sign in sign up
<<
Home , Limp, Transient synovitis

Urgent Care Section 30 Pediatric Emergency Medicine Fellowships Pediatric EmergencyMedicineFellowships Director, EmergencyMedicalServicesand Radiographs showingalongspiralfractureofthetibiain2½-year-old boy. David Geffen School of Medicine at UCLA David GeffenSchoolofMedicineatUCLA David GeffenSchoolofMedicineatUCLA David GeffenSchoolofMedicine at UCLA Marianne Gausche-Hill,MD,FACEP,

Assistant Clinical Professor of Medicine Assistant ClinicalProfessorofMedicine Pediatric Emergency Medicine Fellow Pediatric EmergencyMedicineFellow EMERGENCY MEDICINE Department of Emergency Medicine Department ofEmergencyMedicine Department of Emergency Medicine Department ofEmergencyMedicine Department of Emergency Medicine Department ofEmergencyMedicine South Bay Disaster Resource Center South BayDisasterResourceCenter Professor of Clinical Medicine Professor ofClinicalMedicine Genevive Santillanes,MD Harbor-UCLA MedicalCenter Harbor-UCLA MedicalCenter Harbor-UCLA Medical Center URGENT CARE Amy H.Kaji,MD,PhD Los Angeles, California Los Angeles,California Los Angeles,California Los Angeles,California Torrance, California Torrance, California Torrance, California Clinical Instructor Clinical Instructor Medical Director

|

DECEMBER 2009 FAAP at anyage(eg, fracture,,septic ),manyconditions symptoms oraprecedingtrauma. Althoughsomeconditionsmayappear is painfulorpainless,and whetherthereareanyassociatedsystemic : patientage,whether thelimpisacuteorchronic,whether multiple etiologies(Table 1). course andwhetherchildabuseisapossible factor. the urgentcarephysiciandetermine treatment developmental issues.Athoroughexamination helps etiologies, suchasinfection,, trauma,and A commonprobleminchildren,limphasnumerous Limping Child Evaluation ofthe L Certain factorsareparticularly helpfulindistinguishingthecauseofa

child’s age” Defined as“anydeviationfromanormalgaitpattern forthe imp isarelativelycommonpresentingsymptominchildren. caused bypain,weakness,ordeformity,” Special Section 2 oran“uneven,jerky, orlaboriousgait,usually 1-17

3 pediatriclimphas www.emedmag.com 1

© 2009 Scott Camazine/Phototake Urgent Care Section 31

<<

25 ; cef- TRACK THE LIMPING CHILD CHILD LIMPING THE

(often

C within 1 ° 26

20 22 EMERGENCY MEDICINE FAST

S aureus | Importantly, prior Importantly,

21 Delayed treatment of can result in osteonecrosis femoral of the , osteomyelitis, and sepsis. >> Kingella kingae These findings were later 23 along with neutrophil pre- . 3 3 DECEMBER 2009 Additionally, a CRP level greater than Additionally, Immediate aspiration of the joint is 24 23 27 Therapy consists of Children with septic arthritis typically are febrilewith septic arthritis Children The diagnosis of septic arthritis is confirmed The diagnosis of septic arthritis is Since septic arthritis can be a challenging di- Since septic arthritis dominance or the demonstration of bacteria by dominance or the demonstration of for septic Gram stain is the diagnostic threshold arthritis. thritis can result in osteonecrosis of the femur, of the femur, result in osteonecrosis thritis can sepsis. and femoral osteomyelitis, validated. antibiotic use (eg, in partially treated septic ar- antibiotic use (eg, presentation. Septic arthritisthritis) may alter the thus, disease; of Lyme may also be a presentation children should be evaluatedin endemic regions, and serology. with antibody titers IV antibiotics and urgent drainage of the hip fluid to avoid buildup of intra- articular pressure that may impede the arterial Empiric antibiotic supply. regimens should cover gram-positive and gram- negative organisms, such as methicillin-resistant) and triaxone or cefazolin with vancomycin may be the best choice prior to availability of culture results. 2 mg/dL (>20 mg/L) was prospectively found to be 2 mg/dL (>20 mg/L) was prospectively arthritis. an independent predictor of septic recommended in the patient with an irritable hip to expedite diagnosis and treatment. and appear ill. Weight bearing and movement of and appear ill. Weight resisted in all age-groups. Onlythe hip are usually is multifocal or polyarticular;8% of septic arthritis it is monoarticular. classically, by ultrasound-guided aspiration of inflammatory by ultrasound-guided aspiration of of a causative hip fluid with positive identification or blood. organism in a culture of synovial fluid of greater A joint aspirate showing a WBC count than 50,000 cells/mm agnosis, decision algorithms have been devel- agnosis, decision algorithms have One large oped to identify predictors of disease. a less than retrospective study demonstrated of all 1% risk of septic arthritis in the absence the following: greater than 38.5 weight, ESR week of presentation, refusal to bear count greater greater than 40 mm/h, and WBC than 12,000 cells/mm , 3 Staphylococcus The most common organisms Delayed treatment of septic ar- 18 19 Bacteria may infect the hip either 4 . The bacterial enzymes and products of For instance, slipped capital femoral epiphy- slipped capital For instance, C, and cries when the physician’s examining C, and cries when the physician’s 17 °

