Paediatric Orthopaedics - The Limping Child

Question 1

What is a limp?

Answer 1

Limp = abnormal gait commonly due to pain, weakness or deformity

Defined as shorter stance phase on affected limb

Question 2

What does the clinical presentation of a limp correlate to?

Answer 2

• Pain
  
  • Antalgic gait
• Weakness
  
  • Trendelenberg gait
• Short limb
  
  • Toe walk
• Stiff joint
  
  • Adducted and loss of rotation
• Spasticity
• Poor balance

Question 3

What does the aetiology of a limp change with?

Answer 3

Age group

Question 4

Why is it important to differentiate the cause of a limp when infection and inflammation are involved?

Answer 4

In infection and inflammation important to differentiate the cause as some are more damaging:

• Septic arthritis
  
  • Most urgent
• Osteomyelitis
• Transient synovitis

Question 5

What are the clinical features of a limp due to infection and inflammation?

Answer 5

• Limp (age dependent)
• Pain
• Systemic features
  
  • Malaise, loss of appetite, temperature
• Recent URTI/ear infection
• Trauma
• Pseudoparalysis

Question 6

What is seen in the examination for a limp when infection and inflammation is involved?

Answer 6

• Look sick
• Limp
• Able to weight bear
• Localising area
  
  • Ankle/tibia/knee/thigh/hip
• What movements hurt

Question 7

What investigations are done for a limp when infection and inflammation is involved?

Answer 7

• Bloods
  
  • WCC, CRP, ESR, Creatinine kinase, cultures
• X-ray
  
  • Document state of bone other than see infection as takes 3 weeks to see
• USS
  
  • Confirm effusion of joint which might not be obvious clinically

Question 8

What is used to differentiate between septic arthritis and osteomyelitis?

Answer 8

Kocher criteria

Question 9

What does Kocher criteria look at?

Answer 9

Pyrexia

Weight bearing

WBC count

ESR

Question 10

What does ESR stand for?

Answer 10

Erythrocyte sedimentation rate

Question 11

What does an ESR blood test monitor?

Answer 11

Infection and inflammation rate

Question 12

What bacteria usually causes septic arthritis in children?

Answer 12

Staph. Aureus

Question 13

What is the presentation of septic arthritis in children?

Answer 13

• Limping
• Pseudoparalysis
• Swollen, red joint
• Refusal to move joint
• Pain
• Pyrexia

Question 15

Is septic arthritis more common in lower or upper limbs?

Answer 15

• More common in lower limb than upper
  
  • Knee most common then hip

Question 16

What are routes of entry for bacteria into a joint?

Answer 16

• Haematological spread (most common)
• Dissemination from osteomyelitis
• Spread from adjacent soft tissue infection
• Diagnostic or therapeutic measures
• Penetrating damage by trauma

Question 17

What is the most common route of entry for bacteria into a joint?

Answer 17

• Haematological spread (most common)

Question 18

What is the treatment for septic arthritis?

Answer 18

• Surgery
  
  • Aspiration
  • Usually carried out arthroscopy, but arthrotomy in hip
• Antibiotics
  
  • IV

Question 19

How is the incidence of osteomyelitis changing?

Answer 19

• Incidence is declining

Question 20

What are risk factors for osteomyelitis?

Answer 20

• Blunt trauma
• Recent infection

Question 21

Describe the pathogenesis of acute haematological osteomyelitis?

Answer 21

• 3 factors
• Vascular anatomy
  
  • Vascular loops
  • Terminal branches
• Cellular anatomy
  
  • Inhibited phagocytosis
    
    • Low pO2
• Trauma

Question 22

What are the clinical features of osteomyelitis?

Answer 22

• Pain
• Fever
• Reduced Range Of Movement
• Reduced weight bearing

Question 23

Describe the microbiology of osteomyelitis?

Answer 23

1. Staph aureus
2. Strep pneumoniae
3. Staph epidermidis

Question 24

What is the treatment for osteomyelitis?

Answer 24

• Surgery
  
  • Indications for surgery include
    
    • Aspiration for culture
    • Drainage of subperiosteal abscess
    • Drainage of septic joint
    • Debridement of dead tissue
    • Failure to improve
• Antibiotics

Question 25

What are indications for surgery in osteomyelitis?

Answer 25

* Aspiration for culture * Drainage of subperiosteal abscess * Drainage of septic joint * Debridement of dead tissue * Failure to improve

Question 26

How is transient synovitis diagnosed?

Answer 26

Diagnosis of exclusion

Question 27

What is the presentation of transient synovitis?

Answer 27

* Limping * Slightly unwell * History of viral infection * Apyrexial * **Not that unwell**

Question 28

What does JIA stand for?

Answer 28

Juvenile idiopathic arthritis

Question 29

What are the 3 groups of JIA?

Answer 29

* Pauciarticular * Early onset pauciaritular JIA (EOPA) * Late onset pauciarticular JIA (LOPA) * Polyarticular * Seronegative * Seropositive * Systemic onset

Question 30

What are some features that raise concern of neoplasm?

Answer 30

* Night pain * Stops doing sport/going out * Sweats and fatigue * Abnormal blood results * Low Hb atypical blood film, atypical platelets

Question 31

What is a neoplasm?

Answer 31

A new and abnormal growth of tissue in a part of the body, especially as a characteristic of cancer