pediatric limp: board review - c.ymcdn.comc.ymcdn.com/sites/ 2 the game plan learn about 15 commonly...

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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 %

http://static3.businessinsider.com/image/52545f89eab8ea62534aa515-1200-375/brain%20golfing.jpg

GOALS & OBJECTIVES

• 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

Review diagnosis and management of, and identify buzz words pertaining to, these pathologies:

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THE GAME PLAN

LEARN ABOUT 15 COMMONLY TESTED CAUSES OF PEDIATRIC LIMP

DISCUSS 5 PATIENT CASES

ANSWER 2-3 BOARD STYLE QUESTIONS PER CASE

REVIEW FAST FACTS ABOUT EACH DIAGNOSIS AND DIFFERENTIATING FACTORS

BRIEFLY DEFINE NORMAL GAIT

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

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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 #1THE WORRIED MOTHER

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CASE #1

A. METATARSUS ADDUCTUS

B. CEREBRAL PALSY

C. DEVELOPMENTAL DYSPLASIA OF THE HIP

D. FEMORAL ANTEVERSION

E. INTERNAL TIBIAL TORSION

• 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?

CASE #1


B. CEREBRAL PALSY






OVER HIS FEET.





CASE #1


B. CEREBRAL PALSY






OVER HIS FEET.





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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. PLAIN FILMS

B. CBC, ESR, RF

C. SERIAL CASTING

D. REASSURANCE AND ANTICIPATORY GUIDANCE

E. ORTHOPEDIC REFERRAL



OVER HIS FEET.




• WHAT IS THE MOST APPROPRIATE NEXT STEP?

CASE #1 CONTINUED

A. PLAIN FILMS

B. CBC, ESR, RF

C. SERIAL CASTING





OVER HIS FEET.





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CASE #1 CONTINUED



OVER HIS FEET.





A. PLAIN FILMS

B. CBC, ESR, RF

C. SERIAL CASTING



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

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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

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CASE #2OW, MY LEG!

CASE #2

A. EWING SARCOMA

B. SLIPPED CAPITAL FEMORAL EPIPHYSIS

C. LEGG-CALVÉ-PERTHES DISEASE

D. PATELLOFEMORAL SYNDROME

E. GROWING PAINS

• 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

CASE #2

A. EWING SARCOMA




E. GROWING PAINS






ESSENTIALLY NORMAL.


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CASE #2

A. EWING SARCOMA




E. GROWING PAINS






ESSENTIALLY NORMAL.


CASE #2 CONTINUED

A. IMMEDIATE SURGICAL 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






ESSENTIALLY NORMAL.

• THE MOST APPROPRIATE NEXT STEP IS

CASE #2 CONTINUED

A. IMMEDIATE SURGICAL 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






ESSENTIALLY NORMAL.

• THE MOST APPROPRIATE NEXT STEP IS

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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.

• APPROXIMATELY 30% OF PATIENTS WITH SCFE ALSO HAVE

ASYMPTOMATIC SCFE ON THE OTHER SIDE

• TX: ORTHOPEDIC REFERRAL FOR SURGICAL FIXATION

Top Image source: meds.queensu.ca

Bottom image source: radiopaedia.org






ESSENTIALLY NORMAL.

• THE MOST SERIOUS COMPLICATION THAT CAN DEVELOP IS

CASE #2 CONTINUED

A. AVASCULAR NECROSIS

B. CONTRALATERAL SCFE

C. CHONDROLYSIS

D. RESIDUAL DEFORMITY

E. SEPTIC ARTHRITIS






ESSENTIALLY NORMAL.

• THE MOST SERIOUS COMPLICATION THAT CAN DEVELOP IS

CASE #2 CONTINUED

A. AVASCULAR NECROSIS

B. CONTRALATERAL SCFE

C. CHONDROLYSIS

D. RESIDUAL DEFORMITY

E. SEPTIC ARTHRITIS

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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 FIXATIONImage source: radiopaedia.org

CASE #3HEY, MY HIP!

• 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?

CASE #3

A. CBC WITH DIFF

B. PLAIN HIP AND FEMUR FILMS

C. ESR

D. JOINT FLUID ANALYSIS

E. CRP

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CASE #3

A. CBC WITH DIFF


C. ESR


E. CRP










CASE #3

A. CBC WITH DIFF


C. ESR


E. CRP

CASE #3 CONTINUEDYOUR TEST RESULTS ARE BELOW:

• CBC

• WBC 13 X109/L

• HGB 12 G/DL

• HCT 43 %

• PLATELETS 340 X103 /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

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CASE #3 CONTINUEDYOUR TEST RESULTS ARE BELOW:

• CBC

• WBC 13 X109/L

• HGB 12 G/DL

• HCT 43 %

• PLATELETS 340 X103 /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

http://upload.orthobullets.com/1058/images/chart%20(acute%20disorders%20of%20the%20joints%20and%20bursa).jpg

Our Fluid:Appearance: Clear, Yellow

Cells: WBC 300, PMNs 20%Crystals: negativeGlucose: 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 DEVELOP LEGG-CALVE-PERTHES DISEASE, COXA

MAGNA, OR OSTEOARTHRITIS, OR HAVE RECURRENCES.

