Icm Winter 5 Child With Limp

Front 1

what is...

1. Osteoid Osteoma
2. ewing sarcoma
3. osteosarcoma
4. developmental dysplasia of the hip (DDH)
5. Club foot

Back 1

1. Osteoid Osteoma: benign skeletal lesion, pain

2. ewing sarcoma: bone or soft tissue cancer, common in femur

3. osteosarcoma: MOST COMMON bone cancer in kids

4. developmental dysplasia of the hip (DDH): easy dislocation bc of abnormal shape/development

5. Club foot: both feet excess plantar flex

Front 2

1. Legg Calve Perthes
2. Slipped capital femoral epiphysis
3. ostenonecrosis
4. osgood schlatter
5. chrondromalacia patellae
6. toddlers fracture

Back 2

1. Legg Calve Perthes: idiopathic osteonecrosis of femoral head.

2. Slipped capital femoral epiphysis: slip of femoral head bc of microfracture of growth plate

3. ostenonecrosis: avascular necrosis

4. osgood schlatter: patellar tendon overuse, affects insetion of tibial tubersoiry

5. chrondromalacia patellae: path change in articular cart of patella

6. toddlers fracture: accidental spiral tibial fracture

Front 3

1. sever disease
2. viral myositis
3. transient synovitis
4. juvenile idiopathic arthritis
5. osteochrondritis dissecans
6. discitis

Back 3

1. sever disease: calcaneal apophytisis, heel pain in growing athletes due to overuse and repeat microtrauma, partial avulsionof achilies

2. viral myositis: mm pain and calf tenderness. influenza infection

3. transient synovitis: self limited inflammatory disorder of the hip, common in young kids

4. juvenile idiopathic arthritis: chronic pediatric arthropathies w/onset <16 yo and documented arthritis in >1 joint for >6 weeks

5. osteochrondritis dissecans: acquired, idiopathic, part of articular cart and underlying subchondral bone seperates from rest of joint adn fragments causes locking and clicking of the joint. knee common

6. discitis: inflammation in vertebral disc

Front 4

what is the most common cause of limping in a child, what complicates the dx

Back 4

1 soft tissue injury, minor and resolve

but... Kids dont localize pain well or communicate

*keep abuse in teh back of your mind

*congenital things show up at birth or first few months

Front 5

what are the phases of normal gait

Back 5

1. Stance: 1 foot on the ground

2. Swing: one leg advancing forward

*1 cycle is from R heel strike to R heel
strike
*like adult at 7 yo

Front 6

what gait is response to pain
what gait lifts foot
what gait waddles
what gait is toe walking
what is UL toe walk

Back 6

pain: antalgic. acute- trauma, infection, neoplasm, pheumotologic

waddle: trendelenburg. chronic, not painful. COngenital, developmental or mm nature

Lift foot: steppage, neuro, loose dorsiflexion

toe walk: equinus. CP, tight achilis, calcaneal fracture, foerign body

UL toe walk: short leg side walks on toes

Front 7

whats the gait

1. antalgic
2. trendelenburg
3. steppage
4. equinus
5. Short leg

Back 7

1. painful. "quick step" shorter stance. lots of ext rot (int rot restricted). long stance on healthy leg w/faster swing phase

2. chronic non painful issue. swing over affected leg. when standing on 1 leg opposite hip drops, leg you are standing on has weak glut med- abductor. no change in time spent in stance swing

3. loss of dorsiflexion.

4. equinus- toe walk. CP, tight achilis, calcaneal fracture, foerign body etc

5. Short Leg: toe walk on short leg, long leg has knee flexion

Front 8

ok so minor trauma related injury is the most common reason a child will limp. besides this what is the most common cause of hip pain in kids

Back 8

1. Transient Synovitis: self limited

**not sick but dont want to walk. common after viral infection. increased fluid in joint due to infection

Front 9

what is the reason for limp in a

4-11 yo
11-17

Back 9

4-11: transient synovitis or LCP

11-17: SCFE

Front 10

what are the 10 main categories of the ddx of a child with limp

Back 10

1. cancer: benign- esteoid, osteoma. Malignant- ewing, leukemia, osteosarcoma
2. congenital: DDH
3. acquired: LCP, SCFE
4. Infection
5. Osteonecrosis: Sickle cell
6. trauma/soft tissue: abuse
7. atraumatic/mechanical: leg length discrepency
8. inflammatory
9. neuromuscular: CP, MD, ALS
10. Referred: discitis, abcess, appendicitis, neuroblastoma

**DO NOT MISS CANCER OR INFECTION

Front 11

These clues from the physical exam lead you to think what in the child who has CC limp
1. Abd mass
2. Abd tenderness
3. Conjunctivitis, enthesitis, urethritis
4. Erythema chronicum migrans
5. Ext hip rotation w/hip flexion
6. Loss of internal rotation
7. obesity
8. Galeazzi
9. Lymphadenopathy
10. Warmth, redness
11. Painless, non itchy, skin lesion
12. Psoas sign (Thomas test)
13. Metaphyseab, rib, vertebral fracture in non ambulatory kids

