Child with a limp
Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat
Case 1: 1,5 year old
• Upper airway symptoms until last week
• Fine general condition, no fever or other general
symptoms
• Started to limp two days ago
• No known specific trauma, but goes to kindergarden
and falls often
Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat
Examination
• Lively, general condition seems fine
• Walking pattern: avoids weight on right foot, rotated
outwards
• T 36,8
• Lower extremeties:
–
–
–
–
–
No erytema
No warm skin
No obvious swelling
Manipulation (especially rotation) of right hip seems painful
Palpation seems painful
Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat
Lab
• CRP 8
• WBC 10
• SR 12
• Further investigation?
• Admit to hospital?
Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat
Imaging
• Ultrasound: slightly increased amount of fluid, seems
clear
• Diagnosis?
Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat
Acute bacterial osteomyelitis/septic
arthritis
Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat
History
•
•
•
•
•
•
•
•
Limp
Pain
Avoidance of use of bodypart
Trauma?
General condition lowered (?)
Fever?
Infection in previous weeks?
Similar symptoms previously?
Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat
Clinical examination
• Observation of movement
– Limp?
– Pain?
– Avoidance?
• General condition, T, HR, RF – systemic signs of
infection?
• Systematical examination of joints
– Observation: Erytema, swelling? Compare with opposite side
– Palpation: Temperature, swelling?
– Motion: decreased? Pain?
• Neurological examination?
Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat
Laboratory investigations
• SR, WBC, CRP, blood culture
• Synovial fluid sampling
Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat
Imaging
•
•
•
•
Ultrasound
MRI (general anesthesia)
(X-ray)
(Bone scintigraphy)
Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat
Treatment
• Septic arthritis: joint drainage with flushing
• antibiotics
– klindamycin
– betalactamase-stabile penicillin (kloxacillin)
• osteomyelitis: total 6 weeks, at least 2 weeks
intravenous
• septic arthritis: total 3-4 weeks, at least 1-2 weeks
i.v.
Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat
Treatment
• Inhalations?
–
–
–
–
Saline
Racemic adrenaline (epinephrine)
Salbutamol?
Hypertonic saline?
• Corticosteroids?
Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat
Case 2: 5 year
• 1 day history
• Moderately affected general condition,
– Loss of appetite, nausea
– Fever
• Pain in left knee, don’t want to walk
• No history of trauma or other infections
Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat
Examination
• Good contact, but uninterested in surroundings
• HR 120, RF 25
• Left knee:
–
–
–
–
Erytema
Swollen
Warm
Painful
• Admit to hospital?
Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat
Lab
• CRP 150
• SR 78
• WBC 22
Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat