Professional Documents
Culture Documents
Limping
Spencer Barfuss
12.10.2018
Case
A 15 month old infant presents to the
Emergency Department with a “limp”. His
father reports that his son was walking
well, but started to walk funny yesterday
and today refuses to bear weight on his
left leg. He notes that over this time he
has been very fussy with diaper changes,
but seems fine if you leave his leg alone.
There is no known history of trauma.
Why do I care?
5% of ER visits over a 3 month period were
due to inability to bear weight and/or
limp
Differential is broad and ranges from
minor injury to orthopedic emergency
and malignancy
Differential Diagnosis
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Differential Diagnosis
Traumatic Injuries
Vascular compromise
No pulse, skin blue (vascular congestion) or pale
(arterial insufficiency)
If delay in treatment expected attempt gross
reduction
Open Fractures
Fracture + skin disruption
Requires washout
Compartment Syndrome
Three “A”s: Anxiety, Agitation, and increasing
Analgesia needs
Key Fractures – tibial shaft, suracondylar humerus,
forearm.
Other traumatic injuries
NAT
Lower extremity fractures in non-ambulating child
Metaphyseal corners fractures, epiphyseal separations
Toddler Fracture
Limp after minor twist or fall.
Initial X-rays often negative.
Retained foreign body
Plantar cellulitis, draining laceration, or induration with
fluid collection
Evaluate with X-ray and/or ultrasound
Consider pseudomonas for puncture through shoe
Infections - presentations
Generally present with painful limp/inability to
bear weight and fever
Septic arthritis of the hip
Must not miss as damage to cartilage and blood
supply begins within 6-12 hours and may be
irreversible after 1-2 days.
Hip held in flexion, slight abduction and external
rotation. Resists passive movement due to pain.
Cellulitis, fasciitis, myositis, septic arthritis,
osteomyelitis.
Swelling, tenderness, erythema, effusion, and
limited joint motion.
Septic Arthritis
Toxic (transient) synovitis vs. Septic arthritis
Less acute symptoms, milder elevations in
inflammatory markers
Kocher criteria for septic arthritis
Temperature > 38.5
WBC > 12,000
ESR > 40 or CRP >2.5
Inability to weight bear
Score of 1 = 3% chance of septic arthritis, 2 =
40%, 3 = 93%, 4 = 99%.
Septic Arthritis workup
Radiographs, ultrasound
CBC with diff, ESR, CRP, and blood
cultures
Joint aspiration to confirm
WBC > 50,000
>75% PMNs
+ gram stain
Treatment: washout + antibiotics
Hip ultrasound with effusion