1. A 13 year old boy with complaints of “butt pain” Morning Report July 1, 2009

2.  Otherwise healthy  Noted the pain after attending a school dance……but “he did not dance”  Afebrile  What do you want to know????

3. His exam is “normal” except for tenderness over the right gluteus muscle He is sent home with NSAID’s and a diagnosis of musculoskeletal strain

4. Don’t forget…….Give “what if” instructions….

5. It is now 5 days later……  Now complaining of right knee pain and he is limping  No fever noted at home, Temp is 99 in the office  Now what????????

6. Films are ordered….given Tylenol #3  Plain films of the hips and knees are “normal”….

7. Everyone in thinking SCFE

8. Anatomy

9. SCFE

10. SCFE  Usually in boys at puberty  Usually unilateral  Stable or unstable  Diagnostic radiograph: frog leg hip films  Surgical intervention

11. SCFE Severity

12. But he does not have a SCFE…….. What do you do now? What else is in your differential of a limping child?

13. Differential  Toddler  Septic arthritis  Discitis  Sepsis  Osteomyelitis  Pyomyositis  Neoplasia  Leukemia, bone tumors…  JIA?  Transient synovitis  Child (3-10 years)  Septic Arthritis  Osteomyelitis  Pyomyositis  Neoplasia  Leukemia, bone tumors…  Discitis  JIA?  Perthes  Synovitis  Adolescent…add  SCFE

14. If you send him home… again, the “what if” instructions are KEY….

15. The plot thickens…….  4 days later, the child returns for more tylenol #3  Still limping  Increasing pain with extension of the hip and internal rotation of the leg but there is no redness, warmth or swelling  Now fever to 102, HR is 130, RR 24, BP 90/50

16. Systemic symptoms  His left elbow is red and swollen  Disoriented  Jaundiced (Bili 12/8, SGOT and SGPT nl)  Febrile  Anemic (hgb 6, WBC 24)

17. DIFFERENTIAL???? The patient is hospitalized ………..and a diagnostic procedure is performed

18. The CT Normal Not normal

19. The Psoas (part of the posterior abdominal wall)

20. Psoas Abscess  Hip symptoms  Can be a “primary diagnosis”  Can be associated with GI pathology or sometimes with GU pathology  Not usually associated with hip infection

21. In the hospital…….  Psoas abscess and elbow drained  Antibiotics begun  All cultures positive for St A…blood and abscess and elbow  Remains febrile on POD 1  Remains febrile on POD 2  Remains febrile on POD 3 but continues to “feel better”, jaundice resolves Want to do anything else, antibiotics are given and appropriate???????????

22. In the hospital…….  Remains febrile on POD 4  Remains febrile on POD 5  Remains febrile on POD 6 “feels better” but febrile……. Now what????? “feels better” but febrile……. Now what?????

23. Another diagnostic procedure was performed……..

24. Repeat CT reveals concern for hip disease…the acetabulum appears “moth-eaten” And the child returns to the OR for I and D of the hip joint……. After which he is afebrile…

25. Septic Arthritis of the Hip A True Emergency

26. Septic Arthritis of the Hip  Usually in children under 3 years  Usually unilateral  Fever, high WBC, high sed rate  Diagnostic radiographs: ultrasound, CT/MRI  Plain films are normal in 50% of cases!!!!!

27. When the Xray is diagnostic: there is a loss of the architecture of the pelvis and widening of the joint space

28. The MRI

29. Septic Arthritis Risk Factors for Poor Outcome  Over 5 days to surgical drainage  Associated osteomyelitis in the proximal femur

30. Morals of the story: Sometimes you just have to keep looking…..  Fever  Severe pain  Night pain  Functional impairment  Escalating symptoms A limping child =

31. Peds in Review  http://pedsinreview.aappublications. org/cgi/reprint/27/5/170 http://pedsinreview.aappublications. org/cgi/reprint/27/5/170 http://pedsinreview.aappublications. org/cgi/reprint/27/5/170 Approach to Acute Limb Pain in Childhood Shirley M. L. Tse, MD Ronald M. Laxer, MD The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada Shirley M. L. Tse, MD Ronald M. Laxer, MD The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada