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Home , Limp, Transient synovitis

Destin Hill, MD; John Whiteside, MD in children: Diff erentiating St. Mary’s Family Medicine Residency, St. Mary’s Hospital and Regional Center, benign from dire causes Grand Junction, Colo

john.whiteside@stmarygj. Key decision points in the stepwise approach presented org here can make your investigation more effi cient and The authors reported no potential confl ict of interest productive. relevant to this article.

mother brings her 4-year-old son to the offi ce because PRACTICE he has been limping. She isn’t aware of a specifi c trau- RECOMMENDATIONS A ma. But the boy and his twin brother, while recovering › Use radiographs to identify from “colds,” were rough-housing in their room when this son bone changes from disease complained of pain. He is afebrile and points to his as the (as well as fracture) when area of pain. evaluating a limp. C Although limping in children is common—the incidence › Consider growth plate is roughly 2 per 10001—it is never normal. It indicates pain, as well as tod- weakness, or structural abnormality.2 Most cases result from dler’s fracture; both may trauma.1 Limp usually resolves with little intervention and be radiographically occult no sequelae. However, the diff erential diagnosis is broad and and require immobiliza- daunting (TABLE 1), and some causes of limp are associated tion for treatment. C with signifi cant morbidity. › Consider child abuse if the patient has an isolated mid-shaft tibial fracture. C Helpful tips for your initial assessment › Assess for , elevated Many textbook authors have described some causes of limp as sedimentation rate, elevated “painless.” However, truly painless limp is rare, seldom acute, C-reactive protein, and and usually the result of mechanical or neuromuscular disor- leukocytosis when radio- ders.1 A more likely explanation for acute “painless” limp is that graphs are unrevealing or a young child with pain is unable to express pain or accurately when a patient has systemic symptoms associated with identify its location. Further, the child may instinctively avoid limp. Th ese factors are predic- painful positions or movements and, thus, may present only tors of septic . B with decreased movement of an extremity or refusal to bear weight.3 Strength of recommendation (SOR) With a child who has knee pain, remember the pediatrics A Good-quality patient-oriented maxim: “Knee pain equals pain,”3 underscoring the diag- evidence nostic diffi culty with limp. B Inconsistent or limited-quality patient-oriented evidence Also bear in mind that children of diff erent ages tend to C Consensus, usual practice, have diff erent etiologies of limp TABLE( 2). For example, sep- opinion, disease-oriented evidence, case series tic arthritis, , and transient occur more commonly in children under 10 years. Legg-Calve-Perthes dis- ease and leukemia are more common in children between the ages of 4 and 10. Slipped capital femoral epiphysis (SCFE) is more common in boys over the age of 11. CONTINUED

JFPONLINE.COM VOL 60, NO 4 | APRIL 2011 | THE JOURNAL OF FAMILY PRACTICE 193 TABLE 1 Fracture Possible causes of limp Fracture is a possibility across all age rang- 1-3,17 es, necessitating radiographs if suspected. in a child Beyond detecting fractures, x-ray fi lms can Traumatic/mechanical identify bony changes associated with dis- ease (eg, Legg-Calve-Perthes disease, SCFE). Fractures, stress fractures Radiographs can also identify a clinically sig- Muscle injuries nifi cant joint eff usion at the hip.4 However, Sprains/strains x-ray results may be falsely negative for some Contusions fracture types. ❚ Salter-Harris Type I fractures are trans- Developmental dysplasia of the hip verse fractures through the growth plate with Slipped capital femoral epiphysis epiphyseal separation from the metaphy- Tarsal coalition sis.5 Typical fi ndings are a history of trauma Child abuse and point tenderness over the epiphyseal Overuse injuries plate. Type I fractures are radiographically occult, making the easy to mistake Leg length discrepancy as a sprain. Nonetheless, growth plate in- Infectious juries are common in children, requiring Salter-Harris immobilization. ❚ Toddler’s fracture Type 1 Osteomyelitis was fi rst described as fractures are a spiral, oblique undisplaced fracture of the radiographically distal tibial shaft in children from 9 months occult, making Psoas abscess to 3 years of age.6 It results from a rotational the injury easy Diskitis or twisting force through the while the leg rotates internally on a planted foot.7,8 to mistake as Infl ammatory a sprain. Th is is the most common tibial fracture in in- fants and young children.9 Th e incidence has Juvenile been reported as 0.6 to 2.5 per 1000 pediat- ric visits.10 Accurate diagnosis is important Reiter syndrome because current treatment recommenda- tions suggest a long leg cast for 3 to 5 weeks, Lupus followed by a short leg cast for a total of Vascular 6 weeks.11 Legg-Calve-Perthes disease Despite being the most common tibial fracture, toddler’s fracture is easily missed. Osteonecrosis Initial radiographs are only 53% sensitive.7,10 Hemoglobinopathies (sickle cell disease) Th is implies that nearly 50% of children with Neoplastic tibial fracture will have an initially negative Leukemia, lymphoma x-ray result. However, nearly 94% of children with a confi rmed toddler’s fracture have been Malignant/lytic tumors (Ewing sarcoma, 12 osteogenic sarcoma, etc.) unable to bear weight. Evidence suggests that despite negative radiographs, patients Metabolic with point tenderness over the tibia and an Rickets inability to bear weight should be treated for 12 Hyperparathyroidism presumed toddler’s fracture. Another confusing aspect of toddler’s Neuromuscular fracture is that the causative injury is often Muscular dystrophy considered insignifi cant by parents—eg, Cerebral palsy tripping, falling from a modest height, or a 7,8 Peripheral neuropathy twisting motion. Th ese events may occur countless times during the average day of a

