APPROACH TO LIMB PAIN IN CHILDREN/OSTEOMYELITISMR 7/17/09J.Chen

Approach to Limb Pain in Children

Approach to Child with Limb Pain History History History PE Labs/Imaging

History

Important aspects: Area involved # of joints involved Nature of the pain Presence of systemic symptoms (fever, rash, weight

loss, fatigue) Presence of limp Weight bearing status Morning stiffness History of past medical illneses Travel Family History (Arthritis, Bleeding Disorders, Sickle

Cell Disease, IBD)

Physical Exam

Important Aspects Joint Exam

Swelling Erythema Warmth Tenderness Deformity ROM

Physical Exam Continue

Adjacent Structures Bones Tendons Muscles Skin

Gait Leg length discrepancy Full Neurologic Examination

Basic Screening

CBC with Diff Blood Smear ESR CRP Radiographs

Imaging

Plain Radiograph and Bone Scan (Technetium-99 scan) have long been the mainstay for joint and bone problems

CT useful in diagnosing: Osseus Tumors Pelvic and acetabular fractures Intraarticular Extension of Femoral Fractures

US: Joint effusions Developmental dysplasia of the hip

Imaging Continued

MRI-useful in evaluating Soft tissue Joint spaces Suspected joint infection Soft tissue tumors Muscle injuries Early avasular necrosis

Approach to Limb Pain in Children

Osteomyelitis

Cause: Most commonly results from Hematogenous spread May be from direct invasion of Pathogens into the

bone. May be precipitated by trauma

Pathogens: Staph aureus: 90% Non-group A beta-hemolytic streptococci Hib now less prevalent Salmonella-Sickle Cell Anemia Pseudomonas aeruginosa-puncture wound Neisseria gonorrhacae-sexually active GBS-neonates

Clinical Presentation

Sudden onset Localized pain Swelling Fever +/- trauma Limp/refusal to bear weight Previous infection

Physical Exam

Erythema Swelling Point tenderness Decreased ROM

Most commonly involves femur>tibia>humerous>fibula>radius>calcaneus>ilium

Imaging

X-Ray-not helpful in early diagnosis Findings appear after 7 days

Soft tissue swelling Subperiosteal changes Bone destruction

Bone Scan-85-100% sensitive MRI-equal sensitivity, better specificity

Treatment