1/10/2017 PEDIATRIC LIMP: BOARD REVIEW GOALS & OBJECTIVES RELEVANCE DAVID POHL, D.O. PGY-3 ST. JOHN MACOMB-OAKLAND JANUARY 21, 2017

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1 PEDIATRIC LIMP: BOARD REVIEW DAVID POHL, D.O. PGY-3 ST. JOHN MACOMB-OAKLAND JANUARY 21, 2017 RELEVANCE AOBFP EXAM BLUEPRINT: ORTHO 5% PEDS 4% ADOLESCENTS 4% SPORTS 3 % GOALS & OBJECTIVES Review diagnosis and management of, and identify buzz words pertaining to, these pathologies: EWING S SARCOMA GENU VALGUM/VARUM GROWING PAINS IN-TOEING LEGG-CALVES-PERTHES OSGOOD SCHLATTER OSTEOSARCOMA SEPTIC ARTHRITIS SINDING-LARSEN-JOHANSON SLIPPED CAPITAL FEMORAL EPIPHYSIS TRANSIENT/TOXIC SYNOVITIS 1

2 THE GAME PLAN BRIEFLY DEFINE NORMAL GAIT DISCUSS 5 PATIENT CASES ANSWER 2-3 BOARD STYLE QUESTIONS PER CASE REVIEWFAST FACTS ABOUT EACH DIAGNOSIS AND DIFFERENTIATING FACTORS LEARN ABOUT 15 COMMONLY TESTED CAUSES OF PEDIATRIC LIMP NORMAL GAIT - MILESTONES NORMAL SYNCHRONOUS GAIT DEVELOPS IN THE FIRST 3 YEARS OF LIFE: AT AGE 1 YEAR, MANY CHILDREN CAN WALK WITHOUT SUPPORT. BY AGE 18 MONTHS, MOST CHILDREN WALK, AND MANY CAN RUN. COORDINATION WITH RECIPROCAL ARM SWING DEVELOPS BY AGE 2 YEARS. FINER ADJUSTMENTS TO THE GAIT PATTERN MAY NOT OCCUR UNTIL AGE 8-10 YEARS NORMAL GAIT PHASES 60% STANCE, 40% SWING Image source: physio-pedia.com 2

3 LIMP A DEVIATION FROM A NORMAL AGE-APPROPRIATE GAIT PATTERN EPIDEMIOLOGY VERY COMMON CHILDHOOD COMPLAINT 1-7% OF PEDIATRIC ED VISITS BOYS OUTNUMBER GIRLS MEDIAN AGE OF 4.4 YEARS OLD PAINFUL IN 80% OF VISITS HIP (34%) AND KNEE (19%) PAINS ARE MOST COMMON Image source: giphy.com ANTALGIC GAIT A SHORTENING OF THE STANCE PHASE ON THE AFFECTED LEG THAT IS ADOPTED TO PREVENT PAIN. Image source: gifs.com CASE #1 THE WORRIED MOTHER 3

4 CASE #1 A MOTHER BRINGS HER 18 MONTH OLD SON IN FOR HIS WELL CHILD EXAM. HER ONLY CONCERN TODAY IS THAT HE IS "PIGEON TOED" AND SHE IS WORRIED HE IS GOING TO TRIP OVER HIS FEET. ON EXAM BOTH FEET APPEAR TO POINT INWARD. THE FEET ARE FLEXIBLE AND OTHERWISE LOOK NORMAL. THE PATELLAE ARE IN NEUTRAL, FORWARD FACING POSITION. NO LEG LENGTH DISCREPANCY IS APPRECIATED. WHAT IS THE MOST COMMON CAUSE OF IN-TOEING IN THIS AGE GROUP? A. METATARSUS ADDUCTUS B. CEREBRAL PALSY C. DEVELOPMENTAL DYSPLASIA OF THE HIP D. FEMORAL ANTEVERSION E. INTERNAL TIBIAL TORSION CASE #1 A MOTHER BRINGS HER 18 MONTH OLD SON IN FOR HIS WELL CHILD EXAM. HER ONLY CONCERN TODAY IS THAT HE IS "PIGEON TOED" AND SHE IS WORRIED HE IS GOING TO TRIP OVER HIS FEET. ON EXAM BOTH FEET APPEAR TO POINT INWARD. THE FEET ARE FLEXIBLE AND OTHERWISE LOOK NORMAL. THE PATELLAE ARE IN NEUTRAL, FORWARD FACING POSITION. NO LEG LENGTH DISCREPANCY IS APPRECIATED. WHAT IS THE MOST COMMON CAUSE OF IN-TOEING IN THIS AGE GROUP? A. METATARSUS ADDUCTUS B. CEREBRAL PALSY C. DEVELOPMENTAL DYSPLASIA OF THE HIP D. FEMORAL ANTEVERSION E. INTERNAL TIBIAL TORSION CASE #1 A MOTHER BRINGS HER 18 MONTH OLD SON IN FOR HIS WELL CHILD EXAM. HER ONLY CONCERN TODAY IS THAT HE IS "PIGEON TOED" AND SHE IS WORRIED HE IS GOING TO TRIP OVER HIS FEET. ON EXAM BOTH FEET APPEAR TO POINT INWARD. THE FEET ARE FLEXIBLE AND OTHERWISE LOOK NORMAL. THE PATELLAE ARE IN NEUTRAL, FORWARD FACING POSITION. NO LEG LENGTH DISCREPANCY IS APPRECIATED. WHAT IS THE MOST COMMON CAUSE OF IN-TOEING IN THIS AGE GROUP? A. METATARSUS ADDUCTUS B. CEREBRAL PALSY C. DEVELOPMENTAL DYSPLASIA OF THE HIP D. FEMORAL ANTEVERSION E. INTERNAL TIBIAL TORSION 4

