Myra Lalas PittMorning Report

9/12/11

Orthopedic/Mechanical Slipped capital femoral

epiphysisLegg-Calvé-Perthes

disease

Trauma/Overuse FractureSoft-tissue injuryOsgood-Schlatter diseaseHypermobility

Infection/Infection-related

Septic arthritisOsteomyelitisReactive arthritisRheumatic feverLyme diseaseToxic synovitis

Inflammatory Juvenile idiopathic

arthritisSystemic lupus

erythematosusHenoch Schönlein purpura

Noninflammatory Growing painsFibromyalgiaConversion reaction

Malignancy LeukemiaNeuroblastomaBone tumors

HematologicHemophiliaSickle cell anemia

Noninflammatory condition in which the femoral head is displaced from the femoral neck

Commonly affects overweight boys between 10-14 yo

can be associated with endocrine disorders such as hypothyroidism or pituitary deficiencies (eg, growth hormone deficiency)

Tse S M L , Laxer R M Pediatrics in Review 2006;27:170-180

The left panel demonstrates displacement of the femoral head from the femoral neck in the left hip. Orthopedic correction includes realignment and surgical fixation with a central screw and is depicted in the right panel.

History: may report a preceding history of trauma and often presents with pain and an inability to walk

PE: may show a limb held slightly flexed and externally rotated. Passive internal rotation of the hip often is limited and painful.

Treatment: no weight bearing until seen by Ortho; surgical fixation done

Prognosis: good but at risk for avascular necrosis of the hip

Follow up: do close follow up because the contralateral hip can be involved in up to 1/3 of cases.

Avascular necrosis of the capital femoral epiphysis

Theoretical cause: repeated interruptions of the vascular supply to the femoral heads.

Commonly occurs in boys between 4-10 yo. Presents with a limp, pain, and reduced hip ROM Treatment: maintaining the femoral head within

the acetabulum by abduction splints or casts or surgically with an osteotomy of the proximal femur.

Radiographs of various stages of Legg-Calvé-Perthes disease. Progressive changes of the left proximal femur include Stage 1: initial joint space widening and irregularity of the physis, Stage 2: fragmentation, Stage 3: reossification, and Stage 4: healing.

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Osteochondritis of the tibial tubercle

Traction apophysitis of the proximal tibial tubercle at the insertion of the patellar tendon

Characterized by pain and swelling at the tibial tubercle, the point of insertion of the patellar tendon

Presentation: usually 13-14 yo males; anterior knee pain that worsens over time

Diagnosis: by PE Xrays are not necessary unless the

patient has atypical complaints (pain that awakens the patient at night, pain at rest, pain not directly over the tibial tubercle, associated systemic complaints)

• Management: analgesics, wearing a protective pad over the tibial tubercle, PT; can participate in sports

Most common cause of hip pain in childhood.Self-limited inflammatory condition caused by a

nonpyogenic inflammatory response of the synoviumPeak incidence: 3-6 yoM > F, has a slight predilection for the right sidePresentation: hip or groin pain is the most common initial

symptom, but referred pain to the medial aspect of the thigh or knee is found in 10% to 30% of patients. Affected patients either walk with a limp or, with severe pain, refuse to walk at all. The leg is held in flexion with slight abduction and external rotation.

PE: passive movement is usually pain-free; however, there may be pain and a slightly decreased range of motion with extreme internal rotation or abduction.

Diagnosis: One of exclusionGood H & PCBC, ESR, CRPAP and "frog-leg" lateral

views of the pelvis

Septic arthritis Transient synovitis

H & P Fever (usually >101.3°F)*; refusal to bear weight*; warm red, swollen joint; ROM (may be rigid); if septic hip (hip flexed and abducted)

Recent URI, low grade to normal temperature, allows passive ROM, can bear some weight

Labs CBC* ( WBC, usually >12,000/mm3), ESR* (usually >40), CRP (>2)

CBC usually normal, ESR or CRP mild elevation

Radiologic Studies

US of joint (85% show effusion), MRI ⊕ in 88%, radiography (20% reveal joint space widening)

X rays normal

Etiology Staphylococcus aureus (MRSA) > Kingella > Streptococcus pneumoniae > Salmonella; consider GBS in neonates

Postinfectious reactive fluid in joint (joint fluid cx results negative)

Treatment Joint aspiration and antibiotics NSAIDS scheduled until symptomatically improved

Linear periosteal reaction is extensive around the distal femoral metaphysis. Bone destruction is noted around the distal femoral metaphysis posteromedially (arrow).

Tse S M L , Laxer R M Pediatrics in Review 2006;27:170-180

Occur in children between 3-12 yo Characterized by intermittent nighttime

nonarticular pain most commonly in the legs; typically bilateral; not associated with limping

PE: normal Treatment: heat, massage, and analgesics;

Reassurance

Kimura Yukiko, "Chapter 207. Musculoskeletal Pain Syndromes" (Chapter). Colin D. Rudolph, Abraham M. Rudolph, George E. Lister, Lewis R. First, Anne A. Gershon: Rudolph's Pediatrics, 22e: http://www.accesspediatrics.com/content/7019794.

Lowry AW, Bhakta KY, Nag PK, "Chapter 13. Emergency Medicine" (Chapter). Lowry AW, Bhakta KY, Nag PK: Texas Children's Hospital Handbook of Pediatrics and Neonatology:http://www.accesspediatrics.com/content/7436297.

McQuillen Kemedy K, "Chapter 105. Inflammatory Musculoskeletal Disorders" (Chapter). Gary R. Strange, William R. Ahrens, Robert W. Schafermeyer, Robert A. Wiebe: Pediatric Emergency Medicine, 3e: http://www.accesspediatrics.com/content/5341179.

Tse, S. and R. Laxer. Approach to Acute Limb Pain in Childhood. Pediatrics in Review Vol. 27 No. 5 May 1, 2006 pp. 170 -180

www.uptodate.com

A 12-yo boy presents with an itchy rash that you diagnose as scabies. As he leaves the exam room, you note that he is limping. He is overweight, and his mother states that he has been playing football to get some exercise. She believes he is limping because he was injured during football practice several weeks ago & has been complaining of L knee pain. Findings on PE of the knee are normal, but he complains of pain with hip motion.

Of the following, the radiographic study most likely to yield a diagnosis is

a. AP, lateral, & sunrise radiographs of the kneeb. Bilateral AP & frog leg radiographs of the hipsc. MRI of the kneed. Ultrasound of the hipe. Ultrasound of the knee

B: SCFE