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Peds Ortho - THe Limping Child

1/30/2014

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DDX
- septic hip or osteomyelitis, discitis, transient synovitis; trauma, congenital, neoplastic, SCFE, LCPD

  > Your goal should be to rule out potential catastrophic disease

Physical Exam
- undress!!
- watch gait (antalgic gait - less time in stance phase on injured limb; trendelenberg, leaning over the side of the affected hip)
- Evaluate for point of maximum tenderness

          - Hip pain > think spine

          - Knee pain > think hips

- Range of motion - logroll thigh - gives good range of motion of hip  

Imaging

- plain films are a good place to start
- image everything if hard story or difficult to pinpoint pain

Labs
- ESR, CRP, CBC with diff,  blood cultures

Diagnosis

  -  Transient Synovitis
        - get hip XRay - bony landmakrs are normal; may see widened joint space
        - may have joint effusion on US

        > Management = Rest and NSAIDs; f/up with ortho vs peds in 24-48 hrs;
        > Kids can limp on and off for a month

        > Can look like septic hip, usually follows URI; usually had normal labs

        > Kocher Criteria
            - 4 criteria: non-weight bearing on affected side; ESR > 40, Fever, WBC >12K 
            - All 4 = 99%; 3 criteria 93%; 2 criteria = 40%; 1 criteria,3% chance of septic arthritis

  - Toddlers Fracture
        - Common in young kids; accidental
        - Stable; do above knee cast with knee flexed

        - The developing Bone - thicker periosteum, bone is more eleastic; avulsion before tendon rupture
                                              - Allows for unique fracture type: Torus and Bowing

   - SCFE
        - widened physis; Kleins line - should have bone on other line of femoral neck (get AP and frog leg views)

         > Stable - kid can walk (at all) - 90% - DC home; nonweight bearing; f/up with ortho;

         > Unstable - unable to walk (10%) - higher rate of avascular necrosis - non weight bearing; admit to ortho

   - Septic Arthritis
         - Common in large joints; severe pain; muscle spasms; fever - Staph and think Neiserria in sexually active teens

         > Be aware that little kids (< 3 months) have adjacent osteomyelitis (need MRI); 6mo-2 yrs - 50% will have associated infection

         > Aspirate and OR (antbx after debridement) - ortho urgency
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  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • Global EM
    • Toxicology
    • (All Others)
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • MATCH 2022
    • Alumni
  • STUDENTS/APPLICANTS
    • Prospective Visiting Students
    • Healthcare Disparities Externship
    • UNC/Wake Forest Students
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction
    • Evaluations/Interview Season