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A Limping Child Laura Cuthbert
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Overview An unusual presentation Key learning points Differential diagnosis Some specific examples Case discussion
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RCGP Curriculum 8. Care of children and young people 15.9 Rheumatology and conditions of the musculoskeletal system
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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
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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
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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 ?????????
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Case Presentation (cont) Removing nappy revealed red, swollen tender R testis Testicular torsion!
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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
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Limp in Children
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Differential Diagnosis Multiple!! Inflammatory Transient synovitis, reactive, JIA Infective Septic arthritis, osteomyelitis, discitis Trauma Soft tissue injury, fracture, chondromalacia patella, Osgood Schlatter Developmental DDH, Perthes, Avascular necrosis
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Differential Diagnosis (cont) Neoplastic Leukaemia, sarcoma Other Hernia, inguinal lymphadenopathy, appendicitis, ingrown toenail, verucca Don’t forget NAI
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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
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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
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Perthes Disease Avascular necrosis of femoral head Boys:Girls 5:1 Age 4-8 Limp +/- pain Reduced abduction and int rotation
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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
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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.
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Osgood Schlatter Syndrome Tender swelling over tibial tubercle Repeated minor avulsion trauma Excess physical exertion before skeletal maturity Rest/support
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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
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Case Study Differential Diagnosis Transient synovitis, septic arthritis, osteomyelitis Management? Admit for WCC/CRP Transient synovitis is a diagnosis of exclusion
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Conclusion Common presentation Multiple causes Potentially serious- eg septic arthirtis, SUFE Low threshold for urgent referral/xray Remember full examination
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Any Questions??
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