Septic Arthritis second most After the , the hip joint is the with sep- commonly infected joint in children tic arthritis. erythrocyte sedimentation rate (ESR) is 60 mm/h, erythrocyte sedimentation rate (ESR) 4 mg/dL (40 and C-reactive protein (CRP) level is mg/L); hip ultrasound is pending. CASE PRESENTATIONS Case 1 2-day history of boy presents with a A 2-year-old On refusal to walk, and decreased activity. fever, has a fever of examination, the child is irritable, 39 Plain films hand reaches toward his right hip. The patient’s demonstrate no abnormalities. cells/mm white blood cell (WBC) count is 15,000 typically present in a particular age range (Table age range (Table present in a particular typically 2). sis (SCFE) typically presents in preadolescence in preadolescence typically presents sis (SCFE) acute onset of limp suggests or adolescence. An whereas gradual progres- trauma or infection, Legg- disorder, sion suggests a neuromuscular (LCPD), SCFE, rheumato- Calvé-Perthes disease Nocturnal pain and logic disease, or malignancy. complaints should raise sus- associated systemic It is often difficult to elicit picion for malignancy. or even pain, and it should a history of trauma pain is not uncommon in be noted that referred pathology may present as children. Thus, hip back may be knee pain, and pain from the lower referred to the lateral . involved are streptococci and aureus the inflammatory cells can destroy the joint or the growth plate. Increased pressure from an effusion within the capsule may impede blood resulting in and conse- flow, quent limb length discrepancy and decreased joint mobility. hematogenously or by direct extension from osteomyelitis of the femoral head. The physis of the hip is intracapsular; thus, infection of the proximal femoral metaphysis can easily spread to invade the joint space. Due to the potential for rapid joint destruction and long-term morbidity, it is critical to rapidly recognize and diagnose septic arthritis. www.emedmag.com Urgent Care Section 32

THE LIMPINGCHILD

Stress fractures Chondromalacia patellae Overuse Child abuse Foot fractures(eg,calcaneus,cuboid) Toddler’s fracture Trauma Juvenile idiopathicarthritis Systemic lupuserythematosus Transient Inflammation Psoas abscess Discitis Osteomyelitis Septic arthritis Infection TABLE 1. Flynn andWidmann Data extractedfromSinger al EMERGENCY MEDICINE Osgood-Schlatter disease—osteochondrosis Sinding-Larsen-Johansson syndromeor Sever disease—calcanealapophysitisat 7 of thetibialtuberosity of thepatellaatpatellartendoninsertion “jumper’s knee”—apophysitisofinferiorpole the Achillestendoninsertion ; Wenger etal ESR is 3 mm/h, and CRP level is 0.3 mg/dL. ESR is3mm/h, andCRPlevelis0.3mg/dL. graphs arenormal,WBCcount is8,000cells/mm upon request,buthehasan antalgicgait.Hisradio- hip inexternalrotationand abduction.Hewalks On examination,heappears wellandholdshis tion, althoughhehasnofever uponpresentation. He recentlyhadaviralupperrespiratorytractinfec- mother becauseofa1-dayhistorylefthippain. A 4-year-old boyisbroughttourgentcarebyhis Case 2

Etiologies ofLimpinChildren 8 ; Weinstein 15 ; Barkinetal

| 1

; LeungandLemay 9 DECEMBER 2009 ; Lehmannetal 16 ; LeetandSkaggs. 10 ; LedwithandFleisher 2 ; Brady 17 3 ; KrogstadandSmith