Back 11

1. Abd mass- neuroblastoma, psoas abcess
2. Abd tenderness- appy
3. Conjunctivitis, enthesitis, urethritis- reactive arthritis
4. Erythema chronicum migrans- lyme
5. Ext hip rotation w/hip flexion- SCFE
6. Loss of internal rotation- LCP, SCFE
7. Obesity- SCFE
8. Galeazzi- leg length discrepency
9. Lymphadenopathy- CA
10. Warmth, redness
11. Painless, non itchy, skin lesion
12. Psoas sign (Thomas test)
13. Metaphyseab, rib, vertebral fracture in non ambulatory kids

Front 12

What motion does swelling of hip cause

Back 12

ext rotation, flexion (this is why testing for restriction in int rotation and extension is SO important)

Front 13

What hip motion is of utmost importance in the child with limp

Back 13

int rotation, abduction, extension (any swelling will favor ext rot and flexion)

Front 14

If in the hx of a pt with CC limp what does this clue you into
1. Sexual activity
2. Bleeding disorder
3. Insect bite
4. Diarrhea
5. Pharyngitis
6. Trauma
7. Back pain
8. Abd pain
9. Intermittent pain/ rest
10. Improves with activity
11. Worsens with activity
12. Decrease circumference

Back 14

1. Sexual activity: GC, reactive arthritis
2. Bleeding disorder- hemarthrosis
3. Insect bite- lyme disease
4. Diarrhea- reactive arthritis
5. Pharyngitis- rheumatic fever, transient synovitis
6. Trauma- fx, soft tissue
7. Back pain- discitis, vertebral osteomylitis
8. Abd pain- psoas abcess
9. Intermittent pain/ rest- cancer
10. Improves with activity- rheumatologica, inflammatory
11. Worsens with activity- over use, stress fracture
12. Decrease circumference- chronic

Front 15

Why ask about fever, malaise, weight loss, URI with CC limp

Back 15

fever, malaise can be rheumatological or cancer. Weight loss is cacner. URI is transient synovitis

Front 16

Why ask what time of day the limp is worse

Back 16

1. AM- rheumatological, inflammatory, Transient synovits, JIA 2. PM- musculoskeletal 3. Wakes me up at night- cancer

Front 17

Why ask if limp was abrupt onset or insidious

Back 17

1. Infectious/traumatic is abrupt 2. Insidious is SCFE or LCP

Front 18

When might you consider a malignant tumor

Back 18

bone pain at rest (can also cause intermittent pain at rest)

Front 19

What are some non skeletal causes of limp

Back 19

1. Testicular tumor/tosision /hernia 2. Appendicitis 3. Poorly fitting shoes 4. CNS tumor- regression in toilet traning, vomit, weakness

Front 20

What caused spiral tibial fracture in a 1-3 yo

Back 20

nothing! Minor trauma causes this toddlers fracture. Xray is subtle (no distal displacement of tibia)

Front 21

Common cause of 11+ yo with antalgic gait

Back 21

antalgic: SCFE

Front 22

Common cause of a 4-10 yo with antalgic gait, trendelenberg

Back 22

antalgic: transient synovitis, LCP. Trendelenberg: CP DDH

Front 23

Common cause of 1-3 yo with atalagic gait. Trendelenburg

Back 23

antalgic- toddlers fracture trendelenburg: HHD, CP

Front 24

1. calcaneal apophytisis, heel pain in growing athletes due to overuse and repeat microtrauma, partial avulsion of achilies

2. : mm pain and calf tenderness. influenza infection

3. : self limited inflammatory disorder of the hip, common in young kids

4. : chronic pediatric arthropathies w/onset <16 yo and documented arthritis in >1 joint for >6 weeks

5. : acquired, idiopathic, part of articular cart and underlying subchondral bone seperates from rest of joint adn fragments causes locking and clicking of the joint. knee common

6. inflammation in vertebral disc



1. s: idiopathic osteonecrosis of femoral head.

2. s: slip of femoral head bc of microfracture of growth plate

3. avascular necrosis

4. : patellar tendon overuse, affects insetion of tibial tubersoiry

5. path change in articular cart of patella

6. : accidental spiral tibial fracture




1. benign skeletal lesion, pain

2. : bone or soft tissue cancer, common in femur

3. MOST COMMON bone cancer in kids

4. easy dislocation bc of abnormal shape/development

5. both feet excess plantar flex

Back 24

sever disease:
viral myositis
transient synovitis
juvenile idiopathic arthritis
osteochrondritis dissecan
discitis:

Legg Calve Perthe
Slipped capital femoral epiphysis
ostenonecrosis:
osgood schlatter
chrondromalacia patellae:
toddlers fracture

Osteoid Osteoma:
ewing sarcoma
osteosarcoma:
developmental dysplasia of the hip (DDH):
Club foot:

Front 25

whats happens when blood to femoral head stops in LCP

Back 25

bone gets dead and soft, get small fractures (visualized on frog leg as cresent sigh) bone flattens and subluxes out of acetabulim

