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Approach to the Limping Child

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History

  • pain: CHLORIDE FPP (see the orthopaedic assessment)
  • trauma, injury
  • morning stiffness, limp, swelling/redness/warmth of joints
  • general: fever, rash, fatigue, weight loss, cough, chest pain, back pain, hair loss, medications, voiding or stooling problems, iritis
  • family history: arthritis, psoriasis, IBD, bleeding disorders, sickle cell anemia

Physical Exam

  • complete physical exam; always examine joint above and below joint involved
  • all joints: inspection, palpation, range of motion
  • gait, leg length discrepancy
  • tenderness over tendons or tendon insertion sites, swelling or nodularity
  • muscle weakness or atrophy
  • entheses- swelling, tenderness

Investigations

  • CBC, differential, blood smear, ESR
  • x-rays of painful joints/limbs
  • as indicated: blood C& S, ANA, RF, PTT, sickle cell prep, viral serology, immunoglobulins, complement, urinalysis, synovial analysis and culture, TB test, ASOT, slit lamp

Differential Diagnosis of Limb Pain

Cause

<3 years

3-10 years

>10 years

Trauma

X

X

X

Infectious

 

 


septic arthritis

X

X

X

osteomyelitis

X

X

X

Inflammatory

 

 


transient synovitis

X

X


juvenile idiopathic arthritis

X

X

X

seronegative spondyloarthropathy

 

 

X

systemic lupus erythematosus

 

 

X

dermatomyositis

 

 

X

HSP

 

X


Anatomic/Orthopaedic

 

 


Legg-Calve-Perthes disease

 

X

X

slipped capital femoral epiphysis

 

 

X

Osgood-Schlatter disease

 

 

X

Neoplastic

 

 


leukemia

X

X

X

neuroblastoma

X

X

X

bone tumour

 

X

X

Hematologic

 

 


hemophilia (hemarthrosis)

X

X

X

sickle cell anemia

X

X

X

Pain Syndromes

 

 


growing pains

 

X


fibromyalgia

 

 

X

complex regional pain syndrome

 

 

X

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