disease epididymitis, ovariancysts,pelvicinflammatory Genitourinary causes—testiculartorsion, Gastrointestinal causes—appendicitis Other systemiccauses Cerebral palsy Muscular dystrophy Peripheral neuropathy Neuromuscular causes leukemia, lymphoma,neuroblastoma Malignant—osteogenic sarcoma,Ewing eosinophilic granuloma cysts, aneurysmalbonefibrousdysplasia, Benign—,unicameralbone Tumors third, andfourthmetatarsal Freiberg disease—osteochondritisofthesecond, navicular Kohler disease—osteochondritisofthetarsal Osteochondrosis Legg-Calvé-Perthes disease Aseptic necrosis Tarsal coalition Developmental dysplasiaofthehip Slipped capitalfemoralepiphysis Developmental 3 , 11 ; Aronssonetal of 3%. dence of0.2%andacumulative lifetimeincidence vitis hip, transientsynovitis,oncecalled Characterized bypainandlimitedmotionofthe predominance. in childrenages3to10years, witha2:1male after abacterial orviralinfection,andsymptoms novitis isunknown,although itfrequentlyoccurs , isrelativelycommon,withanannualinci- 4 ; Taylor andClarke 28 Itisthemostcommoncause ofhippain 12 ; Loderetal 28,29 Theetiologyoftransient sy- 5 ; Alexanderetal 13 ; GunnerandScott www.emedmag.com 6 ; Halseyet toxic syno- 14 ; Urgent Care Section 33

THE LIMPING CHILD LIMPING THE Radiographs

32 EMERGENCY MEDICINE 17

|

DECEMBER 2009 Etiologies of Limp by Age in of Limp by Etiologies

Septic arthritis Osteomyelitis Fractures of the hip Developmental dysplasia discrepancy Congenital limb length Legg-Calvé-Perthes disease Data extracted from Leet and Skaggs. TABLE 2. TABLE Ages 1 to 3 years arthritis Ages 4 to 10 years Septic synovitis Osteomyelitis Transient disease Fractures Kohler Leukemia arthritis Juvenile idiopathic arthritis Ages 11 to 18 years Septic Sprains/fractures disease syndromes Osgood-Schlatter epiphysis Slipped capital femoral Overuse Tumors Osteomyelitis Toddlers and Children and Children Toddlers of the may demonstrate a hairline fracture (Figure 1). Less than half of patients have a his- radiographs demonstrate a faint oblique distal tibial fracture. Fracture Toddler’s Occurring in children aged 9 months to 3 years, to be an fracture was once thought toddler’s oblique undisplaced fracture of the distal third occur also it is now known to tibial shaft; however, fracture is in the distal half of the tibia. Toddler’s considered a subset of childhood accidental spiral tibial fractures and involves an indirect twisting or rotational force applied to the foot.

30 Although rare, 5 ; however, more studies are needed to ; however, 31 For children presenting with possible transient For children presenting Management of transient synovitis is conser- Management of transient synovitis

Case 3 A 20-month-old otherwise healthy girl is brought to urgent care by her father due to a 1-day his- tory of limp. He reports that the child fell while playing vigorously with her older brothers on the On examination, playground the previous day. the child is afebrile, appears well, and has mild tenderness to along the distal right The tibia. There is no ecchymosis or deformity. long-term complications of transient synovitis in- clude coxa magna, which is an overgrowth of the femoral head that may be seen on radiographs, and degenerative disease of the femoral head. Some children present with medial thigh or Some children present knee pain. of concern is synovitis, the there is no single septic arthritis. Unfortunately, arthritis test that clearly distinguishes septic ultrasound from transient synovitis. Although does not de- accurately detects an effusion, it and is best termine the cause of this condition aspirate may used to guide hip aspiration. The tran- also assist the physician in differentiating A study by sient synovitis from septic arthritis. used to help Lee et al proposed that MRI may be septic arthri- distinguish transient synovitis from in the bone tis due to signal intensity alterations marrow generally resolve within 1 week. Typically, chil- week. Typically, resolve within 1 generally are afebrile, appear transient synovitis dren with The . present with unilateral well, and to keep the hip in external child usually prefers and may refuse to walk or rotation and abduction some . However, may walk with an to 5% and up a high fever, children present with symptoms. Furthermore, 25% may have bilateral with unilateral symptoms of children presenting effusions on ultrasound. have bilateral hip confirm this. Urgent care physicians should note confirm this. Urgent care physicians are not nec- that expensive tests, such as MRI, a child who essary to rule out septic arthritis in count and has no fever and has a normal WBC inflammatory marker levels. vative with NSAIDs, heat, massage, and weight- bearing activities, as tolerated. The reported re- currence rate is as high as 15%. www.emedmag.com Urgent Care Section 34

THE LIMPINGCHILD

radiograph ofthetibiarevealingatoddler’s fracture. FIGURE 1.

