the child with a limp madesa espana, md, faap pediatric emergency medicine st. joseph’s regional...
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THE CHILD WITH A THE CHILD WITH A LIMPLIMP
Madesa Espana, MD, FAAPMadesa Espana, MD, FAAP
Pediatric Emergency MedicinePediatric Emergency Medicine
St. Joseph’s Regional Medical St. Joseph’s Regional Medical CenterCenter
Paterson, New JerseyPaterson, New Jersey
LIMPLIMP
An uneven, jerky or laborious gait, An uneven, jerky or laborious gait, usually caused by pain, weakness or usually caused by pain, weakness or deformity.deformity.
4/1000 visits in a pediatric ED4/1000 visits in a pediatric ED
A CHILD WITH A LIMPA CHILD WITH A LIMP
EpidemiologyEpidemiology– Median age: 4 years oldMedian age: 4 years old– Male:female ratio: 2:1Male:female ratio: 2:1– Most common diagnosis: Transient Most common diagnosis: Transient
synovitissynovitis– Pain is present in 80% of casesPain is present in 80% of cases– Localization: hip and kneeLocalization: hip and knee– Benign cause: 77%Benign cause: 77%
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
HISTORYHISTORY– DurationDuration– TraumaTrauma– FeverFever
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
HISTORYHISTORY– Location of the painLocation of the pain– Pain characteristicsPain characteristics
Constant severe painConstant severe pain Intermittent mild to moderate painIntermittent mild to moderate pain Bilateral painBilateral pain Modifying factorsModifying factors
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
HISTORYHISTORY– Other symptomsOther symptoms
Morning stiffnessMorning stiffness Incontinence, weakness or sciaticaIncontinence, weakness or sciatica Recent viral or bacterial illnessRecent viral or bacterial illness Recent medicationsRecent medications Endocrine and other systemic diseasesEndocrine and other systemic diseases
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– General appearanceGeneral appearance
Ill or toxic appearingIll or toxic appearing FeverFever Obvious discomfort/pain at restObvious discomfort/pain at rest
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– Gait evaluationGait evaluation
Phases of a gaitPhases of a gait– Stance: time when the foot is in contact Stance: time when the foot is in contact
with the surfacewith the surface Heel-strike to toe flat (contact)Heel-strike to toe flat (contact) Foot-flat to heel-off (mid-stance)Foot-flat to heel-off (mid-stance) Heel-lift to toe off (propulsion)Heel-lift to toe off (propulsion)
– Swing: time from toe-off to heel strikeSwing: time from toe-off to heel strike
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– Young child (<4 years) vs. adult gaitYoung child (<4 years) vs. adult gait
Increased flexion of the hips, knees and Increased flexion of the hips, knees and anklesankles
Rotation of the feet externally, wider Rotation of the feet externally, wider base of supportbase of support
Faster cadence, slower velocity, Faster cadence, slower velocity, shorter stride lengthshorter stride length
Smaller percentage of the gait cycle is Smaller percentage of the gait cycle is spent in single limb stancespent in single limb stance
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
PYSICAL EXAMINATIONPYSICAL EXAMINATION– Gait examinationGait examination
Expose the legsExpose the legs Bare feet or wearing only a pair of Bare feet or wearing only a pair of
sockssocks Listening to the gaitListening to the gait
– CadenceCadence– Foot slapFoot slap– ScrapingScraping
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– Gait examinationGait examination
Observe several gait cyclesObserve several gait cycles Includes jumping/hoppingIncludes jumping/hopping
Gait evaluationGait evaluation
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– MusculoskeletalMusculoskeletal
Muscle strengthMuscle strength Muscular atrophyMuscular atrophy Bony tendernessBony tenderness Bony deformityBony deformity
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