5 IN-TOEING CAUSES < 1 YEAR OLD: METATARSUS ADDUCTUS, ALONE OR COMBINED WITH INTERNAL TIBIAL TORSION. 1 3 YEAR OLDS: INTERNAL TIBIAL TORSION ALONE OR COMBINED WITH METATARSUS ADDUCTUS, AND MAY INVOLVE ONE OR BOTH SIDES. 3 6 YEAR OLDS: FEMORAL ANTEVERSION, AND IS NEARLY ALWAYS BILATERAL. Image source: massgeneral.org CASE #1 CONTINUED A MOTHER BRINGS HER 18 MONTH OLD SON IN FOR HIS WELL CHILD EXAM. HER ONLY CONCERN TODAY IS THAT HE IS "PIGEON TOED" AND SHE IS WORRIED HE IS GOING TO TRIP OVER HIS FEET. ON EXAM BOTH FEET APPEAR TO POINT INWARD. THE FEET ARE FLEXIBLE AND OTHERWISE LOOK NORMAL. THE PATELLAE ARE IN NEUTRAL, FORWARD FACING POSITION. NO LEG LENGTH DISCREPANCY IS APPRECIATED. WHAT IS THE MOST APPROPRIATE NEXT STEP? A. PLAIN FILMS B. CBC, ESR, RF C. SERIAL CASTING D. REASSURANCE AND ANTICIPATORY GUIDANCE E. ORTHOPEDIC REFERRAL CASE #1 CONTINUED A MOTHER BRINGS HER 18 MONTH OLD SON IN FOR HIS WELL CHILD EXAM. HER ONLY CONCERN TODAY IS THAT HE IS "PIGEON TOED" AND SHE IS WORRIED HE IS GOING TO TRIP OVER HIS FEET. ON EXAM BOTH FEET APPEAR TO POINT INWARD. THE FEET ARE FLEXIBLE AND OTHERWISE LOOK NORMAL. THE PATELLAE ARE IN NEUTRAL, FORWARD FACING POSITION. NO LEG LENGTH DISCREPANCY IS APPRECIATED. WHAT IS THE MOST APPROPRIATE NEXT STEP? A. PLAIN FILMS B. CBC, ESR, RF C. SERIAL CASTING D. REASSURANCE AND ANTICIPATORY GUIDANCE E. ORTHOPEDIC REFERRAL 5

6 CASE #1 CONTINUED A MOTHER BRINGS HER 18 MONTH OLD SON IN FOR HIS WELL CHILD EXAM. HER ONLY CONCERN TODAY IS THAT HE IS "PIGEON TOED" AND SHE IS WORRIED HE IS GOING TO TRIP OVER HIS FEET. ON EXAM BOTH FEET APPEAR TO POINT INWARD. THE FEET ARE FLEXIBLE AND OTHERWISE LOOK NORMAL. THE PATELLAE ARE IN NEUTRAL, FORWARD FACING POSITION. NO LEG LENGTH DISCREPANCY IS APPRECIATED. WHAT IS THE MOST APPROPRIATE NEXT STEP? A. PLAIN FILMS B. CBC, ESR, RF C. SERIAL CASTING D. REASSURANCE AND ANTICIPATORY GUIDANCE E. ORTHOPEDIC REFERRAL INTERNAL TIBIAL TORSION TYPICALLY IS ATTRIBUTED TO INTRAUTERINE POSITIONING POSSIBLY SLEEPING IN THE PRONE POSITION AND SITTING WITH THE FEET TUCKED UNDER TYPICALLY RESOLVES SPONTANEOUSLY BY AGE 6 PARENTS SHOULD DISCOURAGE CHILDREN FROM SITTING ON THEIR FEET. PARENTS SHOULD BE REASSURED THAT FUNCTIONAL LIMITATIONS ARE UNLIKELY. Image source: staticflickr.com METARSUS ADDUCTUS ADDUCTION OF FOREFOOT WITH NORMAL HINDFOOT ALIGNMENT CAUSED BY INTRAUTERINE POSITIONING 95% RESOLVE SPONTANEOUSLY BY AGE 4 RESIDUAL METATARSUS ADDUCTUS IS NOT RELATED TO PAIN OR DECREASED FUNCTION. Image source: orthobullets.com 6

7 FEMORAL ANTEVERSION INCREASED ANTEVERSION OF THE FEMORAL NECK RELATIVE TO THE FEMUR CAUSED BY INTRAUTERINE POSITIONING CHILD TYPICALLY SITS IN W POSITION TWICE AS FREQUENT IN GIRLS THAN BOYS MOST SPONTANEOUSLY RESOLVE BY AGE 10 OCCASIONAL FUNCTIONAL LIMITATIONS IN SPORTS AND ADLS IF SEVERE Image source: orthobullets.com FAST FACTS NORMAL KNEE DEFORMITIES GENU VARUM (BOWLEGED) IS NORMAL UNTIL AGE 2. OFTEN PROGRESSES TO GENU VALGUM (KNOCK- KNEED) MAY PERSIST UNTIL AGE 8. PERSISTENCE OF EITHER CONDITION BEYOND THESE AGES REQUIRES REFERRAL AND POSSIBLE SURGICAL INTERVENTION. Image source: ocreurope.com DEFORMITY RED FLAGS PAIN LIMB LENGTH DISCREPANCY PROGRESSIVE DEFORMITY FAMILY HISTORY POSITIVE FOR RICKETS/SKELETAL DYSPLASIAS LIMB ROTATION 2 STANDARD DEVIATIONS OUTSIDE OF NORMAL Image source: agry.purdue.edu 7

8 CASE #2 OW, MY LEG! CASE #2 AN OTHERWISE HEALTHY14-YEAR-OLD MALE PRESENTS FOR EVALUATION OF SEVERE LEFT GROIN AND LATERAL KNEE PAIN. HE HAS DIFFICULTY WITH HIS GAIT AND HAS RECENTLY DEVELOPED A LIMP. HE DENIES ANY RECENT TRAUMA, ILLNESS, OR SYSTEMIC SYMPTOMS. PHYSICAL EXAMINATION REVEALS AN OBESE MALE. EXAMINATION OF THE LEFT HIP SHOWS LIMITED INTERNAL ROTATION, ABDUCTION AND HIP FLEXION. EXAMINATION OF THE LEFT KNEE IS ESSENTIALLY NORMAL. THE MOST LIKELY DIAGNOSIS IS A. EWING SARCOMA B. SLIPPED CAPITAL FEMORAL EPIPHYSIS C. LEGG-CALVÉ-PERTHES DISEASE D. PATELLOFEMORAL SYNDROME E. GROWING PAINS CASE #2 AN OTHERWISE HEALTHY14-YEAR-OLD MALE PRESENTS FOR EVALUATION OF SEVERE LEFT GROIN AND LATERAL KNEE PAIN. HE HAS DIFFICULTY WITH HIS GAIT AND HAS RECENTLY DEVELOPED A LIMP. HE DENIES ANY RECENT TRAUMA, ILLNESS, OR SYSTEMIC SYMPTOMS. PHYSICAL EXAMINATION REVEALS AN OBESE MALE. EXAMINATION OF THE LEFT HIP SHOWS LIMITED INTERNAL ROTATION, ABDUCTION AND HIP FLEXION. EXAMINATION OF THE LEFT KNEE IS ESSENTIALLY NORMAL. THE MOST LIKELY DIAGNOSIS IS A. EWING SARCOMA B. SLIPPED CAPITAL FEMORAL EPIPHYSIS C. LEGG-CALVÉ-PERTHES DISEASE D. PATELLOFEMORAL SYNDROME E. GROWING PAINS 8