1a EMERGENCY MEDICINE than 12months. sis. Accidentalfracturesare rare inchildrenyounger should stillbeconsideredin thedifferentialdiagno- a midshafttransversetibial fracture,childabuse have nosuchconnotation. abuse, spiralfracturesofthemidandlowertibia should beconsidered. fracture isstillsuspected,anuclearbonescan view, butifallviews arenormalandatoddler’s fracture maybeseenonlyontheinternaloblique bowing orperiostealcalcificationofthebone.The terns or signs that should raise the suspicion of terns orsigns thatshouldraisethesuspicion of normal inupto43%ofcases derness. Additionally, radiographsarecompletely formity, although there maybesomelocalten- are oftensubtlewithnoapparentbruisingorde- to bearweight. presenting symptomistypicallyalimporrefusal the responsibleinjurymaybetrivial.Thechief tory ofobvioustrauma,andthemechanismfor Though most spiral fractures suggest child Though mostspiralfracturessuggestchild

Toddler’s Fracture. 34

33

| Table 3

Physical examination findings Physicalexaminationfindings DECEMBER 2009 35 outlinesotherinjurypat- 6 However, ifachildhas

32 1a. or show only elastic orshowonlyelastic APradiographofthetibiarevealingatoddler’s fracture.

1b has beenfound withsecondhandsmoke, lowso- the definiteetiologyisunknown, anassociation avascular necrosisofthefemoral head. ages 3and12years,LCPD resultsfromidiopathic Most commonlyoccurring inchildrenbetween Legg-Calvé-Perthes Disease positive crescentsign(Figure2). left femoralhead,andtheradiologistreportsa cent areaintheanterolateralepiphysisof The plainradiographsdemonstratearadiolu- in aninternallyrotatedandabductedposition. with aTrendelenburg gaitandholdshislefthip brile, doesnotcomplainofpainbutwalk first noticedbyhisteacher. Thechild,whoisafe- his parentsbecauseofagradualonsetlimp, A 6-year-old boyisbroughttourgentcareby Case 4 quire ashortlegwalkingcastfor3to6weeks. child abuse.Childrenwithatoddler’s fracturere- www.emedmag.com 1b. 8 Although Although Lateral 7,35 Urgent Care Section 35

THE LIMPING CHILD LIMPING THE EMERGENCY MEDICINE

|

articular space widen- and DECEMBER 2009 35 Carty.

ture, may be present. Five sequential radiographicture, may be present. Five sequential (1) smallerstages have been described and include femoral head epiphysis Presentation Patterns and Fracture Types Types and Fracture Patterns Presentation

Metaphyseal-epiphyseal fractures Metaphyseal-epiphyseal Rib fractures fractures Vertebral Finger fractures in nonambulatory children younger than 3 years Midshaft humerus fractures in children Fractures inconsistent with the developmental age of the child with the developmental age of the Fractures inconsistent with physical injuries History inconsistent visits for different injuries Repeated health care or fractures in different stages of healing Multiple fractures attention Delay in seeking medical Data extracted from Fracture types TABLE 3. TABLE of Child Abuse Suggestive Presentation Patterns There is a 4:1 There is 36 Anteroposterior (AP) and Anteroposterior 9 Onset is usually insidious,Onset is usually

male predominance, and while and male predominance, are unilat- the majority of cases bilateral.eral, up to 10% are classicallyand children will demonstrate a Trendelenburg maygait. rotated andreveal an internally well as atro- abducted hip, as thigh mus- phy of the affected cles. cioeconomic status, and tran- status, and cioeconomic sient synovitis. lateral hip radiographs, along with frog-leg views, are helpful the di- in diagnosis; however, agnosis can be difficult, as the initial radiographs may be nor- mal. Subtle findings in the early dense- stages include a smaller, appearing epiphysis and widen- ing of the medial joint space, The crescentassociated with an irregular physis. in the antero- sign, a subchondral radiolucent zone frac- lateral epiphysis representing a subchondral www.emedmag.com Urgent Care Section 36

THE LIMPINGCHILD

left hipjoint. FIGURE 2. 3a. FIGURE 3.

2a 3a EMERGENCY MEDICINE Pelviswideningofthephysisonright. treatment. In fact,inchildrenyounger than6 marrow changes. perfusion tothefemoralhead andMRImayreveal plain films,abonescanwill demonstrate decreased stage. (4) ossificationofnewboneand,finally, (5)ahealed ing, (2)subchondralfracture,(3)resorptionofbone, LCPD doesnotrequire emergent inpatient

Radiographic IndicationsofLegg-Calvé-PerthesDisease. Slipped CapitalFemoralEpiphysisDemonstrated onLateralRadiograph. 8 2b. Early on, before changes are evident on Earlyon,beforechanges areevidenton Subchondralcollapsealongwiththecrescentsign.

| 37

DECEMBER 2009 3b. Theepiphysisslippingposteriorlyandinferiorly.