PHYSCIAL EXAMINATONPHYSCIAL EXAMINATON– MusculoskeletalMusculoskeletal
Active and passive ROMActive and passive ROM Joint swelling/tendernessJoint swelling/tenderness Muscle tendernessMuscle tenderness Tenderness on the tendons, insertions Tenderness on the tendons, insertions
sitessites
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– MusculoskeletalMusculoskeletal
Back and spineBack and spine HipHip ThighThigh KneeKnee LegLeg AnkleAnkle FootFoot
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– MusculoskeletalMusculoskeletal
Limb length discrepancyLimb length discrepancy Hip rotationHip rotation Galeazzi testGaleazzi test Trendelenburg testTrendelenburg test FABERE testFABERE test
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– SkinSkin
BruisesBruises Rashes and other lesionsRashes and other lesions SwellingSwelling RednessRedness TendernessTenderness
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– LymphaticLymphatic
LymphadenopathyLymphadenopathy– Localized vs. systemicLocalized vs. systemic
LymphadenitisLymphadenitis LymphangitisLymphangitis
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– NeurologicNeurologic
Muscle strengthMuscle strength Muscle toneMuscle tone DTR’sDTR’s
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– GastroentestinalGastroentestinal
Abdominal tendernessAbdominal tenderness Abdominal swellingAbdominal swelling
– GenitourinaryGenitourinary Testicular or scrotal pain/swellingTesticular or scrotal pain/swelling Inguinal swellingInguinal swelling
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– Age of the childAge of the child– Location of abnormal findingsLocation of abnormal findings– Duration of symptomsDuration of symptoms– Type of gait abnormalityType of gait abnormality
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– OSSEOUSOSSEOUS
FracturesFractures– Salter-Harris or growth plate injuriesSalter-Harris or growth plate injuries– Toddler’s: tibia, calcaneous and cuboidToddler’s: tibia, calcaneous and cuboid– StressStress– Incomplete: buckle, greenstickIncomplete: buckle, greenstick– Complete Complete – Plastic or bowing deformityPlastic or bowing deformity– AvulsionAvulsion– Child abuse: bucket-handle fracturesChild abuse: bucket-handle fractures
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– OSSEOUSOSSEOUS
ApophysitisApophysitis– Sinding-Larsen-Johnson diseaseSinding-Larsen-Johnson disease– Kohler diseaseKohler disease– Sever diseaseSever disease– Freiberg diseaseFreiberg disease– Osgood-schlater diseaseOsgood-schlater disease
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– OSSEOUSOSSEOUS
Vasoocclussive crisis of SCDVasoocclussive crisis of SCD Slipped capital femoral epiphysisSlipped capital femoral epiphysis Legg-Calve-Perthes diseaseLegg-Calve-Perthes disease
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– TUMORSTUMORS
LeukemiaLeukemia LymphomaLymphoma Spinal cord tumorSpinal cord tumor Osteogenic sarcomaOsteogenic sarcoma Ewing’s sarcomaEwing’s sarcoma Osteoid sarcomaOsteoid sarcoma Metastatic neuroblastomaMetastatic neuroblastoma
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– ARTICULARARTICULAR
Transient synovitis of the hipTransient synovitis of the hip Septic arthritisSeptic arthritis Osteochondritis dessicansOsteochondritis dessicans Acute rheumatic feverAcute rheumatic fever Juvenile rheumatoid arthritisJuvenile rheumatoid arthritis
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– ARTICULARARTICULAR
Serum sicknessSerum sickness DiscitisDiscitis Developmental dysplasia of the hipDevelopmental dysplasia of the hip Chondromalacia of the patellaChondromalacia of the patella Hemarthrosis: traumatic, hemophiliaHemarthrosis: traumatic, hemophilia
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– ARTICULARARTICULAR
Henoch-Schonlein purpuraHenoch-Schonlein purpura Lyme diseaseLyme disease SLESLE Patellar dislocationPatellar dislocation
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– SOFT TISSUESOFT TISSUE
