A 13 year old boy A 13 year old boy with with complaints of “butt complaints of “butt pain” pain” Morning Report July 1, 2009Morning Report July 1, 2009

Otherwise healthyOtherwise healthy Noted the pain after attending Noted the pain after attending

a school dance……but “he did a school dance……but “he did not dance”not dance”

AfebrileAfebrile What do you want to What do you want to

know????know????

His exam is “normal” except for His exam is “normal” except for tenderness over the right tenderness over the right gluteus musclegluteus muscle

He is sent home with NSAID’s He is sent home with NSAID’s and a diagnosis of and a diagnosis of musculoskeletal strainmusculoskeletal strain

Don’t forget…….Give Don’t forget…….Give “what if” instructions…. “what if” instructions….

It is now 5 days later……It is now 5 days later……

Now complaining of right knee Now complaining of right knee pain and he is pain and he is limpinglimping

No fever noted at home, Temp No fever noted at home, Temp is 99 in the officeis 99 in the office

Now what????????Now what????????

Films are ordered….given Films are ordered….given Tylenol #3Tylenol #3

Plain films of the hips and Plain films of the hips and knees are “normal”….knees are “normal”….

Everyone in thinking Everyone in thinking SCFESCFE

AnatomyAnatomy

SCFESCFE

SCFESCFE

Usually in boys at pubertyUsually in boys at puberty Usually unilateralUsually unilateral Stable or unstableStable or unstable Diagnostic radiograph: frog Diagnostic radiograph: frog

leg hip filmsleg hip films Surgical interventionSurgical intervention

SCFE SeveritySCFE Severity

But he does not have a But he does not have a SCFE…….. SCFE……..

What do you do now? What do you do now?

What else is in your What else is in your differential of a limping differential of a limping

child?child?

DifferentialDifferential

ToddlerToddler Septic arthritisSeptic arthritis DiscitisDiscitis SepsisSepsis OsteomyelitisOsteomyelitis PyomyositisPyomyositis NeoplasiaNeoplasia

Leukemia, bone Leukemia, bone tumors…tumors…

JIA?JIA? Transient synovitisTransient synovitis

Child (3-10 years)Child (3-10 years) Septic ArthritisSeptic Arthritis OsteomyelitisOsteomyelitis PyomyositisPyomyositis NeoplasiaNeoplasia

Leukemia, bone Leukemia, bone tumors…tumors…

DiscitisDiscitis JIA?JIA? PerthesPerthes SynovitisSynovitis

Adolescent…addAdolescent…add SCFESCFE

If you send him home…If you send him home…again, the “what if” again, the “what if” instructions are KEY….instructions are KEY….

The plot thickens…….The plot thickens……. 4 days later, the child returns for 4 days later, the child returns for

more tylenol #3more tylenol #3 Still limpingStill limping Increasing pain with extension of Increasing pain with extension of

the hip and internal rotation of the the hip and internal rotation of the leg but there is no redness, leg but there is no redness, warmth or swellingwarmth or swelling

Now fever to 102, HR is 130, RR 24, Now fever to 102, HR is 130, RR 24, BP 90/50 BP 90/50

Systemic symptomsSystemic symptoms

His left elbow is His left elbow is redred and swollen and swollen DisorientedDisoriented Jaundiced (Bili 12/8, SGOT and Jaundiced (Bili 12/8, SGOT and

SGPT nl)SGPT nl) FebrileFebrile Anemic (hgb 6, WBC 24)Anemic (hgb 6, WBC 24)

DIFFERENTIAL????DIFFERENTIAL????

The patient is hospitalized The patient is hospitalized ………..and a diagnostic ………..and a diagnostic procedure is performedprocedure is performed

The CTThe CT

Normal Not normal

The Psoas (part of the The Psoas (part of the posterior abdominal wall)posterior abdominal wall)

Psoas AbscessPsoas Abscess

Hip symptomsHip symptoms Can be a “primary diagnosis”Can be a “primary diagnosis” Can be associated with GI Can be associated with GI

pathology or sometimes with GU pathology or sometimes with GU pathologypathology

Not usually associated with hip Not usually associated with hip infectioninfection

In the hospital…….In the hospital……. Psoas abscess and elbow drainedPsoas abscess and elbow drained Antibiotics begunAntibiotics begun All cultures positive for St A…blood and All cultures positive for St A…blood and

abscess and elbowabscess and elbow Remains febrile on POD 1Remains febrile on POD 1 Remains febrile on POD 2Remains febrile on POD 2 Remains febrile on POD 3 but continues to Remains febrile on POD 3 but continues to

“feel better”, jaundice resolves“feel better”, jaundice resolves

Want to do anything else, antibiotics are given and appropriate???????????

In the hospital…….In the hospital…….

Remains febrile on POD 4Remains febrile on POD 4 Remains febrile on POD 5Remains febrile on POD 5 Remains febrile on POD 6Remains febrile on POD 6

““feels better” but febrile……. Now feels better” but febrile……. Now what?????what?????

Another diagnostic Another diagnostic procedure was procedure was performed……..performed……..

Repeat CT reveals concern Repeat CT reveals concern for hip disease…the for hip disease…the acetabulum appears “moth-acetabulum appears “moth-eaten”eaten”

And the child returns to the OR for I and D of the And the child returns to the OR for I and D of the hip joint……. After which he is hip joint……. After which he is afebrile…afebrile…

Septic Arthritis of the HipSeptic Arthritis of the HipA True EmergencyA True Emergency

Septic Arthritis of the HipSeptic Arthritis of the Hip

Usually in children under 3 yearsUsually in children under 3 years Usually unilateralUsually unilateral Fever, high WBC, high sed rateFever, high WBC, high sed rate Diagnostic radiographs: Diagnostic radiographs:

ultrasound, CT/MRIultrasound, CT/MRI Plain films are normal in 50% of Plain films are normal in 50% of

cases!!!!!cases!!!!!

When the Xray is diagnostic: When the Xray is diagnostic: there is a loss of the architecture of there is a loss of the architecture of the pelvis and widening of the joint the pelvis and widening of the joint spacespace

The MRIThe MRI

Septic Arthritis Risk Septic Arthritis Risk Factors for Poor OutcomeFactors for Poor Outcome

Over 5 days to surgical Over 5 days to surgical drainagedrainage

Associated osteomyelitis in Associated osteomyelitis in the proximal femurthe proximal femur

Morals of the story: Morals of the story: Sometimes you just have Sometimes you just have to keep looking…..to keep looking…..

FeverFever Severe painSevere pain Night painNight pain Functional Functional

impairmentimpairment Escalating symptomsEscalating symptoms

A limping child =

Peds in ReviewPeds in Review http://pedsinreview.aappublications.orghttp://pedsinreview.aappublications.org

/cgi/reprint/27/5/170/cgi/reprint/27/5/170

Approach to Acute Limb Pain in Approach to Acute Limb Pain in Childhood Childhood

Shirley M. L. Tse, MDShirley M. L. Tse, MD Ronald M. Laxer, MD Ronald M. Laxer, MD The Hospital for Sick Children; The Hospital for Sick Children; University of Toronto, Toronto, Ontario, University of Toronto, Toronto, Ontario, Canada Canada