2b 3b Surgery may berequiredifthereare gross de- ral headintheacetabulum withexternalsplints. Treatment forLCPDaimstomaintainthe femo- tion shouldbeobtainedfor furthermanagement. with abetterprognosis.An orthopedicconsulta- exercises, asayoungerage atonsetisassociated bed restandinstructionsforabductionstretching years itmaynecessitateonlyobservationwith

2a. Wideningofthe www.emedmag.com Urgent Care Section 37 <<

TRACK

THE LIMPING CHILD LIMPING THE FAST EMERGENCY MEDICINE

| Unstable SCFEs have an increased risk for osteonecrosis and, if untreated, can lead to degenerative joint disease.

>> Physical examination may 11 DECEMBER 2009 AP and frog-leg radiographs are often diag- AP and frog-leg radiographs are the anterior thigh. demonstrate decreased flexion of the affected demonstrate decreased flexion of externally ro- hip, and patients may attempt to the hip. tate and abduct the hip when flexing and usu- Internal rotation of the hip is decreased ally painful. radiographic nostic. The degree of slippage and classification is determined by the amount of femoral head displacement off the femoral neck. Type I involves less than 33% displacement; type II, 33% to 50% displacement; and type III, more than 50% dis- on an placement. Normally, line, AP radiograph, Klein’s which is a line that is drawn along the superior aspect of the femoral neck, intersects the epiphysis (Figure 4). If it does not, Likewise, on the frog-leg radio- SCFE is likely. graph, a line drawn through the center of the proximal femur should intersect the center of the epiphysis, but if the line falls anterior to the and bone scan- MRI, CT, epiphysis, SCFE is likely. Klein’s Line Drawn Along the Greater Trochanter. Drawn Along the Greater Trochanter. Line Klein’s

FIGURE 4. on the side with slipped capi- Note, the line does not cross the epiphysis normal side, where the line clearly tal femoral epiphysis, unlike on the intersects the epiphysis.

38 A younger 39 The slipped epiphysis is bilateral in 10

The long-term outcome of LCPD outcome of The long-term onset on the age at depends involvement and the degree of of the femoral head. formities of the femoral head. formities 20% to 40% of cases. Although some patients report a history of acute pain or minor trauma, there typically is a gradual onset of chronic hip or knee symptoms associated with an antalgic or the presentation is gait; however, Trendelenburg quite variable. Some patients may not have any pain or may have pain referred to the knee or Slipped Capital Femoral Epiphysis This condition results when the femoral epiphy- causing impaired internal sis slips posteriorly, rotation of the hip. The classic presentation of SCFE involves an obese adolescent, with a mean age of 12 years in girls and 13.5 years in boys and a male-to-female ratio of 1.5:1. In one series, the relative incidence of SCFE was reported as nearly four times higher in black children and 2.5 times higher in Hispanic children than in white children. Case 5 obese boy pres- A 13-year-old anterolateral ents with right thigh pain and a limp, which he says began after playing soc- cer in physical education class He notes that earlier in the day. he fell several times during the game but was able to bear weight through the end of the game. On examination, he is afe- brile and appears well. He has no tenderness to palpation of his right thigh, but he has decreased of the af- internal rotation and flexion mobility him to flex fected hip. When the clinician asks rotate his hip, the patient attempts to externally radiographs and abduct the hip. The lateral plain epiphysis demonstrate slipped capital femoral (Figure 3). age at onset is associated with a age at onset is associated children older better prognosis; a high rate of than 10 years have . www.emedmag.com Urgent Care Section 38

THE LIMPINGCHILD

FIGURE 5. CBC =completebloodcount;ESRerythrocytesedimentationrate; CRP=C-reactiveproteinlevel EMERGENCY MEDICINE Consider hip ultrasound and orthopedic consultation Consider hip ultrasoundandorthopedic Radiographs show osteomyelitisRadiographs or Consider blood cultures/urinalysis tumor orsuggestchildabuse, or Admit ings arediagnostic. plain radiographsearlyinthedisease,MRIfind- perfusion. Whiletheremaybenochangeson assess thedegreeofdisplacementandarterial ning mayhelpconfirmthediagnosisofSCFEand with urgentjoint aspiration,followedby closed fixation insitu,whileanunstable SCFEistreated SCFEs areoptimallytreated withasingle-screw unstable can walkwithorwithoutthe aidofcrutchesand Obtain CBC,ESR,and/orCRP lab results show anemia SCFEs areclassifiedas YES Obtain radiographs Algorithm fortheEvaluationandManagementofLimpingChild whenthepatientcannot walk.Stable

