Intern Report Case Discussion 1.6

intern-report

Presented by Kyle Perry, MD

Chief Complaint: “He’s limping.”

History of Present Illness:
A 13 year-old male presents to the emergency department with his parents who say that he has been limping over the past few months and it is progressively getting worse.  He says he limps because he is having pain in his left hip and knee.  He describes it as a dull pain, 7/10, radiates towards his knee at times, exacerbated by standing for extended periods of time and relieved somewhat by rest. The pain is never completely alleviated.  He denies any traumatic injury, weakness, numbness, paresthesias, fever, or recent illness.  He occasionally will take Tylenol or Motrin with some relief.  It has progressively worsened and over the last several days he has been unable to be as active as usual.

Past Medical History: Asthma
Past Surgical History: None
Medications:
Albuterol as needed
Allergies: NKDA
Immunizations: Up to date
Social History: He denies alcohol, tobacco, or drug use.  He is in 7th grade.  He denies sexual activity.  They have smoke detectors in the house.  No pets.
Family History: His brother has asthma.  Grandmother has diabetes and hypertension.

Physical Exam:
Vital Signs: T 36.7, BP 112/72, P 76, R 18, SpO2 100%RA  Wt. 70 kg, Ht. 130 cm
General: Pt appears his stated age.  He lying on the stretcher comfortably
HEENT: Normocephalic, atraumatic.  PERRL, EOMI, MMM
Cardiovascular: Regular rate and rhythm, +S1, S2, no murmurs, rubs or gallops, pulses are palpable in all 4 extremities and symmetrical
Respiratory: Clear to auscultation bilaterally.  No wheezes
Abdomen: Soft, non-tender, non-distended, obese, + bowel sounds.
Neurological: A&O x3 speaking in full, coherent sentences.  Sensation is intact throughout.  Strength is 5/5 in both upper extremities and right lower extremity, and 4/5 in left lower extremity secondary to pain.
Skin: Warm, dry and intact.  No rashes, no erythema or signs of cellulitis.
Extremities: He has a noticeable limp and is favoring his left hip.  He has moderate tenderness over the left hip with palpation over the greater trochanter area. Limited ROM secondary to pain with passive and active flexion and abduction.  He is laying with his hip somewhat abducted and externally rotation for a position of maximal comfort.   He is only able to flex his hip to approximately 60 degrees.  He has slight tenderness over his left knee that is not localizable.  No warmth, erythema, or swelling of either the hip or knee.

Radiographic Studies:

12

Questions:

1.)    What is the most likely diagnosis?
a.    Slipped Capital Femoral Epiphysis
b.    Legg-Calve’ Perthes Disease
c.    Juvenile Rheumatoid Arthritis
d.    Osgood schlatter Disease
e.    Infectious mono-arthritis

2.)    What classification of Salter Harris fracture is this?
a.    I
b.    II
c.    III
d.    IV
e.    V

3.)    What is the treatment for this condition?
a.    Hip replacement
b.    Physical therapy with weight bearing as tolerated
c.    Rest, application of ice to the affected knee for 20 minutes every 2-4 hours, NSAIDs for pain relief, and gradually increasing activity with a brace
d.    Urgent operative repair with internal fixation of the hip with consideration of treating the contralateral side
e.    One time dose of 15,000 mcg of vitamin D, or 125-250 mcg given daily for 2-3 months until healing is well established

_______________________________________________________________________________________________________

Discussion:

1.    What is the most likely diagnosis?
a.    Slipped Capital Femoral Epiphysis
b.    Legg-Calve’ Perthes Disease
c.    Osgood -Schlatter Disease
d.    Infectious Arthritis
e.    Juvenile Rheumatoid Arthritis

2.)    What classification of Salter Harris fracture is this?
a.    I
b.    II
c.    III
d.    IV
e.    V

3.)    What is the treatment for this condition?
a.    Hip replacement
b.    Physical therapy with weight bearing as tolerated
c.    Rest, application of ice to the affected knee for 20 minutes every 2-4 hours, NSAIDs for pain relief, and gradually increasing activity with a brace
d.    Urgent operative repair with internal fixation of the hip with consideration of treating the contralateral side
e.    One time dose of 15,000 mcg of vitamin D, or 125-250 mcg given daily for 2-3 months until healing is well established

A child with a limp can provide a diagnostic challenge for the treating physician.  Both life-threatening and benign conditions can present as a limp.  Gait is a learned, complex coordination of the musculoskeletal, central and peripheral nervous systems.  An insult to any component of these systems can produce a limp; therefore, a careful consideration of all of these must be made to improve diagnostic accuracy.  In the early diagnostic stages, several crucial diagnoses must be ruled in or out to maximize chances of saving the life and limb of the patient.

