Tasty Morsels of EM 109 – #FRCEM Paediatric limp

4 Aug

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here

(Featured image: Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org. From the case rID: 6359)

Give me a broad differential

  • trauma
  • remember NAI
  • hip
    • septic joint
    • osteo
    • perthes
    • SUFE
  • Still’s
  • HSP
  • Rheumatic Fever
  • malignancy
    • leukemia
    • soft tissue tumours eg ewings
  • sickle cell
  • referred
    • discitis
    • spinal osteo the biggies

How do you investigate it?

  • there are lots of potential variations on this and no national UK guidance i could find
  • reasonable to manage well appearing kids with some NSAID and review
  • xray the sore, swollen bit if you can find it
  • remember the hips if you can’t find it
  • WCC/CRP and ESR are the blood tests to consider
  • USS useful for hip effusion

Tell me about Perthes

  • aseptic necrosis of upper femoral epiphysis
  • 3-10 yrs
  • M:F, 4:1
  • grouped with the other osteochodritites
    • kohler’s – age 3-5, navicular
    • keinbocks – lunate
    • freiberg’s – 2nd MT
    • scheurmann’s – vertebral
  • xray changes
    • 1) inc joint space medially
    • 2) appears sclerotic
    • 3) flattening
    • 4) rarefaction and cysts
  • younger age at onset and earlier stage on xray predict better outcomes
  • note if you did an USS don’t expect to see fluid with this one

Tell me about SUFE

  • pubertal
  • M:F, 3:1
  • two body types
    • obese and sexually under developed
    • thin rapidly growing adolescent with normal sexual development
  • often referred to knee
  • this is the importance of your frog leg
  • Trethowan’s sign (not thockmorten…)
    • normally line across sup border of fem neck should go through the epiphysis, if a slip then this line doesn’t touch the epiphysis

What are some traction apophysitides

  • Osgood-Schlatter
    • boys 10-15
    • knee pain after exercise
    • tibial tuberosity can look funny on xray
  • Johannsen-Sinding-Larsen
    • lower pole patella
    • distinguish from osgood
  • Sever’s
    • calcaneal achilles
    • 8-14



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