9 CASE #2 AN OTHERWISE HEALTHY14-YEAR-OLD MALE PRESENTS FOR EVALUATION OF SEVERE LEFT GROIN AND LATERAL KNEE PAIN. HE HAS DIFFICULTY WITH HIS GAIT AND HAS RECENTLY DEVELOPED A LIMP. HE DENIES ANY RECENT TRAUMA, ILLNESS, OR SYSTEMIC SYMPTOMS. PHYSICAL EXAMINATION REVEALS AN OBESE MALE. EXAMINATION OF THE LEFT HIP SHOWS LIMITED INTERNAL ROTATION, ABDUCTION AND HIP FLEXION. EXAMINATION OF THE LEFT KNEE IS ESSENTIALLY NORMAL. THE MOST LIKELY DIAGNOSIS IS A. EWING SARCOMA B. SLIPPED CAPITAL FEMORAL EPIPHYSIS C. LEGG-CALVÉ-PERTHES DISEASE D. PATELLOFEMORAL SYNDROME E. GROWING PAINS CASE #2 CONTINUED AN OTHERWISE HEALTHY14-YEAR-OLD MALE PRESENTS FOR EVALUATION OF SEVERE LEFT GROIN AND LATERAL KNEE PAIN. HE HAS DIFFICULTY WITH HIS GAIT AND HAS RECENTLY DEVELOPED A LIMP. HE DENIES ANY RECENT TRAUMA, ILLNESS, OR SYSTEMIC SYMPTOMS. PHYSICAL EXAMINATION REVEALS AN OBESE MALE. EXAMINATION OF THE LEFT HIP SHOWS LIMITED INTERNAL ROTATION, ABDUCTION AND HIP FLEXION. EXAMINATION OF THE LEFT KNEE IS ESSENTIALLY NORMAL. THE MOST APPROPRIATE A. NEXT IMMEDIATE STEP ISSURGICAL EVALUATION B. PHYSICAL THERAPY C. PLAIN FILMS OF PELVIS, LEFT HIP AND KNEE D. DIET AND EXERCISE FOR WEIGHT LOSS E. CT OF PELVIS, LEFT HIP AND KNEE CASE #2 CONTINUED AN OTHERWISE HEALTHY14-YEAR-OLD MALE PRESENTS FOR EVALUATION OF SEVERE LEFT GROIN AND LATERAL KNEE PAIN. HE HAS DIFFICULTY WITH HIS GAIT AND HAS RECENTLY DEVELOPED A LIMP. HE DENIES ANY RECENT TRAUMA, ILLNESS, OR SYSTEMIC SYMPTOMS. PHYSICAL EXAMINATION REVEALS AN OBESE MALE. EXAMINATION OF THE LEFT HIP SHOWS LIMITED INTERNAL ROTATION, ABDUCTION AND HIP FLEXION. EXAMINATION OF THE LEFT KNEE IS ESSENTIALLY NORMAL. THE MOST APPROPRIATE A. NEXT IMMEDIATE STEP ISSURGICAL EVALUATION B. PHYSICAL THERAPY C. PLAIN FILMS OF PELVIS, LEFT HIP AND KNEE D. DIET AND EXERCISE FOR WEIGHT LOSS E. CT OF PELVIS, LEFT HIP AND KNEE 9

10 SCFE DISRUPTION AT THE GROWTH PLATE THAT LEADS TO DISPLACEMENT OF THE PROXIMAL FEMORAL HEAD. CC: GROIN, HIP, THIGH OR KNEE PAIN PT: OBESE, ADOLESCENT (10-14 Y.O.) MALE (3:2 RATIO) PE: LOSS OF HIP INTERNAL ROTATION, ABDUCTION, AND FLEXION OBLIGATORY EXTERNAL ROTATION DURING PASSIVE FLEXION XR: BILATERAL AP AND FROG LEG. APPEARANCE OF AN ICE-CREAM SCOOP SLIPPING OFF ITS CONE. APPROXIMATELY30% OF PATIENTS WITH SCFE ALSO HAVE ASYMPTOMATICSCFE ON THE OTHER SIDE TX: ORTHOPEDIC REFERRAL FOR SURGICAL FIXATION Top Image source: meds.queensu.ca Bottom image source: radiopaedia.org CASE #2 CONTINUED AN OTHERWISE HEALTHY14-YEAR-OLD MALE PRESENTS FOR EVALUATION OF SEVERE LEFT GROIN AND LATERAL KNEE PAIN. HE HAS DIFFICULTY WITH HIS GAIT AND HAS RECENTLY DEVELOPED A LIMP. HE DENIES ANY RECENT TRAUMA, ILLNESS, OR SYSTEMIC SYMPTOMS. PHYSICAL EXAMINATION REVEALS AN OBESE MALE. EXAMINATION OF THE LEFT HIP SHOWS LIMITED INTERNAL ROTATION, ABDUCTION AND HIP FLEXION. EXAMINATION OF THE LEFT KNEE IS ESSENTIALLY NORMAL. THE MOST SERIOUS COMPLICATION THAT CAN DEVELOP IS A. AVASCULAR NECROSIS B. CONTRALATERAL SCFE C. CHONDROLYSIS D. RESIDUAL DEFORMITY E. SEPTIC ARTHRITIS CASE #2 CONTINUED AN OTHERWISE HEALTHY14-YEAR-OLD MALE PRESENTS FOR EVALUATION OF SEVERE LEFT GROIN AND LATERAL KNEE PAIN. HE HAS DIFFICULTY WITH HIS GAIT AND HAS RECENTLY DEVELOPED A LIMP. HE DENIES ANY RECENT TRAUMA, ILLNESS, OR SYSTEMIC SYMPTOMS. PHYSICAL EXAMINATION REVEALS AN OBESE MALE. EXAMINATION OF THE LEFT HIP SHOWS LIMITED INTERNAL ROTATION, ABDUCTION AND HIP FLEXION. EXAMINATION OF THE LEFT KNEE IS ESSENTIALLY NORMAL. THE MOST SERIOUS COMPLICATION THAT CAN DEVELOP IS A. AVASCULAR NECROSIS B. CONTRALATERAL SCFE C. CHONDROLYSIS D. RESIDUAL DEFORMITY E. SEPTIC ARTHRITIS 10