|

DECEMBER 2009 Does childdisplay: Does physicalObtain thorough exam history, perform Lab results show ESR>20mm/h,CRP>1mg/dL • purpura/petechiae/bruising? • fever refusal to walk • NO YES stable YES ifthepatient Obtain orthopedic consult Obtain orthopedic YES set leadstosignificantlyfewer complications. surgical interventionwithin 24hoursofSCFEon- reduction andsingle-ordouble-screwfixation. be restricted from bearingweight. suspected SCFE,thepatient shouldimmediately hospitalization areindicated. Intheeventofa Thus, emergentorthopedic consultationand generative jointdisease. associated withtheriskforprogressionandde- teonecrosis and,ifuntreated,theconditionis Unstable SCFEshaveanincreasedriskforos- Perthes disease, toddler’s fracture, slipped Diagnosis onradiograph: Legg-Calvé- NO NO Administer orally Next day followNext upfor reexamination capital femoral epiphysis Obtain radiographs Obtain CBC,ESR,CRP NO 13 Thereisevidencethat www.emedmag.com 40 12

Urgent Care Section 39

<< THE LIMPING CHILD LIMPING THE TRACK

EMERGENCY MEDICINE

| FAST

Gait analysis is helpful in narrowing the differential the diagnosis. Ideally, child should be observed walking while barefoot and unclothed. >> DECEMBER 2009 Typically, the stance phase is lon- Typically, ; the patient may lean toward the ; the patient may lean toward the 15 16 For most well-appearing toddlers, consider For most well-appearing toddlers, In patients with any systemic signs or symptoms Gait analysis is helpful in narrowing the dif- is helpful in Gait analysis ger than the swing phase. With an antalgic gait, ger than the swing is shortened to decrease the the stance phase walking on the affected period of pain during pelvic gait is a downward side. A Trendelenburg affected hip, resulting from tilt away from the on the af- a weakened gluteus medius muscle fected side affected side to balance the . A steppage affected side to balance the pelvis. knee flex- gait results from exaggerated hip and an inability ion during the swing phase due to is sometimes to actively dorsiflex the foot; this diseases, seen in children with neuromuscular Children with a leg length such as cerebral palsy. gait in which discrepancy may have a vaulting at the end the knee is hyperextended and locked of the stance phase. and the following plan: Provide oral ibuprofen making sure order plain films of the affected leg, limb. If the to request more than one view of the normal physi- patient easily ambulates and has a with cal exam and normal x-rays, close follow-up all that is war- the primary care physician may be is by ranted. In these patients, transient synovitis far the most common diagnosis. Older patients may also be evaluated for LCPD and SCFE. or continued refusal to walk after administra- tion of ibuprofen, addi- tional laboratory testing is needed, including a and ESR and CRP mea- surement. If septic ar- thritis is suspected due to physical exam findings or laboratory abnor- malities, ultrasound of the hip may be ordered to evaluate for an effusion. If an effusion is present, diagnostic hip aspiration is warranted. If the as- pirate indicates septic arthritis, the patient should ferential diagnosis. Ideally, the child should be the child diagnosis. Ideally, ferential and unclothed, walking while barefoot observed running down a hall- walking and, if possible, physician determine the type way to allow the gait consists of symmetric of limp. A normal two sequential phases: swing motions involving and stance.

2 14 rounding cortical thickening. Leukemia, specifically acute lymphoblastic leu- Leukemia, specifically acute lymphoblastic

When a child comes to urgent care with refusal to walk or a limp, a complete history and physi- cal examination, including evaluation of the abdominal and genitourinary systems, should be performed to assess for systemic symptoms or signs, evaluate for child abuse, and assist in directing the diagnostic process (Figure 5). Hip pathology should always be considered in a child presenting with knee pain, as the former often presents with referred pain to the knee; in other words, “knee pain equals hip pain.” Leg and foot bones should be palpated and all joints should be taken through the full range of motion. OVERALL APPROACH TO LIMP IN CHILDREN kemia, is the most common malignancy to pre- kemia, is the most common malignancy pain is due tosent as bone pain in children. The neoplasmsleukemic infiltration of the bone. Other that can involve joints include neuroblastoma, soft-tissuelymphoma, Ewing sarcoma, and other malignancy signs of possible sarcomas. Warning that is local- include nocturnal bone pain, pain findings ofized away from a joint, or laboratory anemia, thrombocytopenia, or elevated levels of lactate dehydrogenase or uric acid. Tumors and Malignancies Tumors tumor that Osteoid osteoma is a benign bone most com- may present with hip pain, as its femur. mon site of occurrence is the proximal patients present with nocturnal, aching Typically, radiogra- bone pain relieved by NSAIDs. On plain be visible as a lucency the lesion may phy or CT, with sur Systemic Rheumatologic Diseases Systemic diseases common rheumatologic The most isolated hip arthritis are the that present with especially psoriatic , is often difficult to di- arthritis. This condition skin changes sometimes agnose, as classic until after the onset of ar- do not manifest arthritis, previously thritis. Juvenile idiopathic , rarely known as juvenile hip disease, and when presents with isolated hip, it is usually in the set- it does involve the inflammatory state involving ting of a systemic other joints. OTHER POSSIBLE ETIOLOGIES OTHER POSSIBLE www.emedmag.com Urgent Care Section 40

