1) Infectious (Toxic synovitis, Osteomyelitis, Septi

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Limp and Joint Pain

• Sushma Penmetsa
• Carrie De Moor
• 9/01/05

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DIFFERENTIAL DIAGNOSIS

• 1) Infectious (Toxic synovitis, Osteomyelitis,
  Septic Arthritis,, Lyme,Diskitis)
• 2) Developmental- SCFE, Legg Calfe Perthes
  disease, Hip dysplasia
• 3) Orthopedic (Trauma, Hypermobility)
• 4) Neoplastic (Leukemia, Neuroblastoma)
• 5) Systemic (IBD, sickle cell anemia,hemophilia)
  
• 6) Collagen vascular diseases-Juvenile Rheumatoid
  Arthritis (JRA),Polyarteritis Nodosa (PAN),SLE
  ,Scleroderma ,Dermatomyositis, HSP
• 7) Others IBD , Psoas Abscess,

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Diagnosis

• Accurate History
• Thorough physical exam
• Additional history
• -Trauma
• -Recent illness
• -Tick bites
• -Weight loss
• - Fever
• - Night sweats
• - Rash

• Careful attention to joints
• -Tender ,red,warmth
• - Range of motion
• - Deformity
• - Skin
• - Other chronic changes

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DIAGNOSIS

• Laboratory
• Joint fluid aspiration
• CBC ,ESR, CRP
• Others - ASO,throat culture,ANA,RF,Sickle Hb,lyme
  titres,UA for hematuria,uric acid
• Radiology - Xrays, US(effusion and guiding
  aspiration),Bone scan (84-100sensitive and
  70-96specific),CT (soft tissue and bone),MRI
  (diff dead from living tissues as in LCP disease
  to look for Avascular necrosis

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EXAMINATION OF SYNOVIALFLUID BY ASPIRATION
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ANALYSIS OF SYNOVIALFLUID
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TOXIC SYNOVITIS

• Transient synovitis of the hip is the most
  common cause of limp and pain in the hip.(90)
• Caused by an acute inflammatory reaction
• that follows an URI .
• Illness is self-limited and joint aspiration
  reveals yellowish fluid with possible wbcs No
  bacteria Fever is low-grade or not present
• ESR is elevated but not significant
• Seen in 3-10 year olds MgtF with decreased ROM and
  minimal change on x ray.
• Treatment is bed rest, NSAIDS, and f/u Xray due
  to the possible later development of avascular
  necrosis of the femoral head upto 3 mos after the
  illness.

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SEPTIC ARTHRITIS

• Occurs when bacteria from the circulation
  enter the joint space.
• Can occur directly from osteomyelitis or
  penetrating trauma
• Causes destruction of articular cartilage
  because of the lack of normal nutrients in
  synovial space or a result of purulent exudate
  and increased pressure.
• The joint involved is usually warm, swollen,
  and painful. Patient look s sick and holds hip in
  flexion and external rotation.
• A septic hip in a young infant is difficult
  to diagnose because the findings are subtle and
  may only be a fixed flexed hip.
• Joints involved
• Knee (40), Hip (20),Ankle (15), Elbow
  (15), Wrist (5), Shoulder (5)

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Common organisms
Neonate Group B strep Staph
Aureus Gram neg rods Gram neg rods
Children Staph Aureus Group A strep Step
pneumo Neisseria meningitis H. flu
Neisseriae gonorrhea
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Diagnosis and management.

• Aspiration of synovial fluid yields gt100,000
  WBCs in joint
• CBC, ESR, and blood cultures
• X-rays may show widening of joint space
• Ultrasound reveals fluid in joint space
• Bone Scan
• MRI

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Septic arthritis
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TREATMENT

• IV antibiotics for 21days
• If fever or clinical symptoms persist within 24
  hours after abx started, then open surgical
  drainage is indicated
• For Septic hip immediate surgical drainage due to
  low blood supply
• Risk of aseptic necrosis of the femoral head
• Prognosis is excellent if treated early
• May develop arthritis and fibrosis of joint
  with damage to growth plate and osteonecrosis

