESR > 40, CRP > 2mg/dL, temp >38.5, unable to bear weight Validation?

37 TS = Self-limited inflammation of hip/knee Differentiation from septic arthritis? Kocher criteria: WBC > 12, ESR > 40, CRP > 2mg/dL, temp >38.5, unable to bear weight Validation? Variable PPV/NPV General rules: No prediction rule has 100% NPV If BOTH ESR/CRP are normal (<20; <2) -> SA unlikely Joint aspiration: WBC >25,000 suggestive of SA Treatment: vancomycin (+cefotaxime in neonate,+ consider cefazolin for Kingella)

38 Pedi orthopedic emergencies may present as crying, limp or refusal to walk High degree of suspicion in neonates/infants with unexplained fever, non-specific symptoms Diagnosis: MRI: study of choice for OM, discitis Plain films: sufficient to diagnose SCFE, LCP and bone malignancies (but get the right views!) CBC: rarely helpful, except to R/O leukemia CRP/ESR: normal = reassuring against septic arthritis, but get fluid if concern is high

Pediatric Case Studies. Case 1

Pediatric Case Studies. Case 1 Pediatric Case Studies James Naprawa, MD Assistant Clinical Professor Pediatric Emergency Medicine Children s Hospital, Columbus Case 1 Almost 4 year old AA girl PMH UTI x 2 with abdominal pain and fever