ContusionContusion Muscle strainMuscle strain SprainSprain TendonitisTendonitis Viral myositisViral myositis Foreign bodyForeign body
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– SOFT TISSUESOFT TISSUE
CellulitisCellulitis AbscessAbscess PyomyositisPyomyositis IM vaccinationIM vaccination Insect envenomationInsect envenomation Plantar wartsPlantar warts
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– SOFT TISSUESOFT TISSUE
BunionBunion Ingrown toenailIngrown toenail Baker’s cyst ruptureBaker’s cyst rupture Myositis ossificansMyositis ossificans BursitisBursitis Benign hypermobility syndromeBenign hypermobility syndrome
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– NEUROLOGICALNEUROLOGICAL
Meningitis/Intracranial abscessMeningitis/Intracranial abscess Cerebral palsyCerebral palsy Peripheral neuropathyPeripheral neuropathy Epidural abscessEpidural abscess Spinal cord tumorSpinal cord tumor Complex regional pain syndrome (reflex Complex regional pain syndrome (reflex
sympathetic dystrophy)sympathetic dystrophy)
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– INTRA-ABDOMINALINTRA-ABDOMINAL
AppendicitisAppendicitis PIDPID Pelvic abscessPelvic abscess Psoas abscessPsoas abscess Perirectal abscessPerirectal abscess Iliac adenitisIliac adenitis
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– GENITO-URINARYGENITO-URINARY
Incarcerated inguinal herniaIncarcerated inguinal hernia Testicular torsionTesticular torsion STD’sSTD’s
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– PSYCHIATRICPSYCHIATRIC
Conversion disorderConversion disorder MalingeringMalingering
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– DERMATOLOGICDERMATOLOGIC
Erythema multiformeErythema multiforme
– VASCULARVASCULAR Henoch-schonlein purpuraHenoch-schonlein purpura
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES
LIFE OR LIMB-THREATENING CAUSES OFLIFE OR LIMB-THREATENING CAUSES OFLIMP IN CHILDRENLIMP IN CHILDREN
Septic arthritisSeptic arthritis SCFESCFE OsteomyelitisOsteomyelitis FractureFracture
TumorsTumors AppendicitisAppendicitisTesticular torsionTesticular torsion DiscitisDiscitisMeningitisMeningitis Epidural abscessEpidural abscessDevelopmental dysplasia of the hipDevelopmental dysplasia of the hip
CAUSES OF LIMP IN CAUSES OF LIMP IN CHILDREN OF ALL AGESCHILDREN OF ALL AGES
ACUTEACUTE– ContusionContusion– Foreign bodyForeign body– FractureFracture– OsteomyelitisOsteomyelitis– Reactive arthritisReactive arthritis– Septic arthritisSeptic arthritis– Transient Transient
synovitissynovitis– Lyme arthritisLyme arthritis– Poor shoe fitPoor shoe fit
CHRONICCHRONIC– Rheumatic Rheumatic
diseasedisease JRAJRA Acute rheumatic Acute rheumatic
feverfever SLESLE Inflammatory Inflammatory
bowel diseasebowel disease
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
SEPTIC ATHRITISSEPTIC ATHRITIS– Clinical signs/symptomsClinical signs/symptoms
FeverFever PainPain Decreased ROMDecreased ROM Minor traumaMinor trauma
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
SEPTIC ARTHRITISSEPTIC ARTHRITIS– Clinical signs/symptomsClinical signs/symptoms
Toxic or ill appearanceToxic or ill appearance Painful ROMPainful ROM Joint effusionJoint effusion Warmth/erythemaWarmth/erythema
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
SEPTIC ARTHRITISSEPTIC ARTHRITIS– Laboratory findingsLaboratory findings
Elevated WBC count with left shiftElevated WBC count with left shift Elevated ESRElevated ESR Elevated CRPElevated CRP Positive blood culture Positive blood culture
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
SEPTIC ARTHRITISSEPTIC ARTHRITIS– Laboratory findingsLaboratory findings
Synovial fluid analysisSynovial fluid analysis– Volume > 3.5 mlVolume > 3.5 ml– Clarity: opaqueClarity: opaque– Color: yellow to greenColor: yellow to green– WBC: > 100,000/mm3, >75% PMN’sWBC: > 100,000/mm3, >75% PMN’s– Gram stain/Culture: positiveGram stain/Culture: positive– Total protein: 3 – 5 g/dlTotal protein: 3 – 5 g/dl– Glucose: <25 mg/dlGlucose: <25 mg/dl– LDH: variable compared to blood levelLDH: variable compared to blood level
