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Paediatric Limp History ♯1

PATIENT INFORMATION

You are one of the medical students completing your rural General Practice rotation. You are asked to see Jerry Field, a 4-year-old boy who has been brought in by his mother because he has been ‘limping.’

CANDIDATE INSTRUCTIONS

You will have 8 minutes to perform the following:

  1. Take a history from Jerry’ mother Sally regarding the presenting complaint (5minutes).
  2. Outline a differential diagnosis (1 minute).
  3. Outline a basic management plan to the examiner (2 minute).

TASK 1 – HISTORY (5 MINUTES)

History of presenting complaint

  • Site: N/A
  • Onset: the limping started about 3 days ago
  • Character: it seems like only his left-side is affected
  • Radiation: N/A
  • Associated symptoms: (see below)
  • Time course/duration: the limping has been ongoing since it began 3 days ago
  • Exacerbating/relieving factors: It seems to get worse with activity, “I’ve noticed that Jerry has been reluctant to run around like he usually does – he’s usually a very energetic child”
  • Severity: “Since last night he keeps mentioning that his knee is sore as well, but he isn’t distressed by the pain thankfully”
  • Beliefs: “I have no idea what is going on – maybe he has pulled a muscle?”
  • Impact on patient: “It’s currently school holidays, but I’m worried that when he goes back to school the limping will stop him from playing with the other kids at kinder”
  • Concerns: “Is this something serious?”

Systems review/associated symptoms

Symptoms in BOLD indicate positive answers, other answers are suggestions of what is required in terms of questioning.

  • Transient synovitis: Recent coryzal symptoms (cough, cold, runny nose) “Yes now that you mention it, Jerry had a cold about a week ago, but he has recovered now luckily,” limping, refusal to weight bear on the affected side, referred pain to the thigh/knee/hip, pain improves with rest / worsens with activity, otherwise well
  • Osteomyelitis/septic arthritis: Malaise/fatigue, irritability, fever, erythema/warm over the affected area
  • Perthes disease: Pain worsens with activity and improved with rest, gradual onset of limp, limited ability to move the hip
  • SUFE (slipped upper femoral epiphysis): Increased body habitus, one limb appears shorter and more externally rotated compared to the other.
  • JIA (juvenile idiopathic arthritis): Morning joint stiffness, stiffness/pain in joints that it worse with rest / improved with activity, transient erythematous rash, lymphadenopathy.
  • Trauma/non-accidental injury

Past medical history

  • Had to have two stitches over the right eyebrow after falling over at the playground.
  • No previous surgeries
  • No current medical conditions

Paediatric history

  • Birth history: born at term, 38 weeks.
  • Feeding: nil issues, normal appetite, balanced diet
  • Hydration: drinks plenty of water throughout the day,hasn’t changed since onset of limp
  • Vaccinations: up to date
  • Growth/developmental milestones: meeting all developmental milestones, nil concerns
  • Sick contacts/travel history: none

Medications

  • Prescription: none
  • Recreational: none
  • Over the counter: Has been taking paracetamol syrup for the knee pain – also took Panadol 1/52 ago when Jerry had the cold
  • Vitamins/supplements: none

Allergies

  • No known allergies

Family history

  • Mother: has asthma, well controlled
  • Father: hypertension – well controlled with ramipril 2.5mg
  • Siblings: Older brother Henry (8 years old) – he is well

Social history

  • Lives at home with parents and brother.
  • Attends local kindergarten – no issues with attending school

TASK 2 – DIFFERENTIAL DIAGNOSIS (1 MINUTE)

Give 3 differential diagnoses

  • Transient synovitis
  • Perthes disease
  • SUFE
  • Osteomyelitis

TASK 3 – BASIC MANAGEMENT PLAN (2 MINUTES)

Assuming that transient synovitis is the correct diagnosis, what would your basic management plan be?

  • Explain the diagnosis to the parents
  • Supportive measures are the mainstay of management
    • Complete rest
      • Will start to improve in about 3 days and resolve by around 2 weeks
    • Avoid strenuous physical activity until they have completely recovered
    • Anti-inflammatory medications such as ibuprofen (Nurofen) can be used in the short term to help with any discomfort/pain the child is experiencing
Total:

NOTES

  • Transient synovitis is a condition that typically affects children between the ages of 3-10 years, and is more common in boys.
  • It is one of the most common causes of hip pain in younger children.
  • It refers to the inflammation of the synovium of the hip joint.
  • Classically, it occurs following a viral infection, such as an URTI.
  • As the name suggests, the condition is only temporary, and the prognosis is usually excellent – improvement is typically observed within 3 days, and there is usually resolution after two weeks .
  • Signs and symptoms can include: limping, refusal or inability to weight bear, preceding coryzal symptoms, pain in the hip/thigh or knee.
  • Important differentials for transient synovitis include septic arthritis, osteomyelitis, Perthes disease, SUFE and JIA.
    • Some examples of red flag signs and symptoms that would make you more concerned include malaise/lethargy, poor feeding, reduced appetite, erythema/swelling over the affected region, fever, rash, significant pain.
  • Management is conservative, with rest usually the only treatment that is required.
  • Anti-inflammatory medications such as Nurofen can help in the short term with any discomfort or pain that the child may experience.
  • The patient should also avoid any strenuous physical activity and sports until they have recovered.

REFERENCES

https://www.rch.org.au/kidsinfo/fact_sheets/Transient_synovitis/

https://dermnetnz.org/topics/juvenile-idiopathic-arthritis/

https://www.childrenscolorado.org/conditions-and-advice/conditions-and-symptoms/conditions/transient-synovitis/

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