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SEPTIC ARTHRITIS

• AN ORTHOPEDIC EMERGENCY

• 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

SEPTIC ARTHRITIS ORGANISMS:

• < 4 MONTHS: S. AUREUS AND GBS

• 4 MO - 4 YRS: H. INFLUENZAE AND S. AUREUS

• > 4 YEARS : S. AUREUS AND S. PYOGENES

• ADOLESCENCE: CONSIDER N. GONORRHOEAE

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

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CASE #4GOODNIGHT, SLEEP TIGHT

CASE #4

A. REFERRAL TO ORTHOPEDIC SURGERY

B. MRI BILATERAL FEMUR

C. REASSURANCE, NSAIDS, RICE

D. ORAL ANTIBIOTICS

E. BILATERAL KNEE BRACES

• 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.


CASE #4




D. ORAL ANTIBIOTICS










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CASE #4




D. ORAL ANTIBIOTICS










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

A. REASSURANCE, NSAIDS, RICE

B. ORAL ANTIBIOTICS

C. REFERRAL TO ORTHOPEDIC SURGERY

D. HINGED KNEE BRACE

E. PLAIN FILMS, CBC, ESR, CRP

• 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.


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CASE #4 CONTINUED


B. ORAL ANTIBIOTICS












CASE #4 CONTINUED


B. ORAL ANTIBIOTICS












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 15-19

• 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

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AAP’S FLOWCHART

Bone Lesions: Benign and MalignantRani Gereige, Mudra KumarPediatrics in Review Sep 2010, 31 (9) 355-

363

MALIGNANT BONE TUMOR FAST FACTSOSTEOSARCOMA

• 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

• 2ND MOST COMMON

• PEAK AGES 10-20 YR OLD

• TYPICALLY MIDSHAFT OF LONG BONES, PELVIS, AND

SPINE.

• OFTEN SYSTEMIC SYMPTOMS

• XR:

• POORLY MARGINATED INTRAMEDULLARY LYTIC

LESION WITH PERIOSTEAL REACTION

• M IXED, LAYERED SCLEROTIC AND LYTIC LESION, CALLED “ONION-SKINNING” APPEARANCE

• DX: BIOPSY SHOWS UNDIFFERENTIATED, SMALL, ROUND CELLS

• TX: CHEMO, RADIATION, SURGICAL RESECTION

CASE #5WHITE MEN CAN’T JUMP

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CASE #5

A. SEVER'S DISEASE

B. SINDING-LARSEN-JOHANSSON SYNDROME

C. OSTEOCHONDRITIS DESSICANS

D. OSGOOD SCHLATTER'S DISEASE

E. PATELLOFEMORAL PAIN SYNDROME

• 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?

CASE #5 XRAY

Image source: radiopaedia.org

CASE #5

A. SEVER'S DISEASE








ASSOCIATED SYMPTOMS





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CASE #5

A. SEVER'S DISEASE








ASSOCIATED SYMPTOMS








ASSOCIATED SYMPTOMS




• THE MOST APPROPRIATE INITIAL TREATMENT IS:

CASE #5

A. SURGICAL TUBERCLE FIXATION

B. KNEE BRACING

C. CAST IMMOBILIZATION

D. REST, ICE, NSAIDS

E. OSSICLE EXCISION




ASSOCIATED SYMPTOMS




• THE MOST APPROPRIATE INITIAL TREATMENT IS:

CASE #5

A. SURGICAL TUBERCLE FIXATION

B. KNEE BRACING

C. CAST IMMOBILIZATION

D. REST, ICE, NSAIDS

E. OSSICLE EXCISION

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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


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) TO 14 (BOYS), AND FUSE BETWEEN 14-18 YEARS.

• PE: TENDERNESS, SWELLING AT TIBIAL TUBERCLE

• XR: AP AND LATERAL KNEE

• IRREGULARITY AND FRAGMENTATION OF THE TIBIAL TUBERCLE



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.

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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 > 101.3

• 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 - 2ND MOST COMMON. 10-20 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.


• 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


1/10/2017

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SOURCES

• CLARK, MARK C. APPROACH TO THE CHILD WITH A LIMP. UPTODATE.COM. LAST UPDATED: AUG 11, 2016.

• CLARK, MARK C. OVERVIEW OF THE CAUSES OF LIMP IN CHILDREN. UPTODATE.COM. LAST UPDATED: AUG 11, 2016.

• FARAHI, NARGES. PEDIATRIC AND ADOLESCENT MEDICINE. FIRST AID FOR THE FAMILY MEDICINE BOARDS. 2ND ED. MCGRAW HILL, 2008.

• GEREIGE, R. KUMAR, M. BONE LESIONS: BENIGN AND MALIGNANT. PEDIATRICS IN REVIEW. SEP 2010, 31 (9) 355-363

• SAWYER, JR AND KAPOOR, M. THE LIMPING CHILD: A SYSTEMATIC APPROACH TO DIAGNOSIS. AM FAM

PHYSICIAN. 2009. FEB 1:79(3):215-224.

• SOUDER, CHRIS ET AL. SELECTED ARTICLES FROM ORTHOBULLETS.COM. ALL REFERENCED TOPICS ACCESSED DEC 2016.

• WHEELESS, CLIFFORD R. WHEELESS' TEXTBOOK OF ORTHOPAEDICS. ACCESSED ONLINE AT WHEELESSONLINE.COM. LAST

UPDATED NOV 3, 2015.

• ALL IMAGES SOURCED ON SLIDES.

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