194 THE JOURNAL OF FAMILY PRACTICE | APRIL 2011 | VOL 60, NO 4 LIMP IN CHILDREN

TABLE 2 Common causes of limp according to child’s age1

<3 years 3-10 years 11-18 years

Foreign body Legg-Calve-Perthes disease Juvenile arthritis

Osteomyelitis Osteomyelitis Slipped capital femoral epiphysis

Septic arthritis Septic arthritis Trauma (physeal fracture)

Toddler’s fracture Transient synovitis Tumor

Transient synovitis Trauma (physeal fracture)

Tumor Tumor

toddler. Often parents do not witness the in- tis or transient synovitis (FIGURE). Both may jury and are unable to describe the mecha- present with limp and fever as well as pain, nism of injury.7 decreased range of motion, bone tenderness, ❚ When to suspect child abuse. When a swelling, and warmth.15 child presents with fracture after an unwit- ❚ Transient synovitis is the most common A midshaft tibial nessed trauma and the story does not match cause of in children up to 10 years fracture may be the injury pattern, consider child abuse. With of age, with a 3% risk of occurrence through an indication of tibial fractures, the location of the fracture childhood.16,17 Its cause is unclear, but many child abuse. can help distinguish a result of abuse from a experts have proposed a viral agent.17 Tran- toddler’s fracture. Toddler’s fracture is clas- sient synovitis universally resolves without sically described as a distal tibial fracture. sequelae in 1 to 2 weeks. Th erefore, prescribe In contrast, a midshaft tibial fracture often rest and nonsteroidal anti-infl ammatory suggests child abuse.8,13 In a small retrospec- drugs (NSAIDs) for symptomatic relief, and tive study of 37 children diagnosed with tod- reassure parents.16 dler’s fracture, 4 midshaft tibial fractures ❚ Septic arthritis, although often similar were found.8 Child abuse was confi rmed in in presentation to transient synovitis, requires 2 of these cases.8 However, other authors, hospitalization, operative drainage, and par- including Dr. Dunbar in his sentinel article,6 enteral antibiotics.18 A delay in diagnosis is assert that toddler’s fracture may occasion- associated with poor outcome, including os- ally extend into the midshaft of the tibia. teonecrosis, growth arrest, permanent loss of Consequently, a midshaft tibial fracture is joint function, and sepsis.3,18 not pathognomonic for child abuse. But the Several studies have shown children with diagnosis should be considered. Perform a septic arthritis usually appear more acutely ill careful examination for other signs of abuse than those with transient synovitis.4,18-21 Th ey or neglect, and do not hesitate to report sus- are described as toxic-appearing, and have pected child abuse to the proper local and leukocytosis, a high erythrocyte sedimenta- state authorities.14 tion rate (ESR), and a high fever.19 However, no single marker or specifi c laboratory value consistently identifi es septic arthritis. Many Transient synovitis studies have been performed in an eff ort to vs septic arthritis identify a collection of factors, or an algo- A child who or refuses to bear weight rithm, that can predict the probability of sep- on a limb often has associated symptoms tic arthritis. of acute illness. In these cases, or when ra- Fever, an elevated ESR, and leukocytosis diographs have ruled out apparent abnor- are independent multivariate clinical predic- malities such as Legg-Calve-Perthes disease, tors for septic arthritis. Th e prediction algo- SCFE, and fracture, consider septic arthri- rithm published by Jung et al is the only study