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
SEPTIC ARTHRITISSEPTIC ARTHRITIS– Common organismsCommon organisms
Staphylococcus aureusStaphylococcus aureus Beta hemolytic streptococcusBeta hemolytic streptococcus Group A strepGroup A strep Hemophilus influenzaeHemophilus influenzae Neisseria gonorrheaNeisseria gonorrhea
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
SEPTIC ARTHRITISSEPTIC ARTHRITIS– Radiologic findingsRadiologic findings
Plain films:Plain films:– Soft tissue swellingSoft tissue swelling– Widened joint spaceWidened joint space– Periosteal reaction of the adjacent bone, Periosteal reaction of the adjacent bone,
suggestive of osteomyelitissuggestive of osteomyelitis
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
SEPTIC ARTHRITISSEPTIC ARTHRITIS– Radiologic findingsRadiologic findings
UltrasonographyUltrasonography– Increased joint space and amount of joint Increased joint space and amount of joint
fluidfluid– Increased vascularityIncreased vascularity
CT scanCT scan– Joint effusionJoint effusion– Increased vascularityIncreased vascularity– Erosion of the cartillageErosion of the cartillage– Periosteal reaction or osteomyelitisPeriosteal reaction or osteomyelitis
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
SEPTIC ARTHRITISSEPTIC ARTHRITIS– Radiologic findingsRadiologic findings
MRIMRI Radionuclide studiesRadionuclide studies
CAUSES OF LIMP IN PRE-CAUSES OF LIMP IN PRE-SCHOOL CHILDREN SCHOOL CHILDREN
ACUTEACUTE– FracturesFractures
Abusive injuriesAbusive injuries Toddler’s fractureToddler’s fracture Salter I fracturesSalter I fractures
– HemarthrosisHemarthrosis– HSPHSP– Septic hipSeptic hip– IM shotsIM shots– Toxic synovitisToxic synovitis
CHRONICCHRONIC– Blount diseaseBlount disease– Cerebral palsyCerebral palsy– Developmental Developmental
dysplasia of the dysplasia of the hiphip
– DiscitisDiscitis– Kohler diseaseKohler disease– Leg length Leg length
discrepancydiscrepancy– Vertical talusVertical talus
CAUSES OF LIMP IN CAUSES OF LIMP IN SCHOOL-AGE CHILDREN SCHOOL-AGE CHILDREN
ACUTEACUTE– FracturesFractures– MyositisMyositis
CHRONICCHRONIC– Legg-calve-Legg-calve-
Perthes diseasePerthes disease– Baker cystBaker cyst– Kohler diseaseKohler disease– LeukemiaLeukemia– Spinal Spinal
dysraphism dysraphism (tethered cord)(tethered cord)
– Tarsal coalitionTarsal coalition
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
LEGG-CALVE-PERTHES DISEASELEGG-CALVE-PERTHES DISEASE– Idiopathic vascular necrosis of the Idiopathic vascular necrosis of the
femoral headfemoral head– More common in boysMore common in boys– Common in 5 – 9 years old, may affect 2 Common in 5 – 9 years old, may affect 2
– 11 years old– 11 years old– Transitional stage of development of the Transitional stage of development of the
vascular anatomy of the femur vascular anatomy of the femur
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
LEGG-CALVE-PERTHES DISEASELEGG-CALVE-PERTHES DISEASE– Preceding history of minor traumaPreceding history of minor trauma– Predisposing factorsPredisposing factors
SCDSCD Steroid useSteroid use Hip dysplasiaHip dysplasia
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
LEGG-CALVE-PERTHES DISEASELEGG-CALVE-PERTHES DISEASE– Radiologic studiesRadiologic studies
Plain filmsPlain films Radioisotope studiesRadioisotope studies MRIMRI
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
KOHLER DISEASEKOHLER DISEASE– Affects more boys than girlsAffects more boys than girls– Most common in 5 – 10 years old, as Most common in 5 – 10 years old, as
early as 2 years oldearly as 2 years old– Impaired perfusion to the navicular bone Impaired perfusion to the navicular bone
of the talusof the talus– Inflammatory changes over the Inflammatory changes over the
navicular bonenavicular bone
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
KOHLER DISEASEKOHLER DISEASE– TreatmentTreatment
