1. Approach to Limb Pain in Children/Osteomyelitis
MR 7/17/09
J.Chen

2. Approach to Limb Pain in Children

3. Approach to Child with Limb Pain
History PE
Labs/Imaging

4. History Important aspects: Area involved # of joints involved
Nature of the pain
Presence of systemic symptoms (fever, rash, weight loss, fatigue)
Presence of limp
Weight bearing status
Morning stiffness
History of past medical illneses
Travel
Family History (Arthritis, Bleeding Disorders, Sickle Cell Disease, IBD)

5. Physical Exam Important Aspects Joint Exam Swelling Erythema Warmth
Tenderness
Deformity
ROM

6. Physical Exam Continue
Adjacent Structures
Bones
Tendons
Muscles
Skin
Gait
Leg length discrepancy
Full Neurologic Examination

7. Basic Screening
CBC with Diff
Blood Smear
ESR
CRP
Radiographs

8. Imaging
Plain Radiograph and Bone Scan (Technetium-99 scan) have long been the mainstay for joint and bone problems
CT useful in diagnosing:
Osseus Tumors
Pelvic and acetabular fractures
Intraarticular Extension of Femoral Fractures
US:
Joint effusions
Developmental dysplasia of the hip

9. Imaging Continued MRI-useful in evaluating Soft tissue Joint spaces
Suspected joint infection
Soft tissue tumors
Muscle injuries
Early avasular necrosis

10. Approach to Limb Pain in Children

11. Osteomyelitis Cause: Pathogens:
Most commonly results from Hematogenous spread
May be from direct invasion of Pathogens into the bone.
May be precipitated by trauma
Pathogens:
Staph aureus: 90%
Non-group A beta-hemolytic streptococci
Hib now less prevalent
Salmonella-Sickle Cell Anemia
Pseudomonas aeruginosa-puncture wound
Neisseria gonorrhacae-sexually active
GBS-neonates

12. Clinical Presentation
Sudden onset
Localized pain
Swelling
Fever
+/- trauma
Limp/refusal to bear weight
Previous infection

13. Physical Exam Erythema Swelling Point tenderness Decreased ROM
Most commonly involves femur>tibia>humerous>fibula>radius>calcaneus>il ium

14. Imaging X-Ray-not helpful in early diagnosis
Findings appear after 7 days
Soft tissue swelling
Subperiosteal changes
Bone destruction
Bone Scan % sensitive
MRI-equal sensitivity, better specificity

15. Treatment