limp_paed
Table of Contents
the limping child
see also:
all ages:
- trauma:
- fracture
- occult growth plate trauma - esp. distal fibula
- haemarthrosis - usually underlying intra-articular fracture
- foreign body:
- esp. feet/knees eg. occult sewing needles, rose thorns (either may be intra-articular!!)
- new shoes, local foot painful lesions (eg. paronychia, bunions, warts, insect bites)
- haemarthrosis due to haemophilia (males)
- septic arthritis
- osteomyelitis (usually in metaphyses of long bones if haematogenous)
- discitis
- tumor - musculoskeletal, spinal, leukaemia, neuroblastoma (infants)
- reactive arthritis: eg. urticaria, erythema multiforme, serum sickness, post-infectious, Henoch-Schonlein purpura (HSP)
- rheumatic fever
- juvenile chronic arthritis
- haemoglobinopathy (eg. sickle cell crisis)
- long-standing, congenital, birth or genetic lesions:
- cerebral palsy
- spina bifida
- cong. dislocation hip
- muscular dystrophy
- talipes (eg. Charcot-Marie-Tooth peroneal atrophy)
- severe scoliosis
- REMEMBER:
- referred pain from back to hips/thighs & from hip to knees!!!
- thus examine spine, sacro-iliac joints too!!
pre-school:
- toddler's fracture tibia:
- often no history of trauma although Hx of tripping over is common
- usually non-tender but will not weight bear
- classically only seen on one view of xrays - often faint spiral # mid-tibia
- Rx AKPOP 3wks if # evident, otherwise consider re-XR in 10 days looking for periosteal reaction
- other commonly missed, common fractures lower limbs:
- base or necks of 2nd-4th MTs
- greenstick fractures: femoral shaft, upper tibial metaphysis
- occult fractures:
- only evident on XR 10days later & even then only if not growth plate injury
- “irritable hip” / “viral” synovitis hip:
- see hip pain
- usually lasts several days
- pain/spasm on int/ext. rotation of hip
- Mx:
- XR hips to exclude other pathology (trauma, early-onset Perthe's, cong. dislocation hip)
- consider US hips:
- not usually needed if Dx of irritable hip clinically obvious
- reserve for cases where hard to localise pain in lower limb
- FBE, ESR, CRP, BC if suspicion of sepsis (eg. fever, malaise or unwell)
- if sepsis/trauma excluded then non-wt bear until better, regular review (eg. daily) to watch for evidence of sepsis.
- consider avoiding analgesics if child is then likely to run around!
school age:
- commonly missed, common fractures lower limbs:
- base or necks of 2nd-4th MTs
- greenstick fractures: femoral shaft, upper tibial metaphysis
- benign hypermobility syndrome:
- esp. if recurrent pattern
- usually 1-4 week cycles of episodic, nocturnal, post-activity, bilateral, ill-defined pain of lower extremities
- Perthe's disease (avascular necrosis femoral head):
- initially unilateral, early xray changes may be subtle
- usually 5-9yr olds but may have onset at 3-4yrs age
adolescents:
- slipped femoral epiphysis:
- extremely important not to miss as needs early internal fixation & non-wt bearing pre-op
- classically in obese boys 10-15yrs age but can occur in in thin girls 9yrs old!
- often presents as knee pain!!
- other commonly missed, common fractures lower limbs:
- base 5th MT (don't confuse with epiphysis which is longitudinal not transverse line)
- avulsion tibial spines (assume in all adolescents who have acute haemarthrosis knee after falling off bikes or motorbikes, until proven otherwise)
- patello-femoral pain / chondromalacia (esp. in females)
- Osgood-Schlatters disease:
- over-use osteochondritide of tibial tuberosity
- other osteochondritidies:
- Frieberg's disease head 2nd MT
- osteochondritis dessicans medial femoral condyle
-
- often follows minor trauma
- sweaty, tender, mottled, cold skin
- rarely:
- Reiter's syndrome
- Gonococcal arthritis
limp_paed.txt · Last modified: 2009/09/10 11:37 by 127.0.0.1