JFPONLINE.COM VOL 60, NO 4 | APRIL 2011 | THE JOURNAL OF FAMILY PRACTICE 195 FIGURE Diagnostic algorithm for pediatric limp3,4,6,8-12,15

A child presents with limp with Order x-rays to detect fracture or Yes or without joint pain. Is there Yes Treat as appropriate. evidence of bone disease. X-ray focal bone tenderness or history results may be falsely negative for of trauma? some fracture types. Is fracture No. Consider occult detected? fracture types. No

No Does the child have systemic symptoms?

Yes

Does the child have ≥2 of 4 clinical/laboratory values? No With ≤1 value present, prescribe • Fever >38ºC and reassess the child No Continue to observe patient. • ESR >20 mm/h in 1 to 2 days. Has the condition Yes worsened? • CRP ≥1 mg/dL • WBCs >12,000/mL

Yes

Yes Treat septic arthritis according to Order an ultrasound Yes Aspirate the effusion and obtain culture and gram stain results. examination of the painful joint. culture and gram stain of the Is effusion present? fl uid. Does the aspirate contain No >50,000 WBCs/mL? Suspect transient synovitis. No Prescribe NSAIDs and rest; observe for 1 to 2 weeks.

Consider ordering an MRI or Yes bone scan. Do results reveal bony Suspect osteomyelitis. changes suggestive of infection?

No

CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; MRI, magnetic resonance imaging; NSAIDs, nonsteroidal anti-infl ammatory drugs; WBCs, white blood cells.

to have included C-reactive protein (CRP) consistently identifi ed can be useful. Sim- as a predictive factor,4 which happens to be ply, if a patient presents with joint pain and an excellent independent predictor of sep- 2 or more of the 4 predictors, septic arthritis tic arthritis. Specifi cally, with a normal CRP must be fully evaluated. Th e presence of 2 <1 mg/dL, the probability of a patient not of 4 predictors suggests a risk of septic ar- having septic arthritis is 87%.22 thritis between 10% and 40%.4,18,20 A single While no predictive algorithm has been predictor is associated with a risk of 1% conclusively validated, the fact that the to 10%.4,18,20 Yet, you must interpret these same clinical and laboratory predictors are clinical predictors in light of the full clini-