THE LIMPINGCHILD

EMERGENCY MEDICINE . 2. Leung AK,LemayJF. Thelimpingchild. . 7.Halsey MF, FinzelKC,CarrionWV, etal.Toddler’s fracture: 1. Singer JI.Thecauseofgaitdisturbancein425pediatric REFERENCES evaluation. laboratory and graphic examination findings,aswelldirectedradio- algorithm basedonage,history, andphysical child shouldbeapproachedwithamanagement main inthedifferentialdiagnosis. such assepticarthritis,childabuse,orSCFE,re- mitted forfurtherevaluationifseriousconditions, Additionally, anypatientwithalimpshouldbead- be hospitalizedforparenteralantibiotictherapy. 2 12. Aronsson DD,LoderRT, BreurGJ,Weinstein SL.Slippedcapital 11. 10. Le Weinstein9. SL.Legg-CalvéPerthessyndrome.In:LovellWW, Wenger DR,Ward WT, HerringJA.Legg-Calvé-Perthesdisease. 8. 6.Alexander JE,FitzRandolphRL,McConnellJR.Thelimping Taylor5. GR,ClarkeNM.Recurrentirritablehipinchildhood. 4.Krogstad P, SmithAL.Osteomyelitisandsepticarthritis.In: . 3. Brady M.Thechildwithalimp. 0 20. Bennett OM, 19. 18. Beach R.Minimallyinvasiveapproachtomanagementofirri- 17. Leet AI,SkaggsDL.Evaluationoftheacutely limpingchild. 16. Barkin RM,SZ,AZ.Thelimpingchild. 15. Flynn JM,WidmannRF. Thelimpingchild:evaluationanddiag- 14. Gunner KB,ScottAC.Evaluationofachildwith alimp. 13. Although adiagnosticchallenge,limpin presumptive diagnosisandtreatment. patients. femoral epiphysis:currentconcepts. pt 1):660-662. without hippainleadstomisseddiagnosis. Ledwith CA,FleisherGR.Slippedcapitalfemoralepiphysis Orthop ogy ofslippedcapitalfemoralepiphysis:anupdate Williams &Wilkins;2005:1039-1065. Pediatric Orthopaedics Winter RB,MorrissyRT, Weinstein SL,eds. J BoneJointSurgAm 2001;21(2):152-156. child. Bone JointSurgBr Diseases Feigin RD,CherryJD,eds. 1993;7(5):226-228. 2004;18(5):219-223. infancy andchildhood. Orthop of septicarthritisthehipininfancy andchildhood. Betz RR,CoopermanDR,Wopperer JM,etal.Latesequelae table hipinchildren. Fam Physician Med. nosis. Health Care femoral epiphysis. Loder RT, AronssonDD,Weinstein SL,etal.Slippedcapital 2006;14(12):666-679. hmann CL,AronsRR,LoderRT, Vitale MG.Theepidemiol- 2000;18(3):331-339. Curr ProblDiagnRadiol J AmAcadOrthopSurg . 1990;10(3):365-372. . 2006;26(3):286-290. . 5thed.Philadephia,PA: Saunders;2004:729-735. Pediatr EmergCare. . 2001;15(1):38-40. Namnyak SS.Acutesepticarthritisof thehipjointin . 2000;61(4):1011-1018.

InstrCourseLect | . 1995;77(5):748-51.

Lancet. DECEMBER 2009 . 1991;73(5):778-788. Clin OrthopRelatRes . 6thed.Philadelphia,PA: Lippincott 2000;355(9211):1202-1203. 1985;1(1):7-10. . 1987;16(5):229-270. Textbook ofPediatricInfectious . 2001;9(2):89-98. . 2008;57:473-498. J PediatrHealthCare J AmAcadOrthopSurg. J PediatrHealthCare . 1992;(281):123-132. Pediatrics J PediatrOrthop. Lovell andWinter’s . . 1992;89(4 J Pediatr J Pediatr J Pediatr J Emerg Am Q J . .