11 LEGG-CALVES-PERTHES DISEASE IDIOPATHIC AVASCULAR NECROSIS OF THE PROXIMAL FEMORAL EPIPHYSIS. REPEATED SUBCLINICAL TRAUMA AND MECHANICAL OVERLOAD LEAD TO DISRUPTED VASCULATURE AND BONE COLLAPSE / REPAIR CC: INSIDIOUS, LIMP, INTERMITTENT HIP, GROIN, THIGH, KNEE PAIN PT: AVERAGE SIZE, 4-8 Y.O. MALE (5:1 RATIO) PE: LOSS OF INTERNAL ROTATION AND ABDUCTION XR: BILATERAL AP AND FROG LEG. FINDINGS: MEDIAL JOINT SPACE WIDENING (EARLIEST), IRREGULARITY OF FEMORAL HEAD OSSIFICATION, CRESCENT SIGN (REPRESENTS A SUBCHONDRAL FRACTURE) TX: ORTHOPEDIC CONSULT LIKELY CONSERVATIVE TX: NSAIDS, PT BUT MAY NEED SURGICAL FIXATION Image source: radiopaedia.org CASE #3 HEY, MY HIP! CASE #3 A PREVIOUSLY HEALTHY 6 Y.O. BOY PRESENTS WITH RIGHT HIP AND ANTERIOR THIGH PAIN AND DIFFICULTY BEARING WEIGHT FOR 2 DAYS. MOM DENIES ANY RECENT TRAUMA. HE REPORTS HIS LEG "LOOSENS UP" IN THE MORNING, BUT THE PAIN BECOMES WORSE LATER IN THE DAY. PAIN IS WORSENED WITH WEIGHT-BEARING AND ACTIVE OR PASSIVE ROM. MOM REPORTS A MILD URI ~2 WEEKS AGO THAT RESOLVED SPONTANEOUSLY WITHIN A FEW DAYS. ON EXAM, THE PATIENT HAS TEMP 100 F, HR 100, AND RR 20. HIS RIGHT LOWER EXTREMITY IS SLIGHTLY FLEXED AND EXTERNALLY ROTATED, WITHOUT WARMTH OR ERYTHEMA OF THE HIP. PASSIVE ROM IS SLIGHTLY LIMITED DUE TO PAIN. A NORMAL RESULT FROM WHICH OF THE FOLLOWING TESTS WOULD RULE OUT THE MOST DANGEROUS PATHOLOGY? A. CBC WITH DIFF B. PLAIN HIP AND FEMUR FILMS C. ESR D. JOINT FLUID ANALYSIS E. CRP 11

12 CASE #3 A PREVIOUSLY HEALTHY 6 Y.O. BOY PRESENTS WITH RIGHT HIP AND ANTERIOR THIGH PAIN AND DIFFICULTY BEARING WEIGHT FOR 2 DAYS. MOM DENIES ANY RECENT TRAUMA. HE REPORTS HIS LEG "LOOSENS UP" IN THE MORNING, BUT THE PAIN BECOMES WORSE LATER IN THE DAY. PAIN IS WORSENED WITH WEIGHT-BEARING AND ACTIVE OR PASSIVE ROM. MOM REPORTS A MILD URI ~2 WEEKS AGO THAT RESOLVED SPONTANEOUSLY WITHIN A FEW DAYS. ON EXAM, THE PATIENT HAS TEMP 100 F, HR 100, AND RR 20. HIS RIGHT LOWER EXTREMITY IS SLIGHTLY FLEXED AND EXTERNALLY ROTATED, WITHOUT WARMTH OR ERYTHEMA OF THE HIP. PASSIVE ROM IS SLIGHTLY LIMITED DUE TO PAIN. A NORMAL RESULT FROM WHICH OF THE FOLLOWING TESTS WOULD RULE OUT THE MOST DANGEROUS PATHOLOGY? A. CBC WITH DIFF B. PLAIN HIP AND FEMUR FILMS C. ESR D. JOINT FLUID ANALYSIS E. CRP CASE #3 A PREVIOUSLY HEALTHY 6 Y.O. BOY PRESENTS WITH RIGHT HIP AND ANTERIOR THIGH PAIN AND DIFFICULTY BEARING WEIGHT FOR 2 DAYS. MOM DENIES ANY RECENT TRAUMA. HE REPORTS HIS LEG "LOOSENS UP" IN THE MORNING, BUT THE PAIN BECOMES WORSE LATER IN THE DAY. PAIN IS WORSENED WITH WEIGHT-BEARING AND ACTIVE OR PASSIVE ROM. MOM REPORTS A MILD URI ~2 WEEKS AGO THAT RESOLVED SPONTANEOUSLY WITHIN A FEW DAYS. ON EXAM, THE PATIENT HAS TEMP 100 F, HR 100, AND RR 20. HIS RIGHT LOWER EXTREMITY IS SLIGHTLY FLEXED AND EXTERNALLY ROTATED, WITHOUT WARMTH OR ERYTHEMA OF THE HIP. PASSIVE ROM IS SLIGHTLY LIMITED DUE TO PAIN. A NORMAL RESULT FROM WHICH OF THE FOLLOWING TESTS WOULD RULE OUT THE MOST DANGEROUS PATHOLOGY? A. CBC WITH DIFF B. PLAIN HIP AND FEMUR FILMS C. ESR D. JOINT FLUID ANALYSIS E. CRP CASE #3 CONTINUED YOUR TEST RESULTS ARE BELOW: CBC WBC 13 X10 9 /L HGB 12 G/DL HCT 43 % PLATELETS 340 X10 3 /ML ESR 15 MM/H CRP 5 MG/L JOINT FLUID: APPEARANCE: CLEAR, YELLOW CELLS: WBC 300, PMNS 20% THE MOST LIKELY DIAGNOSIS IS: A. MALINGERING B. SEPTIC ARTHRITIS C. OSTEOMYELITIS D. TRANSIENT SYNOVITIS E. TROCHANTERIC BURSITIS CRYSTALS: NEGATIVE GLUCOSE: 90 GRAM STAIN: NEGATIVE 12

13 CASE #3 CONTINUED YOUR TEST RESULTS ARE BELOW: CBC WBC 13 X10 9 /L HGB 12 G/DL HCT 43 % PLATELETS 340 X10 3 /ML ESR 15 MM/H CRP 5 MG/L JOINT FLUID: APPEARANCE: CLEAR, YELLOW CELLS: WBC 300, PMNS 20% CRYSTALS: NEGATIVE GLUCOSE: 90 GRAM STAIN: NEGATIVE THE MOST LIKELY DIAGNOSIS IS: A. MALINGERING B. SEPTIC ARTHRITIS C. OSTEOMYELITIS D. TRANSIENT SYNOVITIS E. TROCHANTERIC BURSITIS JOINT FLUID ANALYSIS Our Fluid: Appearance: Clear, Yellow Cells: WBC 300, PMNs 20% Crystals: negative Glucose: 90 Gram stain: negative TRANSIENT / TOXIC SYNOVITIS: CC: LIMP AND LOWER EXTREMITY PAIN, TYPICALLY AFTER URI PT: 3 10 Y.O. PE: NONTOXIC APPEARING HIP HELD IN FLEXION, ABDUCTION AND EXTERNAL ROTATION MILD TO MODERATE RESTRICTION OF HIP ABDUCTION, BUT TYPICALLY PAINLESS ARC OF MOTION W/U: PLAIN FILMS AND ACUTE INFLAMMATORY MARKERS MUST BE NORMAL. NEED TO RULE OUT MORE SERIOUS CONDITIONS. TX: REASSURANCE, REST, NSAIDS, AND CLOSE FOLLOW-UP. NSAIDS HAVE BEEN SHOWN TO SHORTEN THE DISEASE COURSE FROM 4.5 TO 2 DAYS APPROXIMATELY 1.5% OF PATIENTS CAN LATER DEVELOPLEGG-CALVE-PERTHES DISEASE, COXA MAGNA, OR OSTEOARTHRITIS, OR HAVE RECURRENCES. 13

