Paediatric Acute care Guidelines PMH Emergency Department

Background

Limping may be due to pain referred from elsewhere:

  • Pain from the hip may refer to the thigh or knee
  • Pain from the spine or genitalia may refer to the hip
  • Always consider the possibility of non-accidental injury (NAI)
  • Limping for less than 3 days without any red flags does not require investigation

Assessment

History

Ask about:

  • Trauma
  • Fever
  • Preceding infections
  • Rate of onset
  • Duration of limp / pain
  • Rashes
  • Drug exposure
  • Features of systemic disease with joint involvement
  • Morning stiffness

Examination

General:
  • Temperature
  • Inspect for rashes/bruises
  • Assess for signs of the “unwell child”:
    • Poor perfusion
    • Tachycardia/tachypnoea
Gait:
  • Fully mature gait is attained by the age of 4 years
  • Running accentuates any pathological features of gait
  • Recognised gait patterns include:
    • Antalgic gait due to a pain in the lower limb
    • Trendelenburg gait due to weakened hip abductors or an unstable hip fulcrum e.g. Perthes Disease, Slipped Upper Femoral Epiphysis (SUFE)
    • Spastic gait as seen in cerebral palsy
    • Proximal muscle weakness gait seen in neuromuscular conditions
Standing:
  • Examine the back and spine for tenderness or deformity (discitis may cause exaggerated lordosis)
  • Look for pelvic tilt
Supine:
  • Examine each joint separately for tenderness, swelling, effusion, erythema, warmth and range of movement
  • Disorders of the hip usually cause restriction of hip abduction and internal rotation and pain on these movements
  • Severe restriction of movement suggests septic arthritis
  • Note the position held by the child at rest
  • Check the foot for embedded foreign body
  • Assess for leg length discrepancy
  • Look for muscle atrophy, tenderness, weakness or abnormal reflexes
  • Neurological examination
If no clear cause for limp is found on examination of the lower limbs or spine, examine the groin and abdomen

Investigations

In a well child with < 3 days history of limp
  • No investigations are required
In a sick child, seek advice from an ED Senior Doctor
  • Bloods: FBC, CRP, ESR, blood cultures
  • X-Ray hip – lateral + AP pelvis
  • Hip ultrasound may be required
  • Discuss with Paediatric Orthopaedic Team
In children with fever or severe hip pain/spasm
  • Seek advice from an ED Senior Doctor
  • Blood tests: FBC, CRP, ESR, blood cultures
  • X-Ray hip – lateral + AP pelvis
  • Hip ultrasound may be required
  • Lateral frog-leg view X-Ray needed if considering SUFE (25% are bilateral, therefore X-Ray both sides)

Differential diagnoses

Transient Synovitis (Irritable Hip):
  • Most common cause of limping in pre-school children
  • Diagnosis of exclusion
  • Age range: 3 – 8 years
  • Boys : Girls ratio 2:1
Perthes Disease:
  • Age range: 4 – 12 years
  • Boys : Girls ratio 4:1
Slipped Upper Femoral Epiphysis (SUFE):
  • Age range: 10 – 15 years
  • Boys 12 – 15 years
  • Girls 10 – 13 years
  • Boys : Girls ratio 4:1
  • Typically overweight children

Management

  • If either a fever or raised ESR is present, the patient is 8 times more likely to have an infection or an autoimmune process than if both parameters are normal
  • If both these parameters are raised, more than 90% of cases will be due to an infectious or autoimmune cause

 

Initial management

Well children:
  • Discharge home
  • Advise bed rest
  • Regular non-steroidal anti inflammatory drugs (e.g. Ibuprofen, Naproxen)
  • Review in ED in 2 – 5 days or earlier if the child becomes febrile or the condition worsens
Sick Children:
  • Discuss with and admit under the Orthopaedic Team
Septic Arthritis/Osteomyelitis:
  • Discuss with and admit under the Orthopaedic Team
  • IV antibiotics – consider (do not give without discussing with the Orthopaedic Team)
Perthes:
  • Discuss with the Orthopaedic Team
  • Usually requires admission
SUFE:
  • Discuss with and admit under the Orthopaedic Team
  • Will require surgery

Referrals and follow-up

  • Children with hip pain for longer than 4 weeks can be referred to the Paediatric Rheumatology Team
  • Ask their advice on the appropriate blood tests to do in the meantime

Nursing

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