Topic review: evaluation of a limping child 2017/03/15 R2徐子權/CR潘妤玟/VS劉清泉

Case 1 A 2-year-6-month-old boy Birthday : 2014/08/22 Date of admission : 2017/03/05 Chart number:164800xx 16480025

Chief complaint Right hip pain with limping gait noted for one day (since 3/04 evening)

Brief history Past history of neuroblastoma, stage I s/p total excision on 2014/9/22 at NTUH, currently followed up at Dr.鄭's OPD Playing 滑板車 on 2017/02/28 Right hip pain with limping noted for 1 day Walk on the toes(+) No fever Denied trauma history Father has URI symptoms recently, but the patient did not The patient did not received chemotherapy nor radiotherapy. There was no obvious recurrence signs during OPD follow up.

Physical Examination Consciousness: clear General appearance: fair HEENT: conjunctiva: not pale, sclera: anicteric Neck: supple, no JVE, no LAP Chest: symmetric expansion, bilateral clear breath sounds Heart: regular heart beat, no audible murmur Abdomen: flat and soft, normoactive bowel sound, tenderness (-), rebound tenderness (-), muscle guarding (-), flank pain(-) Skin: no rashes Extremities: warm, pitting edema (-) *** No local erythematous change, no swelling over right hip No tenderness ROM: no limitation

Impression Right hip pain, suspect osteomyelitis or septic arthritis, but malignancy cannot be ruled out

Image

Synovial fluid from right hip joint Lab data

Kocher criteria Non-weight-bearing on affected side Erythrocyte sedimentation rate > 40mm/hr Fever > 38.5 °C White blood cell count > 12,000

Treatment and clinical course

Final diagnosis 1. Right hip pain, favor reactive arthritis

Case 2 A 4-year-old girl Birthday : 2013/02/14 Date of admission : 2017/03/06 Chart number:172570xx 17257026

Chief complaint Unable to walk with acute onset left hip pain after falling down at school on 3/04

Brief history 3/5 morning complained of left hip pain, 3/5 night cannot walk due to left side pain No fever No URI symptoms

Physical Examination Consciousness: clear General appearance: fair HEENT: conjunctiva: not pale, sclera: anicteric Neck: supple, no JVE, no LAP Chest: symmetric expansion, bilateral clear breath sounds Heart: regular heart beat, murmur(-),S3(-),S4(-) Abdomen: flat and soft, normoactive bowel sound, tenderness (-), rebound tenderness (-), muscle guarding (-), flank pain(-) Extremities: warm, pitting edema (-) Swelling at left hip(+), Resist to PROM and AROM at left hip No limitation or ROM at bilateral knee and ankle joint Skin: no rashes, no petechiae or ecchymosis

Impression Left thigh pain, suspect hip arthritis or fracture

Osteosclerotic mixed with osteolytic change at left intertrochanteric line. Image (Plain film)

Image(CT) 1. Left hip synovitis with minimal amount of left joint effusion.

Image(CT)

Image(CT)

Image(CT) Left hip synovitis with minimal amount of left joint effusion

Lab data

Treatment and clinical course Pain control: Voren 50mg/cap 0.25cap qid

Final diagnosis Left hip synovitis

Review article

Clinical evaluation History: Can bear weight or not/the pattern of limping /whether the limp is painful/ the duration of symptoms Recent trauma or sports activities Fever or associated chills A history of recent viral illness of bacterial infections, including MRSA infections; recent weight loss; history of tick bites/ travel history Inability or refusal to bear weight; obvious distress or agitation Inconsolability Holding the extremity in a fixed position

Physical examination Start with the nonpainful limb Looking for skin erythema, swelling, ecchymosis, a laceration, or abrasion Palpate the child’s back for tenderness at the paraspinal muscles and evaluate for tenderness at spinal processes (trauma, osteomyelitis, diskitis) Examination of the plevis for skin changes and tenderness at the anterior superior and inferior illiac spines ( avulsion fracture of the satorius or direct head of the rectus)

