1. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Child with a limp

2. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Case 1: 1,5 year old Upper airway symptoms until last week Fine general condition, no fever or other general symptoms Started to limp two days ago No known specific trauma, but goes to kindergarden and falls often

3. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Examination Lively, general condition seems fine Walking pattern: avoids weight on right foot, rotated outwards T 36,8 Lower extremeties: –No erytema –No warm skin –No obvious swelling –Manipulation (especially rotation) of right hip seems painful –Palpation seems painful

4. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Lab CRP 8 WBC 10 SR 12 Further investigation? Admit to hospital?

5. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Imaging Ultrasound: slightly increased amount of fluid, seems clear Diagnosis?

6. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Acute bacterial osteomyelitis/septic arthritis

7. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat History Limp Pain Avoidance of use of bodypart Trauma? General condition lowered (?) Fever? Infection in previous weeks? Similar symptoms previously?

8. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Clinical examination Observation of movement –Limp? –Pain? –Avoidance? General condition, T, HR, RF – systemic signs of infection? Systematical examination of joints –Observation: Erytema, swelling? Compare with opposite side –Palpation: Temperature, swelling? –Motion: decreased? Pain? Neurological examination?

9. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Laboratory investigations SR, WBC, CRP, blood culture Synovial fluid sampling

10. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Imaging Ultrasound MRI (general anesthesia) (X-ray) (Bone scintigraphy)

11. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Treatment Septic arthritis: joint drainage with flushing antibiotics –klindamycin –betalactamase-stabile penicillin (kloxacillin) osteomyelitis: total 6 weeks, at least 2 weeks intravenous septic arthritis: total 3-4 weeks, at least 1-2 weeks i.v.

12. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Treatment Inhalations? –Saline –Racemic adrenaline (epinephrine) –Salbutamol? –Hypertonic saline? Corticosteroids?

13. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Case 2: 5 year 1 day history Moderately affected general condition, –Loss of appetite, nausea –Fever Pain in left knee, don’t want to walk No history of trauma or other infections

14. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Examination Good contact, but uninterested in surroundings HR 120, RF 25 Left knee: –Erytema –Swollen –Warm –Painful Admit to hospital?

15. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Lab CRP 150 SR 78 WBC 22