A 13 year old boy with complaints of “butt pain”

1. A 13 year old boy with complaints of “butt pain” Morning Report July 1, 2009

2. Otherwise healthy • Noted the pain after attending a school dance……but “he did not dance” • Afebrile • What do you want to know????

3. His exam is “normal” except for tenderness over the right gluteus muscle He is sent home with NSAID’s and a diagnosis of musculoskeletal strain

4. Don’t forget…….Give “what if” instructions….

5. It is now 5 days later…… • Now complaining of right knee pain and he is limping • No fever noted at home, Temp is 99 in the office • Now what????????

6. Films are ordered….given Tylenol #3 • Plain films of the hips and knees are “normal”….

7. Everyone in thinking SCFE

8. Anatomy

9. SCFE

10. SCFE • Usually in boys at puberty • Usually unilateral • Stable or unstable • Diagnostic radiograph: frog leg hip films • Surgical intervention

11. SCFE Severity

12. But he does not have a SCFE…….. What do you do now? What else is in your differential of a limping child?

13. Toddler Septic arthritis Discitis Sepsis Osteomyelitis Pyomyositis Neoplasia Leukemia, bone tumors… JIA? Transient synovitis Child (3-10 years) Septic Arthritis Osteomyelitis Pyomyositis Neoplasia Leukemia, bone tumors… Discitis JIA? Perthes Synovitis Adolescent…add SCFE Differential

14. If you send him home…again, the “what if” instructions are KEY….

15. The plot thickens……. • 4 days later, the child returns for more tylenol #3 • Still limping • Increasing pain with extension of the hip and internal rotation of the leg but there is no redness, warmth or swelling • Now fever to 102, HR is 130, RR 24, BP 90/50

16. Systemic symptoms • His left elbow is red and swollen • Disoriented • Jaundiced (Bili 12/8, SGOT and SGPT nl) • Febrile • Anemic (hgb 6, WBC 24)

17. DIFFERENTIAL???? The patient is hospitalized ………..and a diagnostic procedure is performed

18. The CT Normal Not normal

19. The Psoas (part of the posterior abdominal wall)

20. Psoas Abscess • Hip symptoms • Can be a “primary diagnosis” • Can be associated with GI pathology or sometimes with GU pathology • Not usually associated with hip infection

21. In the hospital……. • Psoas abscess and elbow drained • Antibiotics begun • All cultures positive for St A…blood and abscess and elbow • Remains febrile on POD 1 • Remains febrile on POD 2 • Remains febrile on POD 3 but continues to “feel better”, jaundice resolves Want to do anything else, antibiotics are given and appropriate???????????

22. In the hospital……. • Remains febrile on POD 4 • Remains febrile on POD 5 • Remains febrile on POD 6 “feels better” but febrile……. Now what?????

23. Another diagnostic procedure was performed……..

24. Repeat CT reveals concern for hip disease…the acetabulum appears “moth-eaten” And the child returns to the OR for I and D of the hip joint……. After which he is afebrile…

25. Septic Arthritis of the HipA True Emergency

26. Septic Arthritis of the Hip • Usually in children under 3 years • Usually unilateral • Fever, high WBC, high sed rate • Diagnostic radiographs: ultrasound, CT/MRI • Plain films are normal in 50% of cases!!!!!

27. When the Xray is diagnostic: there is a loss of the architecture of the pelvis and widening of the joint space

28. The MRI

29. Septic Arthritis Risk Factors for Poor Outcome • Over 5 days to surgical drainage • Associated osteomyelitis in the proximal femur

30. Morals of the story: Sometimes you just have to keep looking….. • Fever • Severe pain • Night pain • Functional impairment • Escalating symptoms A limping child =

31. Peds in Review • http://pedsinreview.aappublications.org/cgi/reprint/27/5/170 Approach to Acute Limb Pain in Childhood Shirley M. L. Tse, MD Ronald M. Laxer, MD The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada