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Limping scenarios

4 min read

Clinical Scenarios

Scenario (1)

A 3-year-old male with painful limp and fever. Approach?

History

  • Stabilize the patient… He is stable
  • Onset: 7 days
  • History of Trauma: No
  • Is this recurrent: No
  • Fever: Febrile
  • History of Hematological issues (SCD, hemophilia): No
  • Recent URTI: No
  • Skin rash: No

Physical Findings

  • Joint or bone swelling: Yes, Right knee
  • Any history of raw milk ingestion: No (consider Brucellosis)

Examination

  • Vital signs: Normal
  • General and systemic examinations: Normal
  • Local examination:
    • Right knee: swelling, tender, warm, red, limitation of movement

Diagnosis

Septic arthritis

Investigations

  • CBC, Smear, ESR, CRP, blood culture
  • Radiology: X-ray, ultrasound for effusion and abscess
  • Aspiration for staining and culture
  • Bone scan, MRI if suspected osteomyelitis

Treatment

  • Admission, stabilization, analgesia
  • Orthopedic consultation for joint aspiration
  • Treat infection:
    • < 3 months: Cefotaxime, flucloxacillin
    • Or if MRSA: Clindamycin or vancomycin
  • ID consultation
  • Duration of treatment: 3-4 weeks

Differential Diagnosis

  • Infections:
    • Septic arthritis
    • Osteomyelitis
    • Brucellosis
  • Connective tissue diseases:
    • Juvenile Rheumatoid arthritis
    • SLE
  • Rheumatic fever
  • Malignancy
  • Referred pain from acute appendicitis
  • Testicular torsion, orchitis

Scenario (2)

10-year-old boy with painful limping presented to the clinic. Your approach?

History

  • Stabilize the patient: Stable
  • Onset. Duration: 6 days
  • Which limb affected and which part: Left lower limb, hip joint
  • Is this 1st episode: Yes
  • Any swelling: No
  • Affecting his daily activity: Yes
  • History of trauma: No
  • Any strenuous exercise: No
  • Preceding URTI, Diarrhea: No
  • Any chronic illness (SCD, hemophilia): No
  • Any history of chronic drug use (steroids): No
  • Is he obese: Yes

Imaging

X-ray shows: Posteroinferior displacement of the left capital femoral epiphysis

img-1.jpeg

Diagnosis

Slipped capital femoral epiphysis (SCFE) at left hip joint

Key questions to address:

  • Risk factors?
  • Clinical picture?
  • Differential diagnoses?
  • Complications?
  • Treatment?
  • Prognosis?

Scenario (3)

10-year-old female brought with 2 months history of fever, bone pain, fatigability, limping. Your approach?

History

  • Stabilize the patient: Stable
  • Nocturnal symptoms of fever, sweating: No
  • Weight loss: Mild, due to poor appetite
  • History of skin rash: No
  • History of morning stiffness: No
  • History of taking raw milk or contact with animals: Yes, 3 months back she was in contact with goats
  • Family history of similar problem: No

Examination

  • Vital signs and anthropometric measurements: Normal but febrile
  • Pallor: Some pallor
  • Jaundice: Not clear
  • Hepatosplenomegaly or lymphadenopathy:
    • Liver: moderate enlargement
    • Spleen: 7 cm
    • No lymphadenopathy
  • She received many antibiotics without response

Investigations

CBC:

  • Microcytic hypochromic anemia
  • Leukocytes: normal differential, mild neutrophils
  • Thrombocytosis

Diagnosis

Brucellosis

Not leukemia, lymphoma or any malignancy

Diagnostic Tests

  • Titer of Brucella
  • PCR
  • Brucella culture (1-2 weeks, but can take 6 weeks)

Treatment (>8 years)

Doxycycline + Rifampicin for 6 weeks – Bactrim

Scenario (4)

Ahmed is 10 years old, brought to the ER by his mother because he is limping. Approach.

History

  • Duration: 3 days
  • Which limb is affected: Right lower limb
  • Which part of the right lower limb: Mainly the groin area
  • Any other area or joints pain: Yes, Right thigh and knee
  • Can he bear weight on the right lower limb: No
  • Skin rash: No
  • Febrile, ill or toxic: No
  • Loss of weight or night sweating: No
  • History of trauma or contusion: No
  • Is he obese: No
  • Past history of hematological problem (SCD) or blood transfusion: No
  • Past history of similar problem: No
  • History of URTI within the last weeks: Yes, mild cough, runny nose and mild fever 7 days ago
  • Family history of similar problem: No
  • History of chronic medication: No

Examination

Full examination (general examination, vital signs, measurements, skin, HSM, lymph nodes, etc.): No abnormality detected

Local Examination

  • Pain in the right hip radiating to thigh and knee
  • Cannot bear weight on the right lower limb

Investigations

  • FBC, peripheral blood film, ESR and CRP: Normal
  • X-ray lateral and AP: Widening of joint space
  • Ultrasound: Mild to moderate joint effusion

Diagnosis

Transient synovitis of the right hip joint

Serious Differential

  • Septic arthritis

How to Differentiate

  • Synovial fluid study

Graph View

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