14 SEPTIC ARTHRITIS ORGANISMS: < 4 MONTHS: S. AUREUS AND GBS SEPTIC ARTHRITIS AN ORTHOPEDIC EMERGENCY 4 MO - 4 YRS: H. INFLUENZAE AND S. AUREUS > 4 YEARS : S. AUREUS AND S. PYOGENES ADOLESCENCE: CONSIDER N. GONORRHOEAE CC: ACUTE ONSET OF MONOARTICULAR JOINT PAIN, ERYTHEMA, HEAT, AND IMMOBILITY. PT: ANY AGE PE: TOXIC APPEARING TYPICALLY PAINFUL MOTION, INABILITY TO BEAR WEIGHT W/U: XRAYS, CBC, CRP, ESR, JOINT FLUID SYNOVIAL FLUID SHOULD BE EVALUATED AT THE BEDSIDE AND THEN SENT WBC, CRYSTAL ANALYSIS, GRAM STAIN, AND CULTURE. TX: SURGICAL WASH-OUT, IV ABX KOCHER CRITERIA FOR SEPTIC ARTHRITIS 1 = 3% 2 = 40% 3 = 93% 4 = 99.6% N ON-WEIGHTBEARING ON AFFECTED SIDE E SR > 40 MM/H W BC > 12,000 (SERUM) T EMP > 38.5 C (101.3 F) Image source: twimg.com SEPTIC ARTHRITIS VS TOXIC SYNOVITIS SIGNS SUGGESTING TRANSIENT SYNOVITIS: PT IS AFEBRILE FOR THE PAST 24 HOURS MILD SYMPTOMS, IMPROVED WITH NSAIDS IMPROVED AMBULATION KOCHER SCORE < 2 Image source: pedemmorsels.com 14

15 CASE #4 GOODNIGHT, SLEEP TIGHT CASE #4 AN OTHERWISE HEALTHY 5 YEAR OLD GIRL IS BROUGHT IN BY HER FATHER FOR "NIGHT PAINS." SHE C/O PAIN THAT STARTED IN HER RIGHT THIGH, BUT NOW IS BILATERAL DISTAL THIGH PAIN X 1 MONTH THAT HAS OCCASIONALLY WAKES HER FROM SLEEP. THE PAIN DOES NOT OCCUR DURING THE DAY, AND HAS NOT LIMITED HER DURING HIS FIRST SOCCER SEASON. THEY DENY ANY CONSTITUTIONAL SYMPTOMS, INCLUDING FEVERS, DIAPHORESIS, NAUSEA, DECREASED APPETITE, OR WEIGHT LOSS. ON EXAM VITALS ARE WNL, SHE HAS NO REPRODUCIBLE TENDERNESS OF EITHER LEG. NO SWELLING, ERYTHEMA OR WARMTH OF EITHER LEG. FULL AND SYMMETRIC ROM. NORMAL GAIT PATTERN, NO PAIN WITH AMBULATION, TOE-WALK OR DUCK-WALK. WHAT IS THE MOST APPROPRIATE NEXT STEP? A. REFERRAL TO ORTHOPEDIC SURGERY B. MRI BILATERAL FEMUR C. REASSURANCE, NSAIDS, RICE D. ORAL ANTIBIOTICS E. BILATERAL KNEE BRACES CASE #4 AN OTHERWISE HEALTHY 5 YEAR OLD GIRL IS BROUGHT IN BY HER FATHER FOR "NIGHT PAINS." SHE C/O PAIN THAT STARTED IN HER RIGHT THIGH, BUT NOW IS BILATERAL DISTAL THIGH PAIN X 1 MONTH THAT HAS OCCASIONALLY WAKES HER FROM SLEEP. THE PAIN DOES NOT OCCUR DURING THE DAY, AND HAS NOT LIMITED HER DURING HIS FIRST SOCCER SEASON. THEY DENY ANY CONSTITUTIONAL SYMPTOMS, INCLUDING FEVERS, DIAPHORESIS, NAUSEA, DECREASED APPETITE, OR WEIGHT LOSS. ON EXAM VITALS ARE WNL, SHE HAS NO REPRODUCIBLE TENDERNESS OF EITHER LEG. NO SWELLING, ERYTHEMA OR WARMTH OF EITHER LEG. FULL AND SYMMETRIC ROM. NORMAL GAIT PATTERN, NO PAIN WITH AMBULATION, TOE-WALK OR DUCK-WALK. WHAT IS THE MOST APPROPRIATE NEXT STEP? A. REFERRAL TO ORTHOPEDIC SURGERY B. MRI BILATERAL FEMUR C. REASSURANCE, NSAIDS, RICE D. ORAL ANTIBIOTICS E. BILATERAL KNEE BRACES 15

16 CASE #4 AN OTHERWISE HEALTHY 5 YEAR OLD GIRL IS BROUGHT IN BY HER FATHER FOR "NIGHT PAINS." SHE C/O PAIN THAT STARTED IN HER RIGHT THIGH, BUT NOW IS BILATERAL DISTAL THIGH PAIN X 1 MONTH THAT HAS OCCASIONALLY WAKES HER FROM SLEEP. THE PAIN DOES NOT OCCUR DURING THE DAY, AND HAS NOT LIMITED HER DURING HIS FIRST SOCCER SEASON. THEY DENY ANY CONSTITUTIONAL SYMPTOMS, INCLUDING FEVERS, DIAPHORESIS, NAUSEA, DECREASED APPETITE, OR WEIGHT LOSS. ON EXAM VITALS ARE WNL, SHE HAS NO REPRODUCIBLE TENDERNESS OF EITHER LEG. NO SWELLING, ERYTHEMA OR WARMTH OF EITHER LEG. FULL AND SYMMETRIC ROM. NORMAL GAIT PATTERN, NO PAIN WITH AMBULATION, TOE-WALK OR DUCK-WALK. WHAT IS THE MOST APPROPRIATE NEXT STEP? A. REFERRAL TO ORTHOPEDIC SURGERY B. MRI BILATERAL FEMUR C. REASSURANCE, NSAIDS, RICE D. ORAL ANTIBIOTICS E. BILATERAL KNEE BRACES BENIGN NOCTURNAL LIMB PAINS OF CHILDHOOD FORMERLY KNOWN AS GROWING PAINS THE EXACT PATHOPHYSIOLOGY OF THE PAIN IS UNKNOWN, BUT IT IS NOT ASSOCIATED WITH THE PUBERTAL GROWTH SPURT. CC: CRAMPING PAINS OF THE THIGH AND/OR LEG TYPICALLY OCCURS IN THE EVENING/NIGHT, MAY AWAKEN THE CHILD FROM SLEEP, AND DISAPPEARS BY MORNING - NOT ASSOCIATED WITH A LIMP. PT: UP TO 35 % OF CHILDREN 4-6 Y.O. ALTHOUGH THEY MAY OCCUR UP TO AGE 19 PE: NORMAL W/U: NO DIAGNOSTIC TESTING IS NECESSARY TX: REASSURANCE, NSAIDS IF NEEDED CASE #4 CONTINUED 10 YEARS LATER THE NOW 15 YEAR OLD GIRL IS BROUGHT IN FOR "SIMILAR NIGHT PAINS AS BEFORE." HER PAIN IS INTERMITTENT IN THE LEFT DISTAL THIGH. IT STARTED OFF MILD AGAIN ~ 1 MONTH AGO, AND THEY FIGURED IT WAS "MORE GROWING PAINS." HOWEVER, DESPITE CONSERVATIVE TREATMENT, THE PAIN CONTINUED TO INTENSIFY AND NOW WAKES HER UP AT NIGHT. THEY DENY ANY CONSTITUTIONAL SYMPTOMS, INCLUDING FEVERS, DIAPHORESIS, NAUSEA, DECREASED APPETITE, OR WEIGHT LOSS. ON EXAM VITALS ARE WNL. HER KNEE AND HIP EXAMS ARE NORMAL. THE ONLY FINDING ON PHYSICAL EXAM IS A SMALL AREA OF SWELLING AND TENDERNESS TO PALPATION ALONG THE MID FEMUR. WHAT IS THE MOST APPROPRIATE NEXT STEP? A. REASSURANCE, NSAIDS, RICE B. ORAL ANTIBIOTICS C. REFERRAL TO ORTHOPEDIC SURGERY D. HINGED KNEE BRACE E. PLAIN FILMS, CBC, ESR, CRP 16