Slipped Capital Femoral Epiphysis (SCFE) is a condition in which the epiphysis of the femur becomes displaced at the level of the metaphysis (hence it is considered a Salter-Harris type 1 fracture.)  This can occur as either an acute or chronic process.  The patient can complain of hip pain, medial thigh pain, and/or knee pain.  It is over twice as common in males than females, generally occurs between the ages of 10-16 years and because it is more common in African-American children, a genetic component is suspected.  Other risk factors include obesity, previous irradiation or chemotherapy, renal osteodystrophy, hypothyroidism, and neglected septic arthritis.  Diagnosis is made by obtaining an A-P and frog lateral radiograph of the pelvis.  Klein’s Line is the line drawn from the superior border of the femoral neck that should pass through the femoral head.  If it does not, a SCFE is present.  The patient should be admitted with an urgent orthopedic consultation.  Treatment involves internal fixation with a single cannulated screw.  Treatment of the contralateral side should be considered as this condition is bilateral in up to 25% of cases.  Complications from a SCFE include AVN of the femoral head and chondrolysis, or loss of articular cartilage of the hip joint.  Chondrolysis can cause permanent loss of motion, flexion contracture and pain in the hip.

Radiographic Findings in Slipped Capital Femoral Epiphysis:

11213

Operative repair of a SCFE:

4 Salter-Harris is the name given to the classification system of pediatric fractures around the growth plate.  A Salter-Harris Type 1 fracture is through the growth plate.  Treatment is usually involves splint placement and may require reduction if the epiphysis is significantly displaced.  Prognosis is excellent unless the vasculature to the epiphysis is disrupted.  A Salter-Harris Type 2 fractures is through the growth plate and metaphysis, a Type 3 fracture involves the growth plate and epiphysis, and a Type 4 involves the growth plate, epiphysis, and metaphysis.  Surgery is usually required to reattach the fragment.  A Type 5 fracture is a compression fracture through the growth plate and carries the poorest prognosis because the bone is unable to grow properly.  Stunting is almost always seen.

5

Legg-Calve’-Perthes Disease is the name given to avascular necrosis of the femoral head.  It is seen more commonly in Caucasian children, it is 5 times more common in males than females, and the peak incidence is at 6 years of age.  It is bilateral in 15-20% of cases.  It can present very similarly to SCFE; hence, the proper radiographic studies must be obtained to differentiate the two and make the correct diagnosis.  If plane films are insufficient, a Technetium 99 bone scan be useful to demonstrate vascular insufficiency.  Treatment involves containing the femoral head in the acetabulum to facilitate further rounding and development of the femoral head.

Osgood-Schlatter is one of the most common causes of knee pain in adolescents.  It presents as pain and edema at the tibial tubercle and is usually self-limited.  It is thought that during periods of rapid growth, contraction of the quadriceps against resistance is transmitted through the patellar tendon and causes a partial avulsion fracture at the insertion on the tibial tuberosity.  Approximately 90% of cases do well without surgical intervention, therefore treatment is conservative.  Ice should be applied for 20 minutes every 2-4 hours, NSAIDs can be used to relieve pain, and pain-producing activities such as running and jumping should be avoided.

Acute bacterial infections of the joints require early identification and treatment to avoid long-term sequalae and spread of disease.  While the metaphysis is the most common location of osteomyelitis in the adult, the physeal site is commonly affected in children.  Septic arthritis may result from hematogenous seeding of systemic infection or from spreading of local osteomyelitis.  Systemic symptoms are often present and may include fever, malaise, and decreased oral intake; however, they may be absent in the early stages.  The causative pathogen is nearly always Gram-positive (usually Staphylococcus,) but Gram-negative infections can be seen in neonates, asplenic patients, and patients with sickle cell anemia.  Radiographs, bone scan, MRI, CT, and US guided joint aspiration may be useful in diagnosing this condition.  Treatment involves antibiotics and possible surgical debridement to prevent further spread of the infection.  Even with treatment, many children will have residual arthritis resulting from the destruction of the articular surface.

Juvenile Rheumatoid Arthritis is a condition of unknown etiology that causes inflammation of multiple joints of the body.  Advances in treatment have greatly improved the prognosis over the past 30 years.  Treatment previously consisted of salicylates and NSAIDs for pain control, and as a result several patients were wheel-chair bound by 30 years of age.  Since the addition of gold salt injections and immunological system modulators such as methotrexate, the outlook for patients has improved.

This case discussion presented by Kyle Perry, MD

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