8 38. We 37. 34. Lewis D,LoganP. Sonographicdiagnosisoftoddler’s fracture 33. 9 39. Yrjönen T. Long-termprognosis ofLegg-Calvé-Perthesdisease: 40. Tokmakova KP, StantonRP, MasonDE.Factorsinfluencingthe 6 36. Go 35. Carty HM.Fracturescausedbychildabuse. 32. 32. Dunbar JS,OwenHF, NogradyMB,McLeeseR.Obscuretibial 31. Lee SK,SuhKJ,KimYW, etal.Septicarthritisversustransient 30. Ehrendorfer S,LeQuesneG,PentaM,etal.Bilateralsynovitis 29. Do TT. Transient synovitisasacauseofpainfullimpsinchil- 28. Landin LA,DanielssonLG,Wattsgård C.Transient synovitisof 27. 6 26. Fink AM,BermanL,EdwardsD,Jacobson SK.Theirritablehip: 25. 24. 23. Kocher MS,ZurakowskiD,KasserJR.Differentiatingbetween 22. Wi 21. Welkon CJ,LongSS,FisherMC,AlburgerOD.Pyogenicarthritis outcomes oftreatment. low-up ofpediatricorthopaedicconditions.Naturalhistoryand guished achievementinorthopaedicresearch.Long-termfol- 1995;15(3):362-367. resonance imagingwithbonescintigraphy. disease intheevolutionaryperiod:comparisonofmagnetic Uno A,HattoriT, NoritakeK,SudaH.Legg-Calvé-Perthes in theemergencydepartment. Emerg Med Shravat BP, HarropSN,KaneTP. Toddler’s fracture. 1964;15:136-144. a meta-analysis. 980-990. A(5):798-801. capital femoralepiphysis. development ofosteonecrosisinpatients treatedforslipped Calvé-Perthes’ disease. socio-economic statusintheetiologyandseverityofLegg- Br 190-194. fracture ofinfants—thetoddler’s fracture. 459-465. intensity alterationsinbonemarrow. synovitis atMRimaging:preliminaryassessmentwithsignal 1996;67(2):149-152. ultrasonographic studyin56children. in symptomaticunilateraltransientsynovitisofthehip:an dren. disease. the hip.Itsincidence,epidemiology, andrelationtoPerthes’ Infect DisJ methicillin-resistant StaphylococcusaureusorKingella. otic therapyforacuteosteoarticularinfectionswithsuspected Saphyakhajon P, JoshiAY, HuskinsWC,etal.Empiricantibi- pital admission. immediate ultrasoundguidedaspirationandpreventionofhos- prospective study. septic arthritisfromtransientsynovitisofthehipinchildren.A Caird MS,FlynnJM,LeungYL,etal.Factorsdistinguishing Joint SurgAm arthritis andtransientsynovitisofthehipinchildren. clinical predictionruleforthedifferentiationbetweenseptic Kocher MS,MandigaR,ZurakowskiD,etal.Validation ofa Am evidence-based clinicalpredictionalgorithm. septic arthritisandtransientsynovitisofthehipinchildren:an 2003;23(1):114-118. senting asacutesepticarthritisinchildren. 1986;5(6):669-676. in infantsandchildren:areviewof95cases. . 1993;75(6):849-857. rdon JE,SchoeneckerPL,OslandJD,etal.Smokingand llis AA,WidmannRF, FlynnJM,etal.Lyme arthritispre- . 1999;81(12):1662-1670. instein SL.Bristol-MyersSquibb/Zimmerawardfordistin- Curr OpinPediatr. J BoneJointSurgBr. . 2008;27(8):765-767. . 1996;13(1):59-61. . 2004;86-A(8):1629-1635. Arch DisChild J PediatrOrthopB J BoneJointSurgAm 2000;12(1):48-51. J PediatrOrthopB J BoneJointSurgAm. J BoneJointSurgAm . 1995;72(2):110-113. 1987;69(2):238-242. J ClinUltrasound . 1999;8(3):169-172. Radiology www.emedmag.com . 2006;88(6):1251-1257. Acta OrthopScand. . 2004;13(6):367-370. J CanAssocRadiol. J BoneJointSurg Pediatr InfectDis J BoneJointSurg J PediatrOrthop J PediatrOrthop 2000;82-A(7): . 1999;211(2): . 2006;34(4): . 2003;85- J Accid J Bone Pediatr . . .