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

Approach to Limb Pain in Children

Approach to Child with Limb Pain History PE Labs/Imaging

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)

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

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

Basic Screening CBC with Diff Blood Smear ESR CRP Radiographs

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

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

Approach to Limb Pain in Children

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

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

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

Imaging X-Ray-not helpful in early diagnosis Findings appear after 7 days Soft tissue swelling Subperiosteal changes Bone destruction Bone Scan-85-100% sensitive MRI-equal sensitivity, better specificity

Treatment