Pediatric Limp

8/19/2019 Pediatric Limp

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A brief hobble throughPediatric Limp


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Appreciate the large dierential fora limping child

Review basic approach to H&P andworkup of limping child and how to

narrow the dierential

What are red ags not to miss

oals!


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"ierential for Limp


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ait # Antalgic vs non$antalgicAcute vs %hronic '("%A)*

Location +shin, knee, thigh, hip,abdomen-Age approach

.road categories fordierential


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AA/P


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AA/P


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AA/P


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)(otes


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(ew patient in room

Presenting complaint! Pediatric limp0hipproblem

%heck %)A1 level, Age, ender.efore 2ou see the child # what is a broad

""34

*R approach to limp

Category Condition

nfectious • 1eptic arthritis, 5steom2elitis, %ellulitis

nammator2 • )ransient +to3ic- s2novitis of hip, 6A, H1P, .ursitis,

Reactive arthritis, 7awasaki d8 )rauma )raumatic in9ur2, )oddler :

;alignanc2 Leukemia, bone tumor, metastasis

5ther L%P", 1%/*, 5sgood$1chlatter, ""H, rowing pains,Referred abdo pain +app2-


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A.%


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5n e3am

eneral! 'itals, stable0unstable,

H**()! con9unctivitis, pallor, tonisillar

e3udate, mucosal lesions, l2mphadenopath2%'! tach2cardia, pulses, %H/ +m2ocarditis-

! peritonitis, H1;

"*R;! rashes, nodules, swollen hands0feet

with des@uamation;17 # # #

*R approach to limp


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;17!Look!ait! smooth vs antalgic, )rendelenburg, toe$

walkingB Walk on toes, heels, 9ump, 4as2mmetr2

1*A"1 to hip, knee, ankle, back )one

/eel!.on2 landmarks, eusion, swelling, temperature,

crepitusPain0tenderness ? bone, tendons, 9oints, muscles

;ove +active0passive-.ack, hip, knee, ankleB4limitation, guarding, discomfort

*R approach to limp


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(euro! %( $>, muscle tone0strength, sensation, ")R

1pecial tests! )rendelenburg test assesses weakness in hip A""uctorsPositive test C inabilit2 to keep pelvis parallel to the ground +lean to

compensate-

alea88i sign for conditions causing leg length discrepanc2Have child lie supine wit hips and knees e3ed +aected side lower-

*R approach to limp


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Patrick test0/A.*R test to asses 1 9oint patholog2Positive test C pain to 1 9oint

Pelvic compression test! to assess 1 9oint patholog2Patient supine, compress iliac wings toward each otherPostive test! Pain at 1 9oint

Psoas sign! signal of psoas abscess or appendicitisPatient decubitis, hip passivel2 e3tendedB Positive test C pain with

e3tension


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.arlow test is provocative testB Hip goes in#outB

5rtolani test of hip reductionB Hip goes out #inB

(ewborn hip stabilit2


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.loodwork!

What do 2ou order4 nfection, inammator2,malignanc2

%.%$d

*1R0%RP

%&1

MAYBE: coags, blood smear, sickle test, R/, A(A,%r

6oint aspiration!

W.%, dierential, gram stain, cultures, protein, glucose


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Rads0imaging

What do 2ou order

6oint >$ra2! AP, lateral, frog leg view of pelvis

.one scan

=ltrasound0;R4


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Condition Expected fndings

1eptic arthritis E*1R0%RP, EW.% FGI P;( s2novial uid

5steom2elitis E*1R0%RP, EW.%, Jblood %&1, often normal > ra2,"3 o bone scan or ;R

)ransient12novitis

;inimal Kndings +clinical diagnosis-

L%P" Limited R of hipB (ormal labs, > ra2 diagnostic

1%/* Limited R of hipB (ormal labs, > ra2 diagnostic +frog$legviews-

6A E*1R0%RP, $ve R/, JA(A +I-

(eoplasm MHb0W.%0plts, >$ra2 ma2 have poorl2 deKned margins,onion skin0sun burst appearance w0o sclerosis

What would 2ou e3pect toKnd4

*dmonton ;anual of %ommon %linical1cenarios


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What


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1alter Harris O with displacement of femoralepiph2sis

5lder children who are obese

;F/1ubtle changes can be hidden on O or of

2our views

"raw line along superior border of femoralneck

1%/*


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What


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;edical emergenc212stemic signs of unwell

f hip! %hild holding in position of ma3imum 9ointspace volume # hip rigidl2 in the classic positionof e3ion, abduction, and e3ternal rotation+/A.*R-B )his position ma3imi8es capsularvolumeQ the patient is relativel2 comfortable aslong as the hip 9oint remains immobileB

5btain culture and start antibiotics

1eptic 9oint


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1eptic 9oint

)he natural histor2 of inade@uatel2 treated septic arthritis can bedevastatingB )he 3$ra2 on the left is from a $month$old child withleft hip pain for O week, showing no gross abnormalit2B )he 3$ra2 onthe right was taken weeks after and shows soft$tissue swelling,lateral hip dislocation, indistinctness of the growth plate, and

considerable periosteal reaction of the pro3imal femoral shaft,characteristic of an associated osteom2elitis


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1eptic 9oint

/ollow$up Klms from the same patient are shown, demonstrating the naturalhistor2 of septic arthritisB )he Klm on the left, from months after onset ofinfection, shows complete resorption of the femoral head and regeneration of thefemoral shaftB )he Klm on the right, from S 2ears after onset of infection, showsdestruction and deformit2 of the left hipB )here is also superior sublu3ation of the

femoral shaft with pseudoarticulation, resulting in profound limb$lengthdiscrepanc2B


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1eptic Arthritis organisms


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.ugs and "rugs


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.ugs and "rugs


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.ugs and "rugs


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What


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What


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What


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What


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/everPinpoint pain0tenderness

Pain out of proportion to degree of

inammationWeight loss

*r2thema

12stemicall2 unwell

Pathologic fractures%ertain lab patterns

R*" /LA1


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t


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nfectiousnammator2

)rauma

;alignanc25ther


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Helpful sources!AA/P papers, )(otes, .ugs and "rugs, *dmonton

; l = ) " t ; d

Vuestions4

Documents

Pediatric Limp