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The Limping Or Non-Weight Bearing Child

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The Limping Or Non-Weight Bearing Child The Limping or Non-Weight Bearing Child Guideline Review Amy Romashko, MD Medical Director, Children’s Wisconsin I have no financial relationships to disclose except that I am employed at Children’s Wisconsin. Amy Romashko, MD Poll Everywhere • Option 1: • Option 2: • Download the “Poll Everywhere” App to your • Text smarthouse961 to 22333 smartphone • Then text your response: A, • Enter smarthouse961 B, C, or D to participate in • Click Join each question • You will stay connected to the poll through that text stream until you text LEAVE © Children’s Wisconsin Objectives • Understand the utility of using an evidence based guideline when evaluating non-weight bearing or limping pediatric patients presenting to an Urgent Care setting. • Review elements of the H&P which are particularly helpful in narrowing down the differential dx of a child with a limp. • Reflect on how the guideline applies to sample cases of patients presenting with a limp or non-weight bearing. • Identify barriers that might result in providers not following the guideline. © Children’s Wisconsin The Limping or Non-Weight Bearing Child • A 2 y.o. female presents to Urgent Care with a cc of “difficulty walking”. • Hx sig for: • Intermittent temps up to 100 for a few days approximately one week ago accompanied by one episode of emesis. • No fever and acting well for the past 3 days. • Has refused to put weight on her R leg since waking up this am, points to right knee when asked what hurts. • No hx trauma, patient is otherwise in good spirits. • Temp Measured in clinic 100.5. © Children’s Wisconsin Etiologies of Limp • Source of limp: • Causes: • Osseous • Trauma • Articular • Infectious • Neurological • Immune Mediated • Soft tissue • Acquired or • Intra-abdominal Developmental • Other • Neoplastic • Referred • Benign Musculoskeletal • Neurologic • Metabolic © Children’s Wisconsin Here lies the challenge. • How do we: • Ensure that we do not miss something very serious and time sensitive (e.g.: septic hip) • Keep in mind the less common things that could be causing the symptoms? (e.g.: malignancy, child abuse) • Not waste time and money working up something that could be benign (e.g. toxic synovitis) © Children’s Wisconsin Evidence Based Guideline • Thankfully, EBG can be used help guide us to the best and safest course for our patients. • Our guideline was developed by our Clinical Practice Group • Dr. Olorundami • Ilana Cabrera • Process: • Lit search/Established Guideline Review • Rough Draft • Review by Subspecialists at CW • Review and Edits by Group © Children’s Wisconsin Note • This guideline is not designed to fully diagnose a child with a limp. • Follow-up of those kids discharged home allows for further outpatient workup or subspecialty consult as necessary if the limp was to continue or reoccur. • FOLLOW UP IS KEY!!!! © Children’s Wisconsin Guideline Format- Children’s Wisconsin Urgent Care • Subject • Purpose • Definition of Condition • Etiology and Differential Dx • Guideline • Subjective Data/Hx • Objective Data/PE • Diagnostic Studies • Treatment (if applicable) • Follow-up Recommendations • References • Appendices (Summary Charts, Pathways) © Children’s Wisconsin The Limping or Non-Weight Bearing Child • True incidence unknown. • What is limping? • One published study on the • Deviation from normal gait limping child found: • Can be secondary to pain, weakness, or musculoskeletal deformity. • 1.8 per 1000 kids less than 14 years • Antalgic Gait • Male to female ratio 1.7:1 • Shortening of the stance phase of the • Median age: 4.4 years affected leg to avoid pain. • Most common dx: transient • Non-antalgic gait synovitis • Trendelenburg gait • The hip drops on the normal side during swing phase and the trunk leans to the affected side to compensate for hip abductor weakness. • SCFE, DDH, Legg-Calve Perthes Disease, Muscular Dystrophy © Children’s Wisconsin © Children’s Wisconsin Subjective Data/History: Pain Characteristics • Site • Focal vs generalized • Unilateral vs bilateral • Onset • Acute • Chronic • Severity • How much is this effecting their activity? • Duration • Constant • Intermittent • Aggravating and relieving Factors • Present at rest? • What makes it better or worse? © Children’s Wisconsin Answer: Toxic Synovitis © Children’s Wisconsin Answer: All of the Above © Children’s Wisconsin Subjective Data/History: Pain Characteristics • Radiation • Quality o Aching, dull, burning, sharp • Weight-bearing o Complete or partial refusal • Associated Pain o Abdomen o Back © Children’s Wisconsin Subjective Data/History • Trauma/Known mechanism of injury • Systemic Symptoms • Fever, rash, weight loss, malaise, anorexia, night sweats • Morning stiffness • Neurologic