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Acute Limb Pain. Myra Lalas Pitt Morning Report 9/12/11. Differential Diagnosis. Orthopedic/Mechanical Slipped capital femoral epiphysis Legg-Calvé-Perthes disease Trauma/Overuse Fracture Soft-tissue injury Osgood-Schlatter disease Hypermobility. Infection/Infection-related - PowerPoint PPT Presentation
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Myra Lalas PittMorning Report
9/12/11
Orthopedic/Mechanical Slipped capital femoral
epiphysisLegg-Calvé-Perthes
disease
Trauma/Overuse FractureSoft-tissue injuryOsgood-Schlatter diseaseHypermobility
Infection/Infection-related
Septic arthritisOsteomyelitisReactive arthritisRheumatic feverLyme diseaseToxic synovitis
Inflammatory Juvenile idiopathic
arthritisSystemic lupus
erythematosusHenoch Schönlein purpura
Noninflammatory Growing painsFibromyalgiaConversion reaction
Malignancy LeukemiaNeuroblastomaBone tumors
HematologicHemophiliaSickle cell anemia
Noninflammatory condition in which the femoral head is displaced from the femoral neck
Commonly affects overweight boys between 10-14 yo
can be associated with endocrine disorders such as hypothyroidism or pituitary deficiencies (eg, growth hormone deficiency)
Tse S M L , Laxer R M Pediatrics in Review 2006;27:170-180
The left panel demonstrates displacement of the femoral head from the femoral neck in the left hip. Orthopedic correction includes realignment and surgical fixation with a central screw and is depicted in the right panel.
History: may report a preceding history of trauma and often presents with pain and an inability to walk
PE: may show a limb held slightly flexed and externally rotated. Passive internal rotation of the hip often is limited and painful.
Treatment: no weight bearing until seen by Ortho; surgical fixation done
Prognosis: good but at risk for avascular necrosis of the hip
Follow up: do close follow up because the contralateral hip can be involved in up to 1/3 of cases.
Avascular necrosis of the capital femoral epiphysis
Theoretical cause: repeated interruptions of the vascular supply to the femoral heads.
Commonly occurs in boys between 4-10 yo. Presents with a limp, pain, and reduced hip ROM Treatment: maintaining the femoral head within
the acetabulum by abduction splints or casts or surgically with an osteotomy of the proximal femur.
Radiographs of various stages of Legg-Calvé-Perthes disease. Progressive changes of the left proximal femur include Stage 1: initial joint space widening and irregularity of the physis, Stage 2: fragmentation, Stage 3: reossification, and Stage 4: healing.
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Osteochondritis of the tibial tubercle
Traction apophysitis of the proximal tibial tubercle at the insertion of the patellar tendon
Characterized by pain and swelling at the tibial tubercle, the point of insertion of the patellar tendon
Presentation: usually 13-14 yo males; anterior knee pain that worsens over time
Diagnosis: by PE Xrays are not necessary unless the
patient has atypical complaints (pain that awakens the patient at night, pain at rest, pain not directly over the tibial tubercle, associated systemic complaints)
• Management: analgesics, wearing a protective pad over the tibial tubercle, PT; can participate in sports
Most common cause of hip pain in childhood.Self-limited inflammatory condition caused by a
nonpyogenic inflammatory response of the synoviumPeak incidence: 3-6 yoM > F, has a slight predilection for the right sidePresentation: hip or groin pain is the most common initial
symptom, but referred pain to the medial aspect of the thigh or knee is found in 10% to 30% of patients. Affected patients either walk with a limp or, with severe pain, refuse to walk at all. The leg is held in flexion with slight abduction and external rotation.
PE: passive movement is usually pain-free; however, there may be pain and a slightly decreased range of motion with extreme internal rotation or abduction.
Diagnosis: One of exclusionGood H & PCBC, ESR, CRPAP and "frog-leg" lateral
views of the pelvis
Septic arthritis Transient synovitis
H & P Fever (usually >101.3°F)*; refusal to bear weight*; warm red, swollen joint; ROM (may be rigid); if septic hip (hip flexed and abducted)
Recent URI, low grade to normal temperature, allows passive ROM, can bear some weight
Labs CBC* ( WBC, usually >12,000/mm3), ESR* (usually >40), CRP (>2)
CBC usually normal, ESR or CRP mild elevation
Radiologic Studies
US of joint (85% show effusion), MRI ⊕ in 88%, radiography (20% reveal joint space widening)
X rays normal
Etiology Staphylococcus aureus (MRSA) > Kingella > Streptococcus pneumoniae > Salmonella; consider GBS in neonates
Postinfectious reactive fluid in joint (joint fluid cx results negative)
Treatment Joint aspiration and antibiotics NSAIDS scheduled until symptomatically improved
Linear periosteal reaction is extensive around the distal femoral metaphysis. Bone destruction is noted around the distal femoral metaphysis posteromedially (arrow).
Tse S M L , Laxer R M Pediatrics in Review 2006;27:170-180
Occur in children between 3-12 yo Characterized by intermittent nighttime
nonarticular pain most commonly in the legs; typically bilateral; not associated with limping
PE: normal Treatment: heat, massage, and analgesics;
Reassurance
Kimura Yukiko, "Chapter 207. Musculoskeletal Pain Syndromes" (Chapter). Colin D. Rudolph, Abraham M. Rudolph, George E. Lister, Lewis R. First, Anne A. Gershon: Rudolph's Pediatrics, 22e: http://www.accesspediatrics.com/content/7019794.
Lowry AW, Bhakta KY, Nag PK, "Chapter 13. Emergency Medicine" (Chapter). Lowry AW, Bhakta KY, Nag PK: Texas Children's Hospital Handbook of Pediatrics and Neonatology:http://www.accesspediatrics.com/content/7436297.
McQuillen Kemedy K, "Chapter 105. Inflammatory Musculoskeletal Disorders" (Chapter). Gary R. Strange, William R. Ahrens, Robert W. Schafermeyer, Robert A. Wiebe: Pediatric Emergency Medicine, 3e: http://www.accesspediatrics.com/content/5341179.
Tse, S. and R. Laxer. Approach to Acute Limb Pain in Childhood. Pediatrics in Review Vol. 27 No. 5 May 1, 2006 pp. 170 -180
www.uptodate.com
A 12-yo boy presents with an itchy rash that you diagnose as scabies. As he leaves the exam room, you note that he is limping. He is overweight, and his mother states that he has been playing football to get some exercise. She believes he is limping because he was injured during football practice several weeks ago & has been complaining of L knee pain. Findings on PE of the knee are normal, but he complains of pain with hip motion.
Of the following, the radiographic study most likely to yield a diagnosis is
a. AP, lateral, & sunrise radiographs of the kneeb. Bilateral AP & frog leg radiographs of the hipsc. MRI of the kneed. Ultrasound of the hipe. Ultrasound of the knee
B: SCFE
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