Pediatric Primary Care Case Studies (126 page)

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Haider, A., & Shaw, J. C. (2004). Treatment of acne vulgaris.
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Howell, L., Kochlar, K., Saywell, R., Zollinger, T., Koehler, J., Mandzuk, C., et al. (2006). Use of herbal remedies by Hispanic patients: do they inform their physicians?
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Chapter 32

The Limping Child

Jan Bazner-Chandler

A child with acute onset of a limp presents a diagnostic problem of some complexity and urgency that requires an efficient and structured sequence of diagnosis and treatment. The etiology can be infection, genetic, developmental disorders, physical injury, neoplastic, hematologic, or vascular. This case study explores the presenting symptoms and signs of this condition and will review the workup and treatment of the underlying causes.

Educational Objectives

1.   Define normal gait development as related to developmental age.

2.   Apply guidelines for the diagnosis of the child with a limp, taking into consideration the chronological and developmental age of the child.

3.   Consider the differential diagnoses of a limp of acute onset.

4.   Choose appropriate diagnostic testing and treatment options.

5.   Describe desirable outcomes as a function of disease state.

6.   Describe treatment, follow-up, and compliance with medical management.

   Case Presentation and Discussion

Tyler, a 4-year-old African American male, presents to the clinic with a 2-day history of a limp and now refuses to bear weight. His mother states he felt abnormally warm last night when she put him to bed but she did not take his temperature. Today he has been less active than usual, and his appetite has been poor. He is the youngest of three boys and is usually quite active.

What additional history do you want to collect as the healthcare provider?

The healthcare provider must get additional information regarding chief complaint, history of present illness, past medical history, family, and social history in order to make the diagnosis and begin treatment. In this particular case, you will need more information about the following:

•   
Characteristics of pain:
Degree of pain using FACES pain tool, pattern (Is there any time of day when the limp is worse? Has the limp or pain interfered with normal activity? Is there any weakness in the extremity?), location, and quality.

•   
Activities:
Has there been any trauma, injuries, or potential for child abuse?

•   
Recent infections or exposure to infections:
Family and other contacts.

•   
Constitutional signs or symptoms:
Weight loss, change in eating or sleep patterns, irritability.

•   
Birth, immunization, nutritional, and developmental history:
Any pregnancy, labor, or delivery problems; immunizations to date; details about whether speech and language, personal, social, and fine and gross motor skills are developmentally appropriate for his age based on results of developmental screening.

•   
Family medical history:
Stature, cancer, arthritis, inflammatory or sickle cell disease.

•   
Socialization:
Day care, babysitter, family members.

•   
Medications:
Prescription and over the counter.

•   
Environment:
Lead exposure.

History of Present Illness, Family and Social History

Here is what was revealed in the analysis of the symptoms and the family and social history:

The mother states that Tyler was born full term via a normal spontaneous vaginal delivery. Developmentally he has reached all of his milestones. His immunizations are up-to-date by record review. He has no known allergies. The mother states she took him to the emergency department for a fever, earache, watery eyes, and a cough 1 month ago. He was diagnosed as having an ear infection and a viral upper respiratory infection. His treatment consisted of an antibiotic and cough syrup. He had two doses of acetaminophen for fever after the emergency room visit but none since. Currently there are no immediate family members who are sick with infectious diseases. There was no known trauma. An uncle has the sickle cell trait but Tyler has tested negative for the trait. A grandmother has type 2 diabetes, hypertension, and arthritis.

Physical Examination

What information do you want to collect from the physical examination?

It is important to examine the child to identify the anatomic location of the pain. The examiner must determine what body segment is creating the problem. Observation will reveal body habitus such as preference for supine, side lying, or prone position. Immobility or pseudoparalysis is an indicator of pain. Hip flexion and external rotation are positions of relative comfort for a painful hip, as is flexion of the knee. The presence of guarding (resistance to motion with gentle passive movement) can indicate the location of the pain. Range of motion of each body segment should be measured along with circumference and length of each body segment in the lower extremities. Asymmetry of the
thighs or legs may suggest a chronic condition. The examiner should obtain and record vital signs, perform a vascular examination, and determine if erythema or edema is present.

The essential features of the examination of the extremities are inspection, palpation, and range of motion testing. It is important to inspect the extremities for evidence of deformity, erythema, swelling, effusion, and asymmetry. Palpate for edema, pulses, and manifestations of tenderness or guarding. Examine each joint for range of motion and note any restrictions. The child should be placed prone if possible, with the knees flexed; rotate the hip in and out to check for asymmetry. Examine the child’s shoes for wear patterns and fit. Observe the pattern of walking. In the ambulatory older infant, toddler, or small child, have the child walk back to the caretaker while you observe their gait. In the toddler or small child, the use of distraction can often get the child to cooperate. A child with an inflammation of the hip will keep the hip in a position of flexion, abduction, and external rotation because this position reduces pressure from increased fluid within the joint capsule. In the presence of bacterial infection, any motion is exquisitely painful. The examiner should be aware that developmental dysplasia can cause asymmetric abduction without severe pain. A modified log roll test may help to determine the severity of hip irritation. The child lies supine and the examiner gently rotates the involved limbs from side to side.

Tyler’s physical examination reveals the following: temperature 37.6°C (99.7°F), heart rate 124, respiratory rate 36, blood pressure 115/76, and weight 24 kg (52 lbs 12 ozs).

General appearance: The child is lying across his mother’s lap, immobile but alert and responsive. His skin shows no erythema or rashes.

Neurological: Deep tendon reflexes on the right are 2+ and not determinable on the left due to pain.

Orthopedic:

   No abnormal curvature of the spine; no hair tufts or dimples are noted.

   When asked to locate his pain, he points to the groin and upper thigh.