17 CASE #4 CONTINUED 10 YEARS LATER THE NOW 15 YEAR OLD GIRL IS BROUGHT IN FOR "SIMILAR NIGHT PAINS AS BEFORE." HER PAIN IS INTERMITTENT IN THE LEFT DISTAL THIGH. IT STARTED OFF MILD AGAIN ~ 1 MONTH AGO, AND THEY FIGURED IT WAS "MORE GROWING PAINS." HOWEVER, DESPITE CONSERVATIVE TREATMENT, THE PAIN CONTINUED TO INTENSIFY AND NOW WAKES HER UP AT NIGHT. THEY DENY ANY CONSTITUTIONAL SYMPTOMS, INCLUDING FEVERS, DIAPHORESIS, NAUSEA, DECREASED APPETITE, OR WEIGHT LOSS. ON EXAM VITALS ARE WNL. HER KNEE AND HIP EXAMS ARE NORMAL. THE ONLY FINDING ON PHYSICAL EXAM IS A SMALL AREA OF SWELLING AND TENDERNESS TO PALPATION ALONG THE MID FEMUR. WHAT IS THE MOST APPROPRIATE NEXT STEP? A. REASSURANCE, NSAIDS, RICE B. ORAL ANTIBIOTICS C. REFERRAL TO ORTHOPEDIC SURGERY D. HINGED KNEE BRACE E. PLAIN FILMS, CBC, ESR, CRP CASE #4 CONTINUED 10 YEARS LATER THE NOW 15 YEAR OLD GIRL IS BROUGHT IN FOR "SIMILAR NIGHT PAINS AS BEFORE." HER PAIN IS INTERMITTENT IN THE LEFT DISTAL THIGH. IT STARTED OFF MILD AGAIN ~ 1 MONTH AGO, AND THEY FIGURED IT WAS "MORE GROWING PAINS." HOWEVER, DESPITE CONSERVATIVE TREATMENT, THE PAIN CONTINUED TO INTENSIFY AND NOW WAKES HER UP AT NIGHT. THEY DENY ANY CONSTITUTIONAL SYMPTOMS, INCLUDING FEVERS, DIAPHORESIS, NAUSEA, DECREASED APPETITE, OR WEIGHT LOSS. ON EXAM VITALS ARE WNL. HER KNEE AND HIP EXAMS ARE NORMAL. THE ONLY FINDING ON PHYSICAL EXAM IS A SMALL AREA OF SWELLING AND TENDERNESS TO PALPATION ALONG THE MID FEMUR. WHAT IS THE MOST APPROPRIATE NEXT STEP? A. REASSURANCE, NSAIDS, RICE B. ORAL ANTIBIOTICS C. REFERRAL TO ORTHOPEDIC SURGERY D. HINGED KNEE BRACE E. PLAIN FILMS, CBC, ESR, CRP PRIMARY BONE TUMORS CC: NIGHT PAIN THAT BEGINS INTERMITTENTLY AND INCREASES OVER TIME UNILATERAL PAIN PAIN FROM EWING SARCOMA, THOUGH, MAY DISAPPEAR SPONTANEOUSLY FOR WEEKS OR MONTHS PT: PEAK AGES PE: POSSIBLE PALPABLE MASS TENDERNESS WITH COMPRESSION OF THE BONE AND/OR SOFT TISSUE W/U: PLAIN FILMS, CBC, ESR, CRP TX: REFERRAL TO PEDIATRIC CANCER CENTER 17

18 AAP S FLOWCHART Bone Lesions: Benign and Malignant Rani Gereige, Mudra Kumar Pediatrics in Review Sep 2010, 31 (9) MALIGNANT BONE TUMOR FAST FACTS OSTEOSARCOMA MOST COMMON MALIGNANT BONE TUMOR IN PEDS PEAK INCIDENCE IN ADOLESCENTS TYPICALLY ENDS OF LONG BONES NO SYSTEMIC SYMPTOMS XR: AGGRESSIVE LYTIC LESION WITH SUNBURST REACTION SCLEROTIC, DESTRUCTIVE, BONE-FORMING LESION, WITH OCCASIONAL MINERALIZATION EXTENDING INTO THE SURROUNDING SOFT TISSUES DX: BIOPSY MAY SHOW MESENCHYMAL CELLS TX: CHEMO, SURGICAL RESECTION EWING S SARCOMA 2 ND MOST COMMON PEAK AGES YR OLD TYPICALLY MIDSHAFT OF LONG BONES, PELVIS, AND SPINE. OFTEN SYSTEMIC SYMPTOMS XR: POORLY MARGINATED INTRAMEDULLARY LYTIC LESION WITH PERIOSTEAL REACTION MIXED, LAYERED SCLEROTIC AND LYTIC LESION, CALLED ONION-SKINNING APPEARANCE DX: BIOPSY SHOWS UNDIFFERENTIATED, SMALL, ROUND CELLS TX: CHEMO, RADIATION, SURGICAL RESECTION CASE #5 WHITE MEN CAN T JUMP 18

