1. A Limping Child Laura Cuthbert

2. Overview  An unusual presentation  Key learning points  Differential diagnosis  Some specific examples  Case discussion

3. RCGP Curriculum  8. Care of children and young people  15.9 Rheumatology and conditions of the musculoskeletal system

4. Case Presentation  18m boy seen in A+E with limp  HPC- Started limping R leg 6 hours ago Now unwilling to put R leg on ground Distressed, not feeding No history of trauma- with parents all day No temps, no recent viral symptoms etc

5. Case Presentation (cont)  PMH Born AGH NVD at term, no complications No history DDH Viral induced wheeze Otherwise fit and well  DH Salbutamol UTD with imms  FH- nil  SH- only child, lives with mum and dad

6. Case Presentation (cont)  O/E Apyrexial, obs normal Happy in mum’s arms CVS/RS/abdo examination unremarkable R hip flexed Unwilling to wt bear-distressed No joint erythema/swelling/deformity Good ROM at ankle/knee/hip No obvious tenderness ?????????

7. Case Presentation (cont)  Removing nappy revealed red, swollen tender R testis  Testicular torsion!

8. My learning points  Consider testicular torsion as cause of abdo pain/distress/limp.  Presentation may not be classical in young children  Always fully undress an infant for examination

9. Limp in Children

10. Differential Diagnosis  Multiple!!  Inflammatory Transient synovitis, reactive, JIA  Infective Septic arthritis, osteomyelitis, discitis  Trauma Soft tissue injury, fracture, chondromalacia patella, Osgood Schlatter  Developmental DDH, Perthes, Avascular necrosis

11. Differential Diagnosis (cont)  Neoplastic Leukaemia, sarcoma  Other Hernia, inguinal lymphadenopathy, appendicitis, ingrown toenail, verucca  Don’t forget NAI

12. Septic Arthritis  Hot, swollen, acutely tender joint  More difficult to identify at hip  Unwell, pyrexial  Raised WCC/ESR/CRP  Needs urgent aspiration and IV ABx  Usually S. aureus

13. Toddlers Fracture  Typically age <3  Pain, unwilling to wt bear  May be minimal trauma, often twisting injury  Tender swelling lower leg  Spiral # distal third of tibia  Long leg cast 4 weeks

15. Perthes Disease  Avascular necrosis of femoral head  Boys:Girls 5:1  Age 4-8  Limp +/- pain  Reduced abduction and int rotation

17. Slipped Upper Femoral Epiphysis  During adolescent growth spurt  Posterior slipping of femoral head epiphysis  Increased incidence if obese  25% bilateral  Limp, hip/thigh/knee pain  Risk osteoarthritis and AVN  Surgically fixed

19. Transient Synovitis  Most common cause of limp  Usually after viral URTI  Limp, reduced ROM, pain  Diagnosis of exclusion  Normal WCC/ESR/CRP and XRay  Self limiting, usually 7-10 days  Analgesia, rest, review.

20. Osgood Schlatter Syndrome  Tender swelling over tibial tubercle  Repeated minor avulsion trauma  Excess physical exertion before skeletal maturity  Rest/support

21. Case Study  6yrs old boy, 1d hx of limp  History 4d URTI symptoms and high temps, E+D well, no hx trauma  Examination T38, coryzal, pink TMs and throat, limping, restricted flexion and int rotation

22. Case Study  Differential Diagnosis Transient synovitis, septic arthritis, osteomyelitis  Management? Admit for WCC/CRP Transient synovitis is a diagnosis of exclusion

23. Conclusion  Common presentation  Multiple causes  Potentially serious- eg septic arthirtis, SUFE  Low threshold for urgent referral/xray  Remember full examination

24. Any Questions??