Case 17

4-YEAR-OLD REFUSING TO WALK- EMILY

Author: Jennifer Plant, 4th Year Medical Student, Dartmouth Medical School
Learning Objectives
Be able to construct a differential diagnosis for painful limp in a pediatric
patient.
1.
Know in detail the presentation, work-up, and treatment of transient
synovitis and septic arthritis of the hip.
2.
Appreciate the concept of "lethal and likely." 3.
Be acquainted with how to tailor the physical exam to the age and complaint
of a pediatric patient.
4.
Have a general framework for completing a musculoskeletal exam. 5.
Recognize the role of evidence-based medicine in daily medical practice. 6.
Summary of clinical scenario: 4-year-old Emily has refused to walk since this
morning. She fell off a teeter-totter yesterday, but did not complain of problems
resulting from the fall. Other than this and a current upper respiratory infection,
she feels well. Emilys general physical exam is normal except for a low-grade
fever and decreased passive range of motion of her hip. After ruling out septic
arthritis, Emily is diagnosed with transient synovitis of the hip and is treated with
rest and ibuprofen.
Key Findings from
History
Refusing to walk
Fall from height
Acute onset
Current upper respiratory infection
No fever
No constitutional symptoms
Key Findings from
Physical Exam
Low-grade fever
Rhinorrhea
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Appears well
Decreased passive range of motion of
hip
Rest of musculoskeletal exam normal
Physical exam otherwise normal
Differential
Diagnosis
Trauma
Osteomyelitis
Reactive arthritis
Leukemia
Transient synovitis
Septic arthritis
Juvenile idiopathic arthritis
Key Findings from
Testing
Results do not show a degree of
inflammation consistent with septic hip
Leukocyte count not significantly
elevated
Erythrocyte sedimentation rate below
level expected in septic arthritis
Final Diagnosis Transient synovitis of the hip
Case highlights: Students learn the important aspects of performing a
musculoskeletal exam in a toddler with a limp. History and physical exam will rule
out several joint problems en route to a diagnosis of transient synovitis, and the
student will be engaged in a discussion of appropriate diagnostic testing.
Multimedia features include photos showing a physician testing range of motion in
a child and links to abstracts found in a PubMed search.
Key Teaching Points
Knowledge
Telephone triage: Providing advice to parents over the telephone is an
important aspect of pediatrics. There are many obstacles to caring for such
patients:
Chart usually not available
Obtaining a history over the telephone is challenging
Cannot perform a physical examination
Subtle visual, auditory, and other clues can be missed.
As a general rule, a medical student should not give advice over the telephone.
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(An exception to that is if the parent is calling back about the patient for whom
you helped provide care, such as for clarification of some of the care instructions.)
Ideally, you and your attending physician should talk with the parent together, to
make sure the parent receives appropriate advice, and to give you more
experience with telephone medicine. As with all medical encounters, patient
telephone calls need proper documentation.
Skills
History:
In a focused history, remember to ask about similar symptoms in the past,
eliciting information about a condition that may be chronic or recurring. This
historical information helps to narrow in on the diagnosis. Repeated injuries would
also raise a red flag for non-accidental trauma.
Other elements of a focused history include:
Review of systems
Medications
Allergies
Family history
Social history
Physical exam:
Examination of a young child with musculoskeletal pain
Observe childs natural movements and position: Is she sitting still? What is
the position of her legs and hips?
Observe skin: Any obvious bruising or rashes? Evidence of wound?
Slowly approach patient and try to determine origin of pain. Start with
unaffected limbs. May be helpful to initially examine patient while on
caretakers lap.
Examine all of joints, distal to proximal, first palpating for evidence of
tenderness, warmth or effusion. Meanwhile, distract patient with a toy.
Examine patients fingers, wrists, elbows, shoulders, toes, ankles, and
knees.
Examine patient on exam table. Perform passive range of motion of each
joint, ending with what might hurt the most. Examine toes, ankles, and
knees. Complete exam of hips (observation, palpation, passive and active
range of motion).
Differential diagnosis
More likely diagnoses
Transient synovitis of the hip: Acute, self-limited inflammation of
synovial lining of hip often occurring during or following an upper respiratory
1.
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infection. This inflammatory process most commonly affects the hip or knee
and is one of the most common causes of hip pain in children. Usually
completely resolves within three to four days with no known serious,
long-lasting sequelae.

Septic arthritis: Infection of joint space, usually bacterial in origin. Causes
severe inflammation, often with erythema, warmth, or swelling. Patients
with septic arthritis typically appear quite ill. A septic hip is a medical
emergency that requires urgent attentionpus in the joint space can lead to
irreversible damage of the cartilage. Synovial fluid aspirated from a septic
hip is turbid, has an increased white cell count (predominantly
polymorphonuclear cells), and a low glucose. Bacteria will be present on
gram stain.

