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Lizzie Doll, PGY-2University of Utah

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HPI: 4 yo girl who presents for assessment offrequent tripping.

Has some difficulty keeping up with kids her ownage

Also complains of night pain in her legs 3-4 timesper week, but doesnt interfere with activities

Denies any redness or swelling around the knees

Likes to W sit

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BIRTH HISTORY:Full-term vaginal delivery, 6 lbs. 6 oz.

DEVELOPMENTAL HISTORY:

Crawled at 9 monthsWalked at 11 months

All other milestones normlal

FAMILY HISTORY:

One grandmother was pigeon-toed and one unclewith clubfeet

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VS: age-appropriate, Wt: 17 kg (37%), Ht: 100.5 cm (7%)

GAIT:

Intoeing gait

Foot-progression angle: 30 degrees inward

Windmills with running

MUSCULOSKELETAL:No deformities of spine or upper extremities

Genu valgum

Internal rotation of hips: 90 degrees bilaterallyExternal rotation of hips: 15-20 degrees bilaterally

Tibial torsion: +5 degrees

Thigh-foot angle: +5 degrees

Feet: mild bilateral metatarsus adductus

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Infection/Infection-related

Septic arthritisOsteomyelitis

Reactive arthritis

Rheumatic fever

Lyme disease

Toxic synovitis

Trauma/Overuse FractureSoft-tissue injury

Osgood-Schlatter disease

HypermobilityMalignancy

Leukemia

Neuroblastoma

Bone tumors

Hematologic

HemophiliaSickle cell anemia

Inflammatory

Juvenile idiopathic arthritis

Systemic lupus erythematosus

Henoch Schnlein purpura

Orthopedic/Mechanical

Slipped capital femoral epiphysis

Legg-Calv-Perthes disease

Noninflammatory Growing painsFibromyalgia

Reflex sympathetic dystrophy

Conversion reaction

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Basic ScreeningComplete blood count

Differential count

Blood smear

Erythrocyte sedimentation rate

C-reactive proteinRadiographs

Further InvestigationsBlood (antinuclear antibody,rheumatoid factor, culture,viral/bacterial serology, creatinekinase, partial thromboplastintime, sickle cell screen,

immunoglobulins, complement)

Urinalysis

Synovial fluid (cell count, Gramstain, culture)

Tuberculin skin test

Imaging (bone scan,ultrasonography, computedtomography scan, magneticresonance imaging)

Bone marrow aspiration

Slitlamp examination of eyes

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Birth history

Developmental history

Sleeping posture

Sitting posture

Pain/Limp/Disability

History

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Observe gait

Hip rotation while prone

Tibial torsion (thigh-foot angle)

Foot

Physical

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Natural history

Infant 40

ER > IR

Age 1 year 30

IR > ER

Adolescent 15IR = ER

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Infant 0

Age 1 year +5

Child +10

Adolescent +15-20

Natural history

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Hips

Femoralanteversion

LegInternal tibialtorsion

FeetMetatarsusadductus

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Internal Rotation External Rotation

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Essentials of Musculoskeletal Care. John F.Sarwack, ed. 4th edition, 2010.

Nelson Textbook of Pediatrics. 19th edition,2011.

Tse SM, Laxer RM. Approach to acute limb painin childhood. Pediatrics in review / AmericanAcademy of Pediatrics. May 2006;27(5):170-

179.Thanks to Dr. Jacques DAstous, orthopedicsurgeon at Shriners for his help with this

presentation