September Week 1: Child with Limp

Article: Approach to Acute Limb Pain in Childhood – Pediatrics in Review 2006

1. A 12-year-old boy presents with a 2 week history of pain and swelling of his right leg. The pain is worse on the shin just below the knee, and is exacerbated by running, jumping, and going up and down stairs. His mother states he is a very active child. He plays football and basketball and recently started playing volleyball. Physical examination reveals point tenderness and swelling over the right tibial tubercle. The left leg is unremarkable. Which of the following is the most likely diagnosis?

a) Growing pains
b) Legg-Calve-Perthes disease
c) Osgood-Schlatter disease
d) Osteosarcoma
e) Slipped capital femoral epiphysis

2. A 13-year-old boy who is at the 90th percentile for weight complains of slight pain in the right thigh and knee for about a month. His complaints are made worse by physical activity and he has a mild limp. He has no history of recent infections or trauma. Physical examination reveals a slight decrease in internal rotation of the right hip, leg length discrepancy of 0.5 cm, and intact motor-sensory examination of the lower extremities bilaterally. There is mild right-sided metaphyseal osteopenia on xray.

Of the following, which would be the MOST likely diagnosis in this boy?
a) Transient synovitis
b) Septic arthritis
c) Osteomyelitis
d) Slipped capital femoral epiphysis
e) Legg-Calve-Perthes disease

3. What would be the most appropriate treatment?

a) Send him home with a ten day course of antibiotics
b) Send him home with a prescription for a 0.5cm shoe insert and physical therapy
c) Do CBC & ESR and if results are within normal limits, send him home with a 1 week follow-up in the office
d) Admit him to the hospital for IV antibiotics, non-weight bearing of the right lower extremity, and obtain an orthopedic consultation
e) Admit him to the hospital for internal fixation of the epiphysis with long screws

4. At what age does the risk of developing both osteomyelitis and septic arthritis in the same area decrease? and why?

a) 6 months
b) 1 year
c) 2 years
d) 5 years

5. A 9-year-old boy is being treated for acute hematogenous osteomyelitis of the distal tibia with appropriate IV antibiotic therapy. After three days of treatment, he fails to show any clinical improvement. Imaging is obtained and reveals a 1.5×1.5cm abscess in the distal tibia. The patient subsequently undergoes open surgical debridement without complications. Following surgery, serial evaluations of which of the following studies is the most expeditious method to determine the early success of treatment?

a) White blood cell count
b) MRI
c) ESR
d) C-reactive protein
e) Radiographs

By Dr. Gisella Valderrama