A Limping Child - Laura Cuthbert
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Transcript A Limping Child - Laura Cuthbert
A Limping Child
Laura Cuthbert
Overview
An unusual presentation
Key learning points
Differential diagnosis
Some specific examples
Case discussion
RCGP Curriculum
8. Care of children and young
people
15.9 Rheumatology and conditions
of the musculoskeletal system
Case Presentation
18m boy seen in A+E with limp
HPC
Started limping R leg 6 hours ago
Now unwilling to put R leg on ground
Distressed, not feeding
No history of trauma- with parents all
day
No temps, no recent viral symptoms
etc
Case Presentation (cont)
PMH
DH
Born AGH NVD at term, no complications
No history DDH
Viral induced wheeze
Otherwise fit and well
Salbutamol
UTD with imms
FH- nil
SH- only child, lives with mum and dad
Case Presentation (cont)
O/E
Apyrexial, obs normal
Happy in mum’s arms
CVS/RS/abdo examination unremarkable
R hip flexed
Unwilling to wt bear-distressed
No joint erythema/swelling/deformity
Good ROM at ankle/knee/hip
No obvious tenderness
?????????
Case Presentation (cont)
Removing nappy revealed red,
swollen tender R testis
Testicular torsion!
My learning points
Consider testicular torsion as cause
of abdo pain/distress/limp.
Presentation may not be classical in
young children
Always fully undress an infant for
examination
Limp in Children
Differential Diagnosis
Multiple!!
Inflammatory
Infective
Septic arthritis, osteomyelitis, discitis
Trauma
Transient synovitis, reactive, JIA
Soft tissue injury, fracture, chondromalacia
patella, Osgood Schlatter
Developmental
DDH, Perthes, Avascular necrosis
Differential Diagnosis (cont)
Neoplastic
Other
Leukaemia, sarcoma
Hernia, inguinal lymphadenopathy,
appendicitis, ingrown toenail, verucca
Don’t forget NAI
Septic Arthritis
Hot, swollen, acutely tender joint
More difficult to identify at hip
Unwell, pyrexial
Raised WCC/ESR/CRP
Needs urgent aspiration and IV ABx
Usually S. aureus
Toddlers Fracture
Typically age <3
Pain, unwilling to wt bear
May be minimal trauma, often
twisting injury
Tender swelling lower leg
Spiral # distal third of tibia
Long leg cast 4 weeks
Perthes Disease
Avascular necrosis of femoral head
Boys:Girls 5:1
Age 4-8
Limp +/- pain
Reduced abduction and int rotation
Slipped Upper Femoral Epiphysis
During adolescent growth spurt
Posterior slipping of femoral head
epiphysis
Increased incidence if obese
25% bilateral
Limp, hip/thigh/knee pain
Risk osteoarthritis and AVN
Surgically fixed
Transient Synovitis
Most common cause of limp
Usually after viral URTI
Limp, reduced ROM, pain
Diagnosis of exclusion
Normal WCC/ESR/CRP and XRay
Self limiting, usually 7-10 days
Analgesia, rest, review.
Osgood Schlatter Syndrome
Tender swelling over tibial tubercle
Repeated minor avulsion trauma
Excess physical exertion before
skeletal maturity
Rest/support
Case Study
6yrs old boy, 1d hx of limp
History
4d URTI symptoms and high temps,
E+D well, no hx trauma
Examination
T38, coryzal, pink TMs and throat,
limping, restricted flexion and int
rotation
Case Study
Differential Diagnosis
Transient synovitis, septic arthritis,
osteomyelitis
Management?
Admit for WCC/CRP
Transient synovitis is a diagnosis of
exclusion
Conclusion
Common presentation
Multiple causes
Potentially serious- eg septic
arthirtis, SUFE
Low threshold for urgent
referral/xray
Remember full examination
Any Questions??