**bone can try to regrow all chunky, called coxa magna

Front 26

for a kid with hip pain associated with imp what x ray are orderes

Back 26

AP
lateral- for SCFE
frog leg

**can go to US for effusion: septic arthritis, transient synovitis
**Bone scan for osteomylitis or LCP w/- plain film

**will see cresent for LCP

Front 27

what are labs for limp

Back 27

1. cbc
2. sed rate/CRP
3. blood culture

Front 28

whats the ddx of Jeff McCune

CC limping

Back 28

1. Diffuculty walking
RO SCFE
RO Growing pain
RO LCP
RO transient synovitis
RO stress fracture of femur

Front 29

who gets LCP

Back 29

male
4-11
short, normal weight

**its idiopathic avascular necrosis of femoral head, etc lots of names but its avascular necrosis of femur

Front 30

what happens in LCP after you start to loose blood flow to the femoral head

Back 30

1. bone dies
2. bone gets soft
3. small fracutes
4. bone collapses with weight
5. bone not round
6. femur subluxes out of acetabulum

**can regrow all chunky so still wont fit in acetabulum

Front 31

what are hte classic sx/presentation of LCP

Back 31

4-11 yo small male

**3-6 week hx of limp, not really pain, worse at end of day, ache in groin upper thigh

*abd, int rotation are limited

*atrophy

*no pain/tenderness to palpation

**antalgic gait

Front 32

tx of a 8 yo male in the 20% for height and weight. limp for 6 weeks. Int rotation adn abd restircted. (+) cresent sign

Back 32

stop all weight bearing activity
pediatric orthopedic specualist

Front 33

why type of fracture is SCFE

Back 33

salter harris type I

**fracture right through the growth plate

Front 34

tell me about SCFE

Back 34

post slip of femoral head bc of a type I salter harris fracture through the growth plate

**epiphysis changes from horizontal to oblique , this + weight (its in an older fatty) leads to fracture

11-17 yo fat male

Front 35

what are the sx of SCFE

Back 35

PAIN with activity (PCL wasnt really pain)

pain in ant proximal thigh, greater loss with flexion

antalgic gait (same as LCP)
loss of internal rotation- sensitive and specific

Front 36

what is the most sensitive nad specific PE finding in SCFE

Back 36

loss of internal rotation, greatrer loss of internal rotation with hip flexion

*8*also pain with activity in upper ant thigh

Front 37

what happens to teh leg in a SCFE pt when you flex their hip to 90

Back 37

externally rotations, loose internal rotation

Front 38

what happens to ROM in scfe

Back 38

1. loss of internal rotation, at flexion the hip is external rotation
2. loss of extension
3. loss of abduction

antalgic gait

Front 39

how is SCFE dx

Back 39

lateral, AP, frog leg x ray

klein line- femoral neck wont hit femoral head

hendrons hump- large femoral neck

Front 40

whats kleins line
whats hendons hum
when are they found

Back 40

both seen in scfe

kelin- line from superior femoral neck drawn to femoral head wont touch femoral head (shows post slip of epiphyseal plate)

hendron- widened femoral neck

**both seen in SCFE

Front 41

tx for SCFE

Back 41

repin the femoral head into place

Front 42

whats transient synovitis

Back 42

most common cause of NON traumatic acute limping kids,

dx of EXCLUSION,

steril effusion of joint resolves, self limited

common in boys 2-5

Front 43

what is the time line of a kid with transient synovitis

Back 43

go to bed fine, wake up and refuse to walk

**its steril effusion, heals on its own. common, super common in boys 2-5

pain in proxima thigh;/groin

Front 44

what tests are done for transient synovitis

Back 44

limited ROM
antalgic gait
external rotation is preferred
RO septic arthritis- febrile, WBC, sed rate increased (TS is no fever, normal CBC)
AP/Frog leg X ray
US dx effusion

Front 45

tx for transient synovitis

Back 45

NSAIDS

rest

recover 1-4 weeks
monitor temperature, reevaluate if febrile

Front 46

whats septic arthritis

Back 46

EMERGENCY- can loose fx of joint

commin in knee of kids

hematogenous infection is common

Front 47

what does the pt with septic arthritis present with

Back 47

ill, acute progressive pain in joint. its hot red swollen
limited motion
fever
antalgic gait
M=F
3-6 yo

hip will like flex, ext rot, abduction

Front 48

what is the tx for septic arthritis

Back 48

US guided synovial culture adn blood culture

WBC and sed rate increased

S aureus us most common
x ray normal

Front 49

whats the tx for septic arthritis

Back 49

tx s aureus (nost common) with AB

driain

Front 50

who gets growing pain

Back 50

3-8 yo boys

usually in calf can be in shin, knee, foot ankle thigh

unknown cause, perhaps overactivity

Front 51

you pt has leg pain (calf) after activity. he is 4 yo. he has no limp and both legs hurt

Back 51

growing pain

dx of exclusion
common in boys 3-8
**if there is tenderness to deep palpation do a mroe complete workup