196 THE JOURNAL OF FAMILY PRACTICE | APRIL 2011 | VOL 60, NO 4 LIMP IN CHILDREN

cal picture, as septic arthritis is still possible How the opening case resolved in patients with only 1 predictor. Such pos- Th e boy avoided weight-bearing on the af- sibilities require cautious management and fected leg, but had no focal bone tenderness. close follow-up. Moving the hip, but not the knee, reproduced With 2 of 4 predictors present, suspect pain. Radiographs were negative for fracture septic arthritis and order an ultrasound of or changes typical of Legg-Calve-Perthes the aff ected joint. If eff usion is present, as- disease. He was afebrile in the offi ce, but the pirate the joint. Some authors suggest that mother described a fever at home. Th e child all patients with hip pain should undergo appeared ill, but stable. We decided to obtain ultrasound, and that those with a joint eff u- a blood sample. sion should undergo aspiration.15 However, Results for CRP, ESR, and white blood cell joint aspiration, particularly of the hip, can count were normal. With this information, we be associated with multiple complications reassured the mother that the diagnosis was and should be avoided if possible.22 Eff usion likely transient synovitis. We advised a weight- is also possible with transient synovitis and appropriate dose of ibuprofen and scheduled noninfectious causes of joint pain, but the a follow-up appointment for 2 days later. JFP aspirate will have a negative culture and nor- mal gram stain fi ndings. Ultrasound has been CORRESPONDENCE shown to be 100% accurate in predicting the John Whiteside, MD, St. Mary’s Family Medicine Residency, 1160 Patterson Road, Grand Junction, CO 81506; john. 23 presence of eff usion. [email protected] Children with septic arthritis usually appear References more acutely ill 1. Abbassian A. Th e limping child: a clinical approach to diagno- 13. Mellick LB, Milker L, Egsieker E. Childhood accidental spiral than those sis. Br J Hosp Med. 2007;68:246-250. tibial (CAST) fractures. Ped Emerg Care. 1999;15:307-309. with transient 2. Leung AK, Lemay JF. Th e limping child.J Ped Health Care. 14. Jenny C, Committee on Child Abuse and Neglect. Evaluating 2004;18:219-223. infants and young children with multiple fractures. Pediatrics. synovitis. 3. Frick SL. Evaluation of the child who has hip pain. Orthop Clin 2006;118:1299-1303. North Am. 2006;37:133-140. 15. Dabney KW, Lipton G. Evaluation of limp in children. Curr 4. Jung ST, Rowe SM, Moon ES, et al. Signifi cance of laboratory Opin Pediatr. 1995;7:88-94. and radiologic fi ndings for diff erentiating between septic ar- 16. Sherry DD. Limb pain in childhood. Pediatr Rev. 1990;12:39-46. thritis and transient synovitis of the hip. J Pediatr Orthop. 17. Do TT. Transient synovitis as a cause of painful limps in chil- 2003;23:368-372. dren. Curr Opin Pediatr. 2000;12:48-51. 5. Brown JH, DeLuca SA. Growth plate injuries: Salter-Harris 18. Kocher MS, Zurakowski D, Kasser JR. Diff erentiating between classifi cation. Am Fam Physician. 1992;46:1180-1184. septic arthritis and transient synovitis of the hip in children: an 6. Dunbar JS, Owen HF, Nogrady MB, et al. Obscure tibial frac- evidence-based clinical prediction algorithm. J Bone Joint Surg ture of infants–the toddler’s fracture. J Can Assoc Radiol. Am. 1999;81:1662-1670. 1964;15:136-144. 19. Luhmann SJ, Jones A, Schoolman M, et al. Diff erentiation be- 7. Miller JH, Sanderson RA. Scintigraphy of toddler’s fracture. J tween septic arthritis and transient synovitis of the hip in chil- Nucl Med. 1988;29:2001-2003. dren with clinical prediction algorithms. J Bone Joint Surg Am. 8. Tenenbein M, Reed MH, Black GB. Th e toddler’s fracture revis- 2004;86-A:956-962. ited. Am J Emerg Med. 1990;8:208-211. 20. Kocher MS, Mandiga R, Zurakowski D, et al. Validation of a 9. Tschoepe EJ, John SD, Swischuk LE. Tibial fractures in infants clinical prediction rule for the diff erentiation between septic and children: emphasis on subtle injuries. Emerg Radiol. arthritis and transient synovitis of the hip in children. J Bone 1998;5:245-252. Joint Surg Am. 2004;86-A:1629-1635. 10. Clancy J, Pieterse J, Roberston P, et al. Toddler’s fracture. J Accid 21. Delaney RA, Lenehan B, O’Sullivan L, et al. Th e limping child: Emerg Med. 1996;13:366-367. an algorithm to outrule musculoskeletal sepsis. Ir J Med Sci. 2007;176:181-187. 11. Wheeless CR. Cast treatment of tibial fractures. In: Whee- less’ Textbook of Orthopaedics. 2011. Available at: http:// 22. Levine MJ, McGuire KJ, McGowan KL, et al. Assessment of the www.wheelessonline.com/ortho/cast_treatment_of_tibial_ test characteristics of C-reactive protein for septic arthritis in fractures. Accessed March 11, 2011. children. J Pediatr Orthop. 2003;23:373-377. 12. Halsey MF, Finzel KC, Carrion WV, et al. Toddler’s fracture: 23. Alexander JE, Seibert JJ, Glasier CM, et al. High-resolution presumptive diagnosis and treatment. J Pediatr Orthop. hip ultrasound in the limping child. J Clin Ultrasound. 1989; 2001;21:152-156. 17:19-24. We want to hear from you!

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