Presentation on theme: "A Limping Child Laura Cuthbert. Overview An unusual presentation Key learning points Differential diagnosis Some specific examples Case discussion."— Presentation transcript:
A Limping Child Laura Cuthbert
Overview An unusual presentation Key learning points Differential diagnosis Some specific examples Case discussion
RCGP Curriculum 8. Care of children and young people 15.9 Rheumatology and conditions of the musculoskeletal system
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
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
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 ?????????
Case Presentation (cont) Removing nappy revealed red, swollen tender R testis Testicular torsion!
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
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
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
Perthes Disease Avascular necrosis of femoral head Boys:Girls 5:1 Age 4-8 Limp +/- pain Reduced abduction and int rotation
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
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.
Osgood Schlatter Syndrome Tender swelling over tibial tubercle Repeated minor avulsion trauma Excess physical exertion before skeletal maturity Rest/support
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
Case Study Differential Diagnosis Transient synovitis, septic arthritis, osteomyelitis Management? Admit for WCC/CRP Transient synovitis is a diagnosis of exclusion
Conclusion Common presentation Multiple causes Potentially serious- eg septic arthirtis, SUFE Low threshold for urgent referral/xray Remember full examination