19 CASE #5 A PREVIOUSLY HEALTHY 15 Y.O. BASKETBALL PLAYER PRESENTS WITH RIGHT ANTERIOR KNEE PAIN THAT IS INCREASING SINCE STARTING THE SEASON 2 MONTHS AGO. PAIN IS WORSE WITH JUMPING AND RUNNING, IMPROVED WITH REST AND IBUPROFEN. DENIES ANY SYSTEMIC OR OTHER ASSOCIATED SYMPTOMS ON EXAM, VSS, AFEBRILE. THERE IS TENDERNESS OF THE RIGHT INFERIOR POLE OF THE PATELLA WITHOUT OVERLYING ERYTHEMA OR WARMTH. PASSIVE KNEE FLEXION CAUSES PAIN AT THE END OF NORMAL ROM. REMAINDER OF THE KNEE EXAM IS NORMAL. RIGHT KNEE XRAY AS FOLLOWS. WHAT IS A THE MOST LIKELY DIAGNOSIS? A. SEVER'S DISEASE B. SINDING-LARSEN-JOHANSSON SYNDROME C. OSTEOCHONDRITIS DESSICANS D. OSGOOD SCHLATTER'S DISEASE E. PATELLOFEMORAL PAIN SYNDROME CASE #5 XRAY Image source: radiopaedia.org CASE #5 A PREVIOUSLY HEALTHY 15 Y.O. BASKETBALL PLAYER PRESENTS WITH RIGHT ANTERIOR KNEE PAIN THAT IS INCREASING SINCE STARTING THE SEASON 2 MONTHS AGO. PAIN IS WORSE WITH JUMPING AND RUNNING, IMPROVED WITH REST AND IBUPROFEN. DENIES ANY SYSTEMIC OR OTHER ASSOCIATED SYMPTOMS ON EXAM, VSS, AFEBRILE. THERE IS TENDERNESS OF THE RIGHT INFERIOR POLE OF THE PATELLA WITHOUT OVERLYING ERYTHEMA OR WARMTH. PASSIVE KNEE FLEXION CAUSES PAIN AT THE END OF NORMAL ROM. REMAINDER OF THE KNEE EXAM IS NORMAL. RIGHT KNEE XRAY AS FOLLOWS. WHAT IS A THE MOST LIKELY DIAGNOSIS? A. SEVER'S DISEASE B. SINDING-LARSEN-JOHANSSON SYNDROME C. OSTEOCHONDRITIS DESSICANS D. OSGOOD SCHLATTER'S DISEASE E. PATELLOFEMORAL PAIN SYNDROME 19

20 CASE #5 A PREVIOUSLY HEALTHY 15 Y.O. BASKETBALL PLAYER PRESENTS WITH RIGHT ANTERIOR KNEE PAIN THAT IS INCREASING SINCE STARTING THE SEASON 2 MONTHS AGO. PAIN IS WORSE WITH JUMPING AND RUNNING, IMPROVED WITH REST AND IBUPROFEN. DENIES ANY SYSTEMIC OR OTHER ASSOCIATED SYMPTOMS ON EXAM, VSS, AFEBRILE. THERE IS TENDERNESS OF THE RIGHT INFERIOR POLE OF THE PATELLA WITHOUT OVERLYING ERYTHEMA OR WARMTH. PASSIVE KNEE FLEXION CAUSES PAIN AT THE END OF NORMAL ROM. REMAINDER OF THE KNEE EXAM IS NORMAL. RIGHT KNEE XRAY AS FOLLOWS. WHAT IS A THE MOST LIKELY DIAGNOSIS? A. SEVER'S DISEASE B. SINDING-LARSEN-JOHANSSON SYNDROME C. OSTEOCHONDRITIS DESSICANS D. OSGOOD SCHLATTER'S DISEASE E. PATELLOFEMORAL PAIN SYNDROME CASE #5 A PREVIOUSLY HEALTHY 15 Y.O. BASKETBALL PLAYER PRESENTS WITH RIGHT ANTERIOR KNEE PAIN THAT IS INCREASING SINCE STARTING THE SEASON 2 MONTHS AGO. PAIN IS WORSE WITH JUMPING AND RUNNING, IMPROVED WITH REST AND IBUPROFEN. DENIES ANY SYSTEMIC OR OTHER ASSOCIATED SYMPTOMS ON EXAM, VSS, AFEBRILE. THERE IS TENDERNESS OF THE RIGHT INFERIOR POLE OF THE PATELLA WITHOUT OVERLYING ERYTHEMA OR WARMTH. PASSIVE KNEE FLEXION CAUSES PAIN AT THE END OF NORMAL ROM. REMAINDER OF THE KNEE EXAM IS NORMAL. RIGHT KNEE XRAY AS FOLLOWS. THE MOST APPROPRIATE INITIAL TREATMENT IS: A. SURGICAL TUBERCLE FIXATION B. KNEE BRACING C. CAST IMMOBILIZATION D. REST, ICE, NSAIDS E. OSSICLE EXCISION CASE #5 A PREVIOUSLY HEALTHY 15 Y.O. BASKETBALL PLAYER PRESENTS WITH RIGHT ANTERIOR KNEE PAIN THAT IS INCREASING SINCE STARTING THE SEASON 2 MONTHS AGO. PAIN IS WORSE WITH JUMPING AND RUNNING, IMPROVED WITH REST AND IBUPROFEN. DENIES ANY SYSTEMIC OR OTHER ASSOCIATED SYMPTOMS ON EXAM, VSS, AFEBRILE. THERE IS TENDERNESS OF THE RIGHT INFERIOR POLE OF THE PATELLA WITHOUT OVERLYING ERYTHEMA OR WARMTH. PASSIVE KNEE FLEXION CAUSES PAIN AT THE END OF NORMAL ROM. REMAINDER OF THE KNEE EXAM IS NORMAL. RIGHT KNEE XRAY AS FOLLOWS. THE MOST APPROPRIATE INITIAL TREATMENT IS: A. SURGICAL TUBERCLE FIXATION B. KNEE BRACING C. CAST IMMOBILIZATION D. REST, ICE, NSAIDS E. OSSICLE EXCISION 20

