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RE: case 5
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RE: case 5 - August 9, 2007 9:52:44 AM
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FLAOrthoPT
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can we get some of the PT evaluation findings in the future before assuming we need to order any tests, for example, up until the fever part, without any real trauma, i would have been runing through all my exam to find out if it is muscular, joint, ligamentous, etc, and have a working theory that I would be running a test against to confirm or deny, i think running blind tests isn't really ebm. I think it would help to know how they are presenting clinically first...I know you are doing this to help, but can we play PT clinic and not ER for the next cases?
but since we jumped the gun already....any insect bites or rashes, and virus/sickness recently, coughing, etc? family hx, when did it start, why did it start etc? i think we skipped a lot of the actual clinical eval and hx here..
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RE: case 5 - August 9, 2007 4:54:57 PM
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Dr.Wagner
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FL, about we get past medical history prior to physical exam...
< Message edited by Dr.Wagner -- August 9, 2007 4:59:41 PM >
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RE: case 5 - August 9, 2007 4:58:51 PM
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Dr.Wagner
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Past Medical History: No history of illness requiring hospitalization. Previous visits to "med check" for asthma exacerbation 3 years ago.
Recently the mother has noted a "cold". She states "he's getting over the sniffles"
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RE: case 5 - August 9, 2007 5:06:24 PM
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Dr.Wagner
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The patient will take a few steps for you...it is a limp, as in...he really dislikes bearing weight on the extremity.
He notes discomfort at end range of motion, in particular IR and ER, particularly when this evaluation is done in supine and prone.
His isometric strength evaluation is limited as he is 6 and doesn't feel well, so effort makes the examination suspect and unreliable, but the strength appears appropriate and funcional and clearly no less than 4/5.
Evaluation of the skn reveals no signs of significant trauma, only age appropriate bruising to the shin, c/w an active 6 year old. No rash is noted.
There is no leg length discrepency of significance noted.
< Message edited by Dr.Wagner -- August 9, 2007 5:10:41 PM >
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RE: case 5 - August 9, 2007 6:16:48 PM
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Bournephysio
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Is that a picture of rom or approx anteversion. Is it the left or right leg that is symptomatic?
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RE: case 5 - August 9, 2007 6:47:52 PM
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FLAOrthoPT
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shpilkits in his gizikindoints
saw it on SNL with mike meyers as linda richmond...must be
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RE: case 5 - August 10, 2007 5:38:12 PM
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Dr.Wagner
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Ill add some information to get you back on track.
If blood was drawn (very resonable for temp of 99.5 with non traumatic hip pain in a pediatric patient) CBC 12, hgb 14, hct 34, plt 235. ESR 14
There ya go.
Answer tomorrow...please note, this is not tricky. Go through the history, look at the films, look at the exam and lastly look at the labs. This is a bread and butter case in pediatric orthopedics.
< Message edited by Dr.Wagner -- August 10, 2007 7:58:37 PM >
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RE: case 5 - August 10, 2007 9:13:37 PM
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jma
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I'll say juvenile rheumatoid arthritis.
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RE: case 5 - August 11, 2007 12:02:57 AM
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Bournephysio
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Transient synovitis
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RE: case 5 - August 11, 2007 11:17:31 AM
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Chocco
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It still sounds like hip dysplasia that was missed early on. The first x-ray also shows increased gapping between femur and acetabelum on one side.
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RE: case 5 - August 11, 2007 6:25:21 PM
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Dr.Wagner
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We have a correct answer...
Transient Synovitis of the Hip or Aseptic Synovitis of the Hip
This is a relatively common disorder in the pediatric population, boys more frequently than girls and commonly found in those between the ages of 2-6. Some of the hallmarks are the acutely NON TOXIC appearing child with normal radiographs, no history of trauma, and a recent history of a viral infection with almost complete resolution of symptoms. Rotational movements of the hip and weight bearing are essentially the only painful movements (the child will be perfectly fine on mom or dads lap), but it is important to note the physical examination of a painful joint in a pediatric patient is relatively difficult! With normal xrays, and the correct recent medical history and symptomatology, the most important differential diagnosis is Septic Arthritis. Usually a child with Septic Arthritis will have an ESR of greater than 40, will have a fever (core temp greater than 38 degrees C), and a white count greater than 12 with a greater specificity at 15. Septic joints are difficult to examine and often time require joint aspiration to define the pathology.
Treatment: NSAIDS and rest with relative non weight bearing for no less than 48 hours (give or take a day or two). This will usually spontaneously resolve with no problems. Septic arthritis requires IV antibiotics and in the worst cases, irrigation of the joint in an operative setting.
Thank you to everyone for taking part in this case.
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RE: case 5 - August 13, 2007 1:15:26 PM
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jma
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What is the ESR for someone with JRA? Just curious. Are their other laboratory values for this as well? Thanks
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RE: case 5 - August 13, 2007 3:33:25 PM
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Dr.Wagner
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Are there other laboratory values for JRA?
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RE: case 5 - August 13, 2007 3:41:29 PM
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Dr.Wagner
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I think I understand your question...here is what distinguishes Transient Synovitis from JRA...in particular is the recent viral history and the "low grade" fever as well as the saying "common things being common" ie statistics. If this was a child with a LONG history of weight bearing pain, then I would be more cautious, but monoarticular JRA is a real zebra.
Lab tests for JRA include CRP, ESR, RNA, and RF. Radiographic evidence can be found on xrays, MRIs etc. These would all be normal in Transient Synovitis.
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Dr. Wagner DO
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RE: case 5 - August 14, 2007 9:48:51 PM
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jma
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Thanks for the info. Keep bringing the cases.
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RE: case 5 - August 30, 2007 2:09:41 AM
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bonez
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Sorry for being late to the game (new member) but the three findings of painful use especially of the hip , recent urti and low grade fever ice it for transient synovitis.
Seen three in 20+ years and few days of Advil, rest and all back to normal.
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RE: case 5 - August 30, 2007 2:13:57 PM
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Dr.Wagner
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yep, exactly
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