Quiz 17: Refusing To Walk

Front 1

An 8-year-old obese male comes to the clinic with a chief complaint of right knee pain with the right foot medially rotated. On an exam the right knee is neither swollen nor erythematous but he is noted to have a limited ROM of the right hip. In addition, when he lifts his right leg, it externally rotates. The patient did not have a URI or any trauma preceding the onset of pain. The vital signs are normal at the time of the visit and he is well appearing and afebrile. What is/are the best next step(s) in management?

Back 1

AP and lateral x-ray followed up by internal reduction of the femoral head

Front 2

Legg-Calves-Perthes disease

Back 2

Do an AP and lateral x-ray followed by casting and crutches

Front 3

Bone scan

Back 3

• acute hematogenous osteomyelitis
  
• febrile
  
• localized bone pain
  

Front 4

Slipped capital femoral epiphysis

Back 4

• medical emergency
  
• Do an AP and lateral x-ray followed up by internal reduction of the femoral head
  
• obese patient
  
• limited ROM of hip
  
• normal vitals
  

Front 5

Aspiration of the knee is done when?

Back 5

septic joint

febrile

Front 6

Observation and weight reduction counseling is done when?

Back 6

non urgent condition

Front 7

A 6-year-old female comes to the clinic with a chief complaint of worsening right knee pain over the past month. On exam, you note generalized lymphadenopathy and splenomegaly. She coughs intermittently throughout the visit, and her mother explains that she is just getting over a cold. You note absence of tenderness, erythema, effusion or warmth over the hip, knee, or ankle joints. Her vitals are unremarkable except for a low-grade fever (100.8 F). Reviewing her chart, you note that she has lost 5 lbs since her visit 2 months ago. She sits with her right leg externally rotated but appears to be in pain despite trying several different positions, refusing to bear weight on that side. What is the most likely diagnosis?

Back 7

Leukemia

Front 8

Reactive arthritis

Back 8

• follow infection outside the joint
  
• affects GU or GIT
  
• presents two to four weeks post infection
  
• children commonly afebrile
  
• may involve multiple joints
  

Front 9

Leukemia

Back 9

bone pain

limp

refusal to walk

systemic symptoms, including

• fever
• chronic insidious joint pain
• generalized LAD
• weight loss
• hepatosplenomegaly

Front 10

Osteomyelitis

Back 10

• point tenderness over bony joint
  
• signs of joint inflammation
  
• infection by staph aureus or strep pyogenes
  
• pain worse upon weight bearing
  
• fever
  

Front 11

Transient synovitis

Back 11

• weight loss
• hepatosplenomegaly
• generalized LAD
• otherwise well appearing child with isolated involvement of joint, hip MC
• may follow upper resp infection
• resolves on its own within three to seven days

Front 12

Septic arthritis

Back 12

• erythema
• warm and swelling of deep joint
• fever, likely high grade
• CBC and diff
• US

Front 13

A 3-year-old girl comes to the clinic with a limp and a slightly externally rotated right hip. Which of the following signs/symptoms would you expect in the history or exam if a diagnosis of transient synovitis were made?

Back 13

History of a recent upper respiratory tract infection

Front 14

High grade fever

Back 14

osteomyleitis

septic arthritis

Front 15

Iridocyclitis (inflammation of iris)

Back 15

juvenile idiopathic arthritis

(also rash and fever)

Front 16

Significantly high ESR

Back 16

septic arthritis

Front 17

A 3-year-old female is at the pediatrician’s office for continued right knee pain after a ground-level fall six weeks ago. The patient is UTD on all immunizations, has no significant PMH, and no recent illnesses. Mom reports the patient complains of pain mostly in the morning when going to daycare but doesn’t seem to be bothered by it while playing outside in the afternoon. On exam the patient’s vitals are all within normal limits. Her physical exam reveals a well-appearing toddler who walks stiffly and avoids bending her right knee. The knee has a mild effusion but no obvious erythema. There is pain with passive flexion and extension of the right knee. During the exam the girl tells you her left ankle also hurts, which mom had forgotten about but says started hurting the same time as the right knee. Her CBC is normal, while her ESR and CRP are mildly elevated. Which of the following is the most likely cause of this patient’s condition?

Back 17

Juvenile idiopathic arthritis

Front 18

A 4-year-old child is refusing to walk over the course of a week. Her mother recalls that she fell off her bike yesterday. On exam, she is afebrile, but has decreased ROM of her hip. You review her file and note that she is up-to-date on her immunizations and she was last seen three weeks ago for a self-limited episode of diarrhea that she developed while visiting family in rural Mexico. Aspiration of her affected hip joint reveals slight increase in inflammatory cells but normal chemistries and a negative gram stain. Culture is pending. Which of the following is the most likely diagnosis?

Back 18

Reactive arthritis