symptoms • Incontinence, sciatica or leg weakness © Children’s Wisconsin Subjective Data/History • Medical Hx • Social Hx: • Bleeding disorders • Sports participation • Surgical Hx • Sexual activity • Developmental Hx • Sick Contacts • Prior Injuries • Preceding Events • Viral illness/diarrhea • Tick Bite • Pharyngitis © Children’s Wisconsin Objective Data/Physical Exam • Do as much inspection/palpation in parent’s lap as possible! • What does “normal” limb look like? • Try to examine supine and seated. © Children’s Wisconsin Inspection, Palpation, ROM Limbs • Looking for: • Erythema • Swelling • Deformity • Lacerations/Abrasions • Bruising • Increased warmth • Tenderness to movement and palpation • Limb length discrepancy © Children’s Wisconsin Answer: All of the above © Children’s Wisconsin Answer: True! © Children’s Wisconsin Joint Range of Motion • Ankle • Knee • Hip © Children’s Wisconsin Answer: A hip joint effusion (flexion and external rotation decreases pressure in the hip joint, relieving pain © Children’s Wisconsin Answer: Legg-Calve Perthes Disease © Children’s Wisconsin Examination Back/Abdomen • Back • Abdomen • Palpate Paraspinal Muscles, • Tenderness Spinous Processes, Iliac • Masses Spines • Psoas and obturator signs • ROM Back © Children’s Wisconsin Examining Gait • Have child barefoot and minimally clothed • Will child bear weight? • Standing, Walking and Running • Symmetry • Stance • Gait pattern/Type of Limp © Children’s Wisconsin Diagnostic Studies: Imaging • Begin with the area of • X-Ray can be initially normal concern in: • Both AP and lateral views • Some acute fractures • Hips: • Early Legg-Calve Perthes • AP and frog leg views of hips • Osteomyelitis or septic arthritis • Suspected SCFE • AP and true lateral of BOTH hips for comparison • NO FROG LEG VIEW • Other Imaging Modalities • Ultrasound • Young children or non-focal • CT exam: image both legs • MRI • Bone scan © Children’s Wisconsin Laboratory Studies • Directed by the H&P findings • Not indicated if: • Initial Lab Assessment • Afebrile Child • CBC with diff • Normal imaging • ESR • Esp if: • CRP • Isolated injury • Pain <24 hours • Additional Labs to Consider: • Lyme Studies • Indicated if: • Blood Cultures • Concern for infectious, • If suspicious for septic arthritis or inflammatory, or neoplastic osteomyelitis etiology © Children’s Wisconsin Kocher criteria for septic arthritis: • The risk of septic arthritis has • Inability to been found to be successively ambulate greater with each additional number of positives. • Fever of 38.5 C (101 F) or above • If all 5 are present, septic arthritis is highly likely (99%) • WBC > 12K • ESR > 40 • If none of these are present, the risk of septic arthritis is • CRP > 2 very low (0.2%). © Children’s Wisconsin Septic Arthritis vs Osteomyelitis Septic arthritis Osteomyelitis Most often infants and young children under age 4 Most common under age 5, but can occur at any age Hip and knee most common sites Effects metaphyseal regions of bones so can cause peri-articular pain and tenderness Child is often toxic, febrile, with decreased appetite Child may appear toxic or have very little outward evidence of infection Prognosis for full recovery good only if treatment Prognosis is better than septic arthritis provided w/in 24 hours of symptom onset Delay in diagnosis causes proportionally bad prognosis Established infection can damage growth plate causing for osteonecrosis and permanent joint damage limb length discrepancy © Children’s Wisconsin Treatment and Follow-up • Afebrile child, no hx trauma, normal imaging (suspected toxic synovitis) • Bed rest • Pain relief with NSAD or acetaminophen • FU with PCP in 2-3 days • Consider referral to Rheumatology for sx >4 weeks • Prompt reassessment for + fever, worsening symptoms • Suspected toddler fracture • Splint and ortho FU • Febrile child without joint effusion, normal radiologic and blood studies • Close FU as an outpatient © Children’s Wisconsin © Children’s Wisconsin Barriers to Use of Guideline • Lack of resources in our UCs (Blood work) • Pushback from family when transfer necessary for further work-up • Desire to “solve the mystery now.” • Lack of awareness of guideline © Children’s Wisconsin Cases Pre Guideline 2 yo boy presents with limp since yesterday HISTORY • Since yesterday, slightly fussy when walking and seems to be favoring L leg. • No known injury/trauma. • Had some loose stools and tactile fever for a few days earlier in the week. • Pt otherwise has been acting well and is in good spirits. Eating and drinking well. • Tylenol given, no help • Sick contacts: around lots of other kids for birthday party the day before yesterday, nobody sick. OBJECTIVE: (POSITIVE FINDINGS ONLY) • AF, VS normal • MSK: No apparent tenderness to palpation, swelling, erythema, or apparent loss of ROM left leg. Fussing
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