2.
Reactive (post-infectious) arthritis: This inflammatory process typically
follows an infection outside the jointmost often in the gastrointestinal or
genitourinary tractpresenting two to four weeks after the infection.
Children are frequently afebrile at presentation. The classic association with
urethritis and conjunctivitis is uncommon in children. The condition may be
clinically indistinguishable from septic arthritis except that aspiration of an
affected joint reveals inflammatory cells, but is sterile (the culture is
negative). The arthritis may last a few weeks and require anti-inflammatory
treatment. Antibiotics may need to be used to treat the underlying infection
if it is still present.

3.
Trauma: Minor accidental trauma such as a sprain or occult fracture is
possible after a fall. Many infectious, inflammatory, and other conditions
causing limp are often initially incorrectly diagnosed as due to trauma. Hip
or leg radiographs would be indicated to definitively rule out this cause.

4.
Osteomyelitis: Infection of bone, usually bacterial in origin (most often
Staphylococcus aureus andbefore routine immunizationHaemophilus
influenza, type B). Usually indolent presentation, so diagnosis can be
delayed.In toddlers, usually presents as pain and refusal to bear weight
(when affecting a leg bone). Fever, often high, is present in about half of
cases.

5.
Leukemia: Replacement of bone marrow by leukemic cells can cause bone
pain that presents as limp, refusal to walk or localized discomfort of the jaw,
long bones, vertebral column, hip, scapula or ribs. These symptoms may
precede systemic signs such as fever and weight loss. The pain of leukemic
infiltration would not be affected by position or movement and would be
more chronic in nature. Also, additional findings such as lymphadenopathy,
hepatosplenomegaly, fever, or other constitutional symptoms would be
expected in a systemic disease like leukemia.
6.
Less likely diagnoses
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Juvenile idiopathic arthritis (JIA): A group of disorders characterized by
chronic inflammation of the joints in a child under 16 years of age. Symptoms
must be present in at least one joint for six weeks before the diagnosis can be
made. There are seven subtypes of JIA, including:
Systemic (additional constitutional symptoms such as fever and rash)
Oligoarthritis (previously called pauciarticular)
Polyarthritis (rheumatoid factor positive)
Polyarthritis (rheumatoid factor negative)
Psoriatic arthritis
Enthesitis-related arthritis
Other arthritis (has overlapping features or does not meet full criteria for
one category)
May be associated with an evanescent salmon-colored macular rash on trunk and
extremities.
Slipped capital femoral epiphysis (SCFE):The most common hip disorder in
adolescents, characterized by posterior displacement of the capital femoral
epiphysis from the femoral neck through the cartilage growth plate, resulting in
limp and impaired internal rotation. Etiology has not been clearly defined. Patients
present most commonly with months of vague hip or knee symptoms and limp
with or without an acute exacerbation. Occurs more commonly in obese
adolescents, suggesting that mechanical strain on the growth plate could be at
least partially responsible for the slip. Endocrine factors also may be important.
Studies
Radiograph (X-ray): Will confirm absence of fracture.
Ultrasound: This study can demonstrate whether or not an effusion is present in
the hip joint as well as guide arthrocentesis, if needed.
Complete blood count (CBC):The leukocyte count is a measure of
inflammation. The more serious condition of septic arthritis should be associated
with a greater increase than that seen in transient synovitis.
Blood culture: Will determine bacterial organism if there is septic arthritis due to
bacteria entering the joint space via the blood.
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): Both
of these are nonspecific measures of inflammation and will be elevated in many
conditions, including infections and malignancies. Transient synovitis and septic
arthritis are both inflammatory processes; however, the more serious condition of
septic arthritis should be associated with greater increases in ESR and CRP.
Two studies that assist in differentiating between septic arthritis and
transient synovitis:
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The first found four independent predictors of septic arthritis of the hip:
Fever
Non-weightbearing
ESR > 40 mm/hr
WBC > 12.0 cells x 103/!L
Number of predictors
present
Risk of septic arthritis
0 2%
1 9.5%
2 35%
3 72.8%
4 93%
Reference:
Kocher et al. Differentiating between septic arthritis and transient synovitis of the
hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg
Am. Dec, 1999; 81(12): 1662-70.
The second found five independent predictors of septic arthritis of the hip:
Fever
Elevated CRP
Elevated ESR
Refusal to bear weight
Elevated WBC count
Number of predictors
present
Risk of septic arthritis
0 16.9%
1 36.7%
2 62.4%
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3 82.6%
4 93.1%
5 97.5%
Reference:
Caird et al. Factors Distinguishing Septic Arthritis from Transient Synovitis of the
Hip in Children. A Prospective Study. J Bone Joint Surg Am. June, 2006; 88 (6):
1251-7.
Management
Transient synovitis:
Treat with rest and ibuprofen
Pain resolves within three to ten days
Chance of recurrent episode
No serious or long-lasting consequences
Instruct parents to call if child develops a high fever, becomes increasingly
irritable or uncomfortable in spite of the ibuprofen, or if develops redness,
swelling, or warmth of the joint.
Schedule close follow-up.

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