21 SINDING-LARSEN-JOHANSSON PEDIATRIC JUMPER S KNEE OVERUSE INJURY LEADING TO CHRONIC APOPHYSITIS OR MINOR AVULSION INJURY OF INFERIOR PATELLA POLE CC: INSIDIOUS ANTERIOR KNEE PAIN, WORSE WITH ACTIVITY PT: ADOLESCENTS (10-15 Y.O.) AND CHILDREN WITH CP. PE: TENDERNESS, SWELLING AT INFERIOR PATELLA XR: AP AND LATERAL KNEE EARLY FINDINGS ARE SUBTLE OR ABSENT. DYSTROPHIC CALCIFICATION/OSSIFICATION OF INFERIOR PATELLA MAY EVENTUALLY OCCUR. TX: NSAIDS, RICE Image source: radiopaedia.org OSGOOD SCHLATTER TIBIAL TUBERCLE APOPHYSITIS OVERUSE INJURY LEADING TO CHRONIC APOPHYSITIS OR MINOR AVULSION INJURY OF TIBIAL TUBURCLE CC: INSIDIOUS ANTERIOR KNEE PAIN, WORSE WITH ACTIVITY TYPICALLY JUMPING, RUNNING, AND CLIMBING. CAN BE BILATERAL IN UP TO 1/3 OF CASES. PT: BOYS (12-15 Y.O.) > GIRLS (8-12 Y.O.) OSSIFICATION CENTERS OF TIBIAL TUBERCLE USUALLY FORM BETWEEN AGE 12 (GIRLS) TO14 (BOYS), AND FUSE BETWEEN YEARS. PE: TENDERNESS, SWELLING AT TIBIAL TUBERCLE XR: AP AND LATERAL KNEE IRREGULARITY AND FRAGMENTATION OF THE TIBIAL TUBERCLE TX: NSAIDS, RICE Image source: radiopaedia.org FAST FACTS #1-7 IN TOEING NO WORK-UP IF PE BENIGN. TREAT WITH REASSURANCE. < 1 YEAR OLD: METATARSUS ADDUCTUS RESOLVES BY 4 Y.O. 1 3 YEAR OLDS: INTERNAL TIBIAL TORSION RESOLVES BY 6 Y.O 3 6 YEAR OLDS: FEMORAL ANTEVERSION RESOLVES BY 10 Y.O. GENU VARUM NORMAL UNTIL 2 Y.O. CAN PROGRESS TO: GENUM VALGUM RESOLVES BY 8 Y.O. SCFE - OBESE, ADOLESCENT, MALE, C/O LE PAIN. XRAYS: ICE CREAM SCOOP OFF CONE. NEEDS ORTHO REFERRAL FOR FIXATION. LCP = AVN OF FEMORAL HEAD. 4-8 Y.O. NONOBESE MALE. C/O INTERMITTENT LE PAIN XRAYS: CRESCENT SIGN, FEMORAL HEAD ABNORMALITY NEEDS ORTHO REFERRAL FOR CONSERVATIVE TX. 21

22 FAST FACTS DX #8-10 TRANSIENT SYNOVITIS 3-10 Y.O., NONTOXIC, MILDLY PAINFUL ROM, SYMPTOMS AFTER URI DX OF EXCLUSION NEED NEGATIVE XRAYS AND BLOODWORK TX: NSAIDS AND REASSURANCE. MONITOR CLOSELY SEPTIC ARTHRITIS AN ORTHO EMERGENCY. TOXIC APPEARING. VERY PAINFUL ROM. MOST COMMONLY S. AUREUS, BUT CONSIDER GBS IF <4MO AND N. GONORRHEA IF SEXUALLY ACTIVE KOCHER / NEWT: NONWEIGHTBEARING, WBC >12, ESR >40, TEMP > JOINT FLUID: CLOUDY, WBC >50, PMN >50%, GLUCOSE <40 TX: IV ABX AND SURGICAL WASHOUT BENIGN NOCTURNAL LIMB PAIN OF CHILDHOOD 4-6 Y.O. UP TO ADOLESCENTS, NOT RELATED TO GROWING. PAIN AT NIGHT, RESOLVED BY MORNING, NO LIMP. PE NORMAL NO W/U, TX WITH REASSURANCE, NSAIDS FAST FACTS DX #11-13 BONE TUMORS INCREASING, INTERMITTENT, NGHT PAIN, UNILATERAL, PERSISTS DURING DAY. TENDERNESS, POSSIBLE MASS ON PE. XRAYS, CBC, ESR, CRP. EARLY REFERRAL TO PEDS ONC CENTER OSTEOSARCOMA - MOST COMMON MALIGNANT BONE TUMOR IN ADOLESCENTS. NO SYSTEMIC SYMPTOMS XRAY: AGGRESSIVE LYTIC LESION WITH SUNBURST REACTION AT ENDS OF LONG BONES BIOPSY MAY SHOW MESENCHYMAL CELLS. TX: CHEMO, SURGICAL RESECTION EWING S SARCOMA - 2 ND MOST COMMON YR OLD. OFTEN SYSTEMIC SYMPTOMS TYPICALLY MIDSHAFT OF LONG BONES, PELVIS, AND SPINE. XRAY: INTRAMEDULLARY LESION WITH PERIOSTEAL REACTION, LAYERED SCLEROTIC AND LYTIC, ONION-SKINNING BIOPSY: UNDIFFERENTIATED, SMALL, ROUND CELLS. TX: CHEMO, RADIATION, SURGICAL RESECTIO FAST FACTS DX #14-15 SLJ - PEDIATRIC JUMPER S KNEE. APOPHYSITIS OR MINOR AVULSION INJURY OF INFERIOR PATELLA POLE ADOLESCENTS AND CHILDREN WITH CP. XRAY: NML OR DYSTROPHIC CALCIFICATION/OSSIFICATION OF INFERIOR PATELLA. TX: NSAIDS, RICE OSGOOD SCHLATTER - TIBIAL TUBERCLE APOPHYSITIS. WORSE WITH ACTIVITY. 33% BILATERAL. PT: BOYS (12-15 Y.O.) > GIRLS (8-12 Y.O.) XR: IRREGULARITY AND FRAGMENTATION OF THE TIBIAL TUBERCLE TX: NSAIDS, RICE 22

23 SOURCES CLARK, MARK C. APPROACH TO THE CHILD WITH A LIMP. UPTODATE.COM. LAST UPDATED: AUG 11, CLARK, MARK C. OVERVIEW OF THE CAUSES OF LIMP IN CHILDREN. UPTODATE.COM. LAST UPDATED: AUG 11, FARAHI, NARGES. PEDIATRIC AND ADOLESCENT MEDICINE. FIRST AID FOR THE FAMILY MEDICINE BOARDS. 2 ND ED. MCGRAW HILL, GEREIGE, R. KUMAR, M. BONE LESIONS: BENIGN AND MALIGNANT. PEDIATRICS IN REVIEW. SEP 2010, 31 (9) SAWYER, JR AND KAPOOR, M. THE LIMPING CHILD: A SYSTEMATIC APPROACH TO DIAGNOSIS. AM FAM PHYSICIAN FEB 1:79(3): SOUDER, CHRIS ET AL. SELECTED ARTICLES FROM ORTHOBULLETS.COM. ALL REFERENCED TOPICS ACCESSED DEC2016. WHEELESS, CLIFFORD R. WHEELESS' TEXTBOOK OF ORTHOPAEDICS. ACCESSED ONLINE AT WHEELESSONLINE.COM. LAST UPDATED NOV 3, ALL IMAGES SOURCED ON SLIDES. CLEAR AS MUD? 23