Peds Ortho - THe Limping Child

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