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SUGGESTED READINGS
Arabella, LI, Skaggs, DL. “Evaluation of the Acutely Limping Child.”
OBJECTIVES
- Discuss the common clinical presentations, diagnosis and management of the child with a painful limp.
- Understand why septic arthritis requires urgent surgery.
- Understand why slipped capital femoral epiphysis requires urgent surgery.
- Describe fractures with regard to clinical appearance (skin condition, swelling, deformity) and x-ray appearance (angulation, displacement, shortening, rotation, comminution).
- Understand why an “open” fracture require urgent surgery.
- Understand why compartment syndrome is a surgical emergency.
- Discuss the following fractures’ special concerns:
- Scaphoid fractures—Risk of missed diagnosis, nonunion, AVN
- Femoral neck fractures—Risk of nonunion, AVN
- Pediatric monteggia fractures—Missed diagnosis
- Pediatric supracondylar humerus fractures—neurovascular compromise
- Unstable pelvis fractures—blood loss
- Review basic splinting techniques (hands-on session at end of lecture) and tips to avoid problems.
CASE HISTORIES
- A 4-year-old girl presents with refusal to bear weight. She was fussy last night and did not sleep well, and then she refused to walk this morning. She felt warm, but Mom did not take her temperature at home. In the E.R., her temp is 102.6. She has pain with “log rolling” of the right hip (internal and external rotation) and she guards against any attempt to do more range of motion.
- What further evaluation would you like to do (exam/labs/imaging)?
- What would you recommend as treatment?
She presented on a Saturday, and there is no Orthopaedic Surgeon on call over the weekend. The E.R. physician admits the patient, starts her on antibiotics, and waits for the Ortho doctor to see her on Monday.
- Discuss whether you agree or disagree with this plan of treatment, and what the prognosis would be.
- A 12-year-old boy presents with knee pain for 3 months. His parents have noticed him limping, and he says the pain worsens with activity. On physical exam, he has a BMI of 32. He walks with the right foot pointing outward more than the left (video clip will be shown). He has full knee flexion and extension without pain, has no effusion, and has a stable ligamentous exam.
- What further evaluation would you like to do (exam/labs/imaging)?
- What would you recommend as treatment?
His pediatrician obtains x-rays of the knee, which are normal. He gives the patient crutches and a note to stay out of P.E. He refers him to an Orthopaedic Surgeon for further evaluation. The appt is in one month.
- Discuss whether you agree or disagree with this plan of treatment. Would you want to do any further work-up?
- A series of x-rays and clinical photographs will be reviewed. Be prepared to describe physical exam and x-rays and then make a plan for treatment for the following patients:
- 6-year-old girl with elbow injury after a fall from monkey bars.
- 20-year-old woman with wrist pain after her hand was struck by the air bag in a minor motor vehicle accident.
- 19-year-old soccer player with leg pain after another player kicked his shin. He was placed in a splint at an urgent care and was supposed to follow up with his doctor tomorrow, but the pain has increased. He presents requesting a stronger prescription for pain medication.
- 22-year-old woman is intubated in the trauma bay after severe motor vehicle accident. She is hemodynamically unstable.
- Another 6-year-old with elbow injury after a fall from monkey bars.
- Casting/splinting session to follow case histories.
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