MORNING REPORTMarch 22, 2011
Septic Arthritis
Most common organism? Staph Aureus
Presentation? Acute Monoarthritis Erythema Warmth Swelling Intense pain on movement Fever – 70%
Septic Arthritis
Definitive Diagnostic Test? Joint fluid analysis and culture
Other labs or studies? CBC ESR/CRP US CT/MRI
Septic Arthritis
Emergency? Outcome depends of
timing of diagnosis, initiation of antibiotics, adequacy of drainage, virulence and host factors
Osteomyelitis
Presentation Fever Localized pain Erythema Swelling Pinpoint tenderness Decreased ROM
Osteomyelitis
Diagnosis? Bone scan MRI Bone Culture
Other labs? WBC ESR/CRP Blood culture – 60% Bone culture – 80% Plain films
Transient or Toxic Synovitis
Emergency? Benign, self-limited
Causes? Acute or post infection Trauma
30% of all nontraumatic limps
Transient Synovitis
Presentation? Limp Painful hip Afebrile or low-grade Otherwise appears well Mild restriction of ROM
Transient Synovitis
Diagnosis? Exclude septic arthritis and osteo Four predictors associated with septic arthritis
History of fever Inability to bear weight ESR >40 WBC >12
Transient Synovitis
Treatment? Rest Anti-inflammatory
Most children do very well
JIA
Definition of arthritis Joint effusion + 2 of the
following Stress pain Limited ROM Increased warmth
JIA One joint for at least 6
weeks Cause
Host Enviromental
JIA
Oligo Most common Girls 1-3y Large joints
Knee, ankle, wrist elbow
Morning stiffness ANA +
Anterior uveitis
JIA
Poly Symmetric involvement
Small and large joints Most RF –
RF+ are typically adolescent females and behave like adult RA
Systemic Fevers Evanescent rash
Salmon pink macules Other
HSM, pericarditis, serositis, LAD
JIA
Psoriatic Knees and small joints of hands
and feet Look for the rash Other
Nail changes or dactylitis Enthesitis
More common in boys Asymmetric lower limbs
Tendons of heel, plantar fascia or patella
May develop ankylosing spondylitis or other HLA-B27 diseases
JIA
Diagnosis? History and exam
Testing? CBC ESR/CRP ANA RF Radiographs
JIA
Treatment Anti-inflammatories Rheumatologist
Intra-articular corticosteroids Disease modifying agents
MTX Sulfasalazine Biologics
PT
Lyme Disease
Name of infective agent Borrelia burgdorferi
Transmission Ticks
Presentation Erythema migrans Arthritis
May occur months to years after infection
Other Meningitis, cranial nerve palsies,
carditis, ocular involvement
Lyme Disease
Diagnosis History and PE Lab testing
Culture Stain PCR
Blood, synovial fluid or synovial tissue
Serologic testing IgG may remain positive
for years
Lyme Disease
Treatment Antibiotics
Ceftriaxone or Amoxicillin or Doxycycline
Anti-inflammatories Prognosis for children
Good
Growing Pains
Definition Intermittent Nonarticular
Diagnosis History and normal PE
Benign Age range
3-10y
Growing Pains
Pain At night Limited to calf, thigh or shin Short-lived
Alleviated by Heat Massage Mild analgesics
SCFE
Definition Femoral head is
displaced from the femoral neck
Typical patient Overweight Boy 10-14y
SCFE
History and PE Trauma Acute
Pain Inability to walk
Subacute or Chronic Pain Limb held flexed and externally rotated Passive internal rotation is painful
SCFE
Diagnosis Radiographs
Bilateral 30% Treatment
Referral to ortho for repair No weight bearing Close follow up
Legg-Calve-Perthes
Definition Avascular necrosis of
the capital femoral epiphysis
Typical patient Boy 4-10y
Legg-Calve-Perthes
Presentation Limp Pain Reduced hip ROM
Diagnosis Radiographs MRI
Early disease Treatment
Refer to ortho Splints Casts surgery