Weight bearing with below the knee Weight bearing with below the knee cast followed by arch supportcast followed by arch support
CAUSES OF LIMP IN CAUSES OF LIMP IN ADOLESCENTSADOLESCENTS
ACUTEACUTE– SprainSprain– StrainStrain– TendonitisTendonitis
CHRONICCHRONIC– ArthritisArthritis– Herniated discHerniated disc– SCFESCFE– ScoliosisScoliosis– Spinal Spinal
dysraphismdysraphism– SpondylolisthesisSpondylolisthesis– Chondromalacia Chondromalacia – RSDRSD– Osgood-SchlatterOsgood-Schlatter
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
OSGOOD-SCHLATTER DISEASEOSGOOD-SCHLATTER DISEASE– Over use injury affecting the insertion Over use injury affecting the insertion
site of the patellar tendon on the anterior site of the patellar tendon on the anterior tibial tubercletibial tubercle
– Inflammatory changes over the tubercleInflammatory changes over the tubercle– Treatment goal: decrease the stress on Treatment goal: decrease the stress on
the tuberclethe tubercle RestRest CastCast Excision of an ossicle Excision of an ossicle
Surface Anatomy of the Surface Anatomy of the KneeKnee
Saggital view of the kneeSaggital view of the knee
Osgood-Schlatter Disease Osgood-Schlatter Disease radiographsradiographs
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
SINDING-JOHANSSON-LARSEN SINDING-JOHANSSON-LARSEN DISEASEDISEASE– Traction tendinitis of the proximal Traction tendinitis of the proximal
attachment of the patellar tendon attachment of the patellar tendon (inferior pole of the patella)(inferior pole of the patella)
– Boys more than girlsBoys more than girls– Age of presentation: 10 –16 years old Age of presentation: 10 –16 years old – Overuse injury, athletesOveruse injury, athletes
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
SINDING-JOHANSSON-LARSEN SINDING-JOHANSSON-LARSEN DISEASEDISEASE– Radiologic findingsRadiologic findings
Irregular calcification of the inferior Irregular calcification of the inferior pole of the patellapole of the patella
– TreatmentTreatment RestRest CastCast
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
SLIPPED CAPITAL FEMORAL EPIPYSIS SLIPPED CAPITAL FEMORAL EPIPYSIS (SCFE)(SCFE)– Epiphyseal dislocation in superolateral Epiphyseal dislocation in superolateral
displacement and external rotation of displacement and external rotation of the femoral metaphysis, Salter I injurythe femoral metaphysis, Salter I injury
– Causes kinking of the epiphyseal vessels Causes kinking of the epiphyseal vessels that leads to compromised blood to the that leads to compromised blood to the epiphysisepiphysis
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
SCFESCFE– IncidenceIncidence
10/10000010/100000– Boys: 13.5, Girls 8.5/100000Boys: 13.5, Girls 8.5/100000
Regional and seasonal variationRegional and seasonal variation Initial presentation 20% bilateral hipInitial presentation 20% bilateral hip
– 20 – 40% eventually develop bilateral 20 – 40% eventually develop bilateral involvement within 18 months of initial involvement within 18 months of initial presentationpresentation
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
SCFESCFE– Radiologic classificationRadiologic classification
I: < 33%I: < 33% II: 33 – 50%II: 33 – 50% III: > 50%III: > 50% Displacement in relation to the femoral Displacement in relation to the femoral
neckneck
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
TreatmentTreatment– Depends on the onset of symptoms and Depends on the onset of symptoms and
gradegrade– Internal fixation with single cannulated Internal fixation with single cannulated
screwscrew– Prophylactic fixation of the unaffected Prophylactic fixation of the unaffected
hiphip– Osteomy of the proximal femurOsteomy of the proximal femur
SCFE radiographsSCFE radiographs
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
LABORATORY STUDIESLABORATORY STUDIES– Blood testsBlood tests
CBC, differential CBC, differential ESRESR CRProteinCRProtein Blood cultureBlood culture Lyme studiesLyme studies ANAANA ASOASO
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