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OSTEOMYELITIS

• Infection of the bone secondary to penetrating
  trauma or hematogenous spread (most common)
• Organisms involved are identical to septic
  arthritis ( Remember Salmonella as common cause
  in patients with SCD)
• Bone involved is extremely tender to palpation
• May be erythematous over skin
• Diagnosis is made by clinical history, PE, Bone
  scan or MRI, and x-ray.
• Treatment is IV antibiotics (3-4 weeks)
• Blood cultures are only 50 reliable Careful
  follow-up with physician

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VIRAL (Reactive Arthritis)

• Aseptic and usually following an infection
  elsewhere in the body
• GI, URI, etc.
• Organisms include Rubella
• Hepatitis B Herpes Viruses (EBV, CMV,
  Zoster, HSV)
• Parvoviruses Mumps
• Enteroviruses including echo and
  Coxsackie's. Occurs 1-2 weeks following an
  illness .Usually the arthritis is self-limited
  .
• No treatment is necessary . Must rule out septic
  arthritis before arriving at the diagnoses of
  viral arthritis

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HENOCH-SCHONLEIN PURPURA

• Immune complex (IgA) disease It is a vasculitis
  (Platelets are N)
• Clinical manifestations
• - Palpable purpura
• - Arthralgia or arthritis
• - Abdominal pain
• - Renal disease
• Usually follows upper respiratory infection
  Occurs in children 2-11 years of age Symptoms
  last 4-6 weeks Complications include renal
  failure and
• intussusception

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Legg-Calve-Perthes disease

• Aseptic necrosis of the femoral head
• 5 10 years.more common in males.bilat in 10
  
• Slow insidious onset of limp and hip pain, which
  is progressive. Have limitation of motion of
  hip.limb length discrepency.
• Diagnosis by radiography of affected hip (see
  lucency of femoral head and eventually sclerosis
  and destruction of femoral head). Bone scan may
  reveal abnormalities earlier than a plain
  radiograph.
• Treatment-Femoral head containment and bracing .
  Selflimiting, resolves in 2-4 years

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Palpable Purpura
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Slipped capital femoral epiphysis.

• Generally seen in overweight teenagers,
  especially boys who are prepubertal. Displacement
  of femoral head posterior and medial.
• May have insidious onset of pain but can also
  follow acute trauma. Knee pain
• Pt has loss of int rotation and adduction. Pain
  with passive motion. Patient will hold hip in
  external rotation.
• Diagnosis by frog-legged radiographs of both
  hips. Icecream cone sign.
• Treatment is by orthopedic referral and surgical
  fixation by pinning followed by a spica cast.

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Diskitis

• An inflammatory process of the disk or disks
  (usually L3 to L5), which may be infectious in
  cause (staphylococcal primarily).
• Presents with refusal to walk or limp, low-grade
  fever, and "tripod posturing" - leaning back with
  back extended onto outstretched arms when
  sitting.
• Generally have pain over involved disk area but
  may also have pain on straight-leg raising, hip
  motion.
• Sedimentation rate almost always elevated, but
  CBC may be normal. Disk space may be narrowed on
  radiograph. Bone scan will show inflammatory
  focus.
• Treatment is generally supportive with
  anti-inflammatories but may need antibiotics.
  Orthopedic consultation recommended

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Juvenile rheumatoid arthritis.

• Defined as presentation of rheumatoid arthritis
  before 16 years of age,lasting gt6 wks,.
• 20 have "Stills disease," which is JRA plus
  fever, thrombocytopenia, splenomegaly,
  generalized adenopathy.
• 40 have onset in one or a few joints.
• 40 have polyarticular onset similar to adult
  onset.
• 75 have complete remissions.

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JRA

• Systemic (5 -10 of all cases)
• Characterized by high fevers (usually to 39C
  or higher once or twice a day rapidly
  returning to baseline and unresponsive to
  NSAIDS.
• Fever can be associated with a morbilliform
  rash found on the trunk and extremities.
• Arthritis may occur at any time of the
  disease.

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JRA

• Laboratory finding
• PMN leukocytosis
• Elevated ESR
• Anemia
• Occasional RF positive
• Synovial fluid may show an inflammatory
  reaction

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Treatment

• Treatment
• NSAIDS (aspirin, Tolectin, Naprosyn, ibuprofen)
• Gold salts and Penicillamine for patients who do
  not respond to NSAIDS
• Methotrexate
• Corticosteroids
• Physical Therapy
• Orthopedic Care
• Ophthalmic care
• Rest

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Lyme disease
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Lyme disease
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Lyme disease
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Management