Infection and inflammatory conditions Septic arthritis of hip Toxic (Transient) Synovitis Damage to hip cartilage and blood supply to femoral head within 6-12 hours of onset Self-limited virus-related synovitis 3 to 8 years of age group Painful limp, fever, unable to bear weight, local swelling, erythema, joint effusions, limited joint motion Most commonly preceded by a viral infection 2 weeks to 1 month ago BT>38.5℃ , WBC> 12000/microL, ESR>40mm/hr, CRP>2.5mg/L WBC, ESR, CRP within normal limits Synovial fluid analysis: WBC> 50000/microL, Seg>75%, positive Gram stain S.aureus, S. pneumoniae, GBS, Kingella kingae WBC 5000~15000/microL, negative Gram stain vs

Infection and inflammatory conditions Osteolmyelitis and deep soft tissue infection Fever and limping, worsen slowly over 1 to 3 days Extrimity induration, swelling and fullness, local tenderness, painful range of motion of the hip, knee or ankle Elevated WBC, ESR, CRP Radiograph: may reveal only evidence of deep soft-tissue swelling until 7 to 10 days after onset MRI with contrast to detect abscess, fascitits, myositis, and pyomyosistis

Infection and inflammatory conditions Lyme disease Spirochete(Borrelia burdorferi), transmitted by tick bite Northest United states is most commom endemic area Skin lesion, erythema migrans Headache, mailaise, and fatigue Acute onset arthritis, knee: most common Erythema, an effusion in knee joint Popliteal cyst

Infection and inflammatory conditions Juvenile idiopathic arthritis(JIA) Children younger than 16 years old Joint pain, swelling without large effusions, and stiffness Duration longer than 6 weeks A limp and painful joint(oligoarticular), most commonly of knee Multiple joint involvement(polyarticular) Systemic symptoms lethargy, loss of apppetite, more joint stiffness in the morning Diagnosis: excusion, after traumatic and infectious causes have been r/o

Developemntal causes Hip diseases of Childhood, 3 most commom Developmental dysplasia of the hip(DDH) Legg-Calvé-Perthes Disease (LCPD) Slipped Capital Femoral Epiphysis(SCFE)

Developemntal causes Developmental dysplasia of the hip(DDH) Painless limp, abnormal gait or a leg-length discrepancy Most cases are detected before walking age Bilateral missed hips dislocation Wide-based, waddling, Trendelenburg limp Symmetric limitations of hip abduction of 40degree or less(normal abduction 50 degrees or greater) Unilateral dislocation Hop over the longer(normal) leg, walks on his/her toes on the shorter (hip dislocation) site

Developemntal causes Legg-Calvé-Perthes Disease (LCPD) Idiopathic avscular necrosis of femoral head Between 2 and 12 years of age, increased incidence in 6 to 8 years of age, more commom in boys than girls. Painful limp, limited hip motion Figure: 4-y/o boy, intermittent limping for 3 months. Right hip severe flattening of the femoral epiphysis

Developemntal causes Slipped Capital Femoral Epiphysis(SCFE) Displacement of the proximal femoral(capital) epiphysis from the metaphysis of the femur Causes: weak-ended physis Endocrine/metabolic condition: hypothyroidism, renal osteodystrophy Excessive of abnormal mechanical stress Most common in children and adolescents between 10-14 years, in obese children

NEOPLASMS Benign tumors: Osteochondroma Ostoid osteoma Malignancies: Primary bone tumors, or blood cell tumors(leukemia, lymphoma) Most commom: osteosarcoma, peak>10 years of age The clinical presentations varies: intermittent limping, dull pain, rapidly enlarging mass, pathologic fracture Night pain Lethargy, fever, and weight loss

Overuse injuries The site of inflammation is typically at the apophysis (a secondary growth center at the origin or insertion of the tendon) Symptoms of overuse injuries may mimic more serious problems Consider these diagnosis only after potentially more serious diagnosis (fractures, infection and tumors) have been considered and ruled out Osgood-Schlatter disease (apophysitis of the tibial tubercle) Sever disease (apophysitis of the calcaneus)

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