LABORATORY STUDIESLABORATORY STUDIES– Normal synovial fluid characteristicsNormal synovial fluid characteristics
Highly viscousHighly viscous ClearClear Essentially acellularEssentially acellular Protein concentration is 1/3 of plasma Protein concentration is 1/3 of plasma
proteinprotein Glucose concentration is similar to Glucose concentration is similar to
plasma plasma
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
LABORATORY STUDIESLABORATORY STUDIES– Components of synovial fluid analysisComponents of synovial fluid analysis
ClarityClarity ColorColor ViscosityViscosity Glucose contentGlucose content Protein contentProtein content
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
LABORATORY STUDIESLABORATORY STUDIES– Components of synovial fluid analysisComponents of synovial fluid analysis
Microscopic examinationMicroscopic examination– WBC countWBC count– Crystal searchCrystal search– Gram satinGram satin
CultureCulture– Routine bacterial cultureRoutine bacterial culture– GC cultureGC culture– Unusual organismsUnusual organisms
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
RADIOLOGIC TESTSRADIOLOGIC TESTS– Plain radiographsPlain radiographs
Affected siteAffected site Comparison viewsComparison views Skeletal surveySkeletal survey
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
RADIOLOGIC TESTSRADIOLOGIC TESTS– MRIMRI– Radionuclide studiesRadionuclide studies– UltrasonographyUltrasonography– CT scanCT scan
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DISPOSITIONDISPOSITION– In-patientIn-patient
IV antibioticsIV antibiotics Diagnostic work-upDiagnostic work-up Surgical interventionSurgical intervention
– Out-patientOut-patient Observation with close follow upObservation with close follow up NSAID’sNSAID’s Sub-specialty referralsSub-specialty referrals
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DISPOSITIONDISPOSITION– ConsultationConsultation
OrthopedicOrthopedic– Joint aspirationJoint aspiration– Surgical interventionSurgical intervention
Hematology-OncologyHematology-Oncology– Bone marrow aspirationBone marrow aspiration– ChemotherapyChemotherapy
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DISPOSITIONDISPOSITION– ConsultationConsultation
Gynecologic Gynecologic – Pelvic examinationPelvic examination– Surgical interventionSurgical intervention
UrologyUrology– Surgical interventionSurgical intervention
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DISPOSITIONDISPOSITION– ConsultationConsultation
NeurosurgeryNeurosurgery Pediatric or general surgeryPediatric or general surgery
– Surgical interventionSurgical intervention
Infectious diseaseInfectious disease– Choice of antibioticsChoice of antibiotics– Length of treatmentLength of treatment
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DISPOSITIONDISPOSITION– ConsultationConsultation
RheumatologyRheumatology Pain specialistPain specialist PsychiatryPsychiatry PhysiatryPhysiatry
– Physical/occupational therapyPhysical/occupational therapy– OrthoticsOrthotics
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DISPOSITIONDISPOSITION– Diagnoses that require immediate Diagnoses that require immediate
interventionintervention Septic arthritisSeptic arthritis OsteomyelitisOsteomyelitis MeningitisMeningitis Epidural abscessEpidural abscess
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DISPOSITIONDISPOSITION– Diagnoses that require immediate Diagnoses that require immediate
interventionintervention FracturesFractures Dislocated patellaDislocated patella SCFESCFE Developmental dysplasia of the hipDevelopmental dysplasia of the hip
THE CHILD WITH A LIMPTHE CHILD WITH A LIMP
DISPOSITIONDISPOSITION– Diagnoses that require immediate Diagnoses that require immediate
interventionintervention Neoplasms/tumorsNeoplasms/tumors Testicular torsionTesticular torsion AppendicitisAppendicitis PID with tuboovarian abscessPID with tuboovarian abscess DiscitisDiscitis
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