case 5 (Full Version)

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Dr.Wagner -> case 5 (August 6, 2007 8:48:45 PM)

A 6 year old boy comes in with his mother.  The primary complaint by the mother is that the child is limping.  The child appears to be in good health without noticeable injury.  He is interactive and sitting on his mothers lap.



jma -> RE: case 5 (August 6, 2007 9:12:09 PM)

How does the child look when he does walk across the room? Any gait deviations and if so where? Any bruises on the LE's?



hmgross -> RE: case 5 (August 6, 2007 10:17:50 PM)

I would observe gait, ask mom about what type of activities he is involved in--sports?



Dr.Wagner -> RE: case 5 (August 7, 2007 1:56:01 PM)

Mom states "he plays in the yard, but he is too young for sports"

The child stands, leans toward the opposite side, but refuses to walk.  Mom says "he walks with a limp...sometimes he won't walk"

There are a few bruises on his shins, but no signs of severe trauma or significant injury.



Tom Reeves DPT ATC -> RE: case 5 (August 7, 2007 2:02:44 PM)

What is the general build of the kid?  is he pear shaped?  Xray of the affected hip could rule out slipped femoral capital epiphysis.  Kind of young for that though.  Is ROM full?  FABER symmetrical?  hip impingement/labral tests?



FLAOrthoPT -> RE: case 5 (August 7, 2007 4:55:24 PM)

slipped capital? out of time, will reply more later!



Sebastian Asselbergs -> RE: case 5 (August 7, 2007 5:20:17 PM)

I did not see anything about pain, just about limping. Would consider neuro as primary system of concern.



jma -> RE: case 5 (August 7, 2007 9:06:20 PM)

What tests have been performed? Xrays and what were the results if any?



Dr.Wagner -> RE: case 5 (August 7, 2007 10:15:47 PM)

The child states "It hurts, especially when I walk"

He is a lanky, normal looking 6 year old of typical build.  In PROM, there appears to be discomfort at end range of ER and IR.

Anything else you would like to know or see?



FLAOrthoPT -> RE: case 5 (August 7, 2007 10:56:21 PM)

ok limping:
let's find out if from foot, ankle, knee, hip, pelvis first by doing some bread and butter being isometric testing and ROM testing.  Then test the muscles with functional tests both WB and NWB and some MMT if warranted.  LEt's then see if we can recreate any pain through longitudinal loading or shearing etc...
let's start there....



Bournephysio -> RE: case 5 (August 7, 2007 11:22:02 PM)

What does the x-ray look like?

A bit young for a slipped capital epiphysis.  The one I saw had marked restriction in flex, add and ir.

I would guess legge-calve perthes.



Sebastian Asselbergs -> RE: case 5 (August 8, 2007 7:00:31 AM)

Thanks - now I know there is pain when walking, I would indeed want x-ray results - possible dysplasia or L-C-P as per Doug.



Shill -> RE: case 5 (August 8, 2007 8:18:55 AM)

I would want to know more about observation supine for LLD, rotational malpositioning of the femur /hip, AROM on his own in all directions while supine, sidelying, and prone, and maybe standing on the unaffected side, to see if any of these bother him.   PROM to ER and IR end range is painful, so this combined with pain in weight bearing makes films reasonable.  I would ask the child if he fell, twisted it, jumped from something too high, etc, etc.  Mom might need to go out to clarify insurance at the front desk while asking those questions.  Not necessarily due to fear of abuse toward the child, but the child is not likely to admit behavior (if any) that caused the problem with mom in the room.  Dysplasia seems to be top of the list at the moment.



Bournephysio -> RE: case 5 (August 8, 2007 1:00:10 PM)

Any history of hip problems as a baby? If so did it need treatment?

How is hip anteversion?



Dr.Wagner -> RE: case 5 (August 8, 2007 8:48:54 PM)

vitals: Heart Rate 108, Resp: 22, O2 sat 100, temp 99.5




[image]local://2287/8F3AE95482B94D2C9FA633A8D738A075.jpg[/image]



Dr.Wagner -> RE: case 5 (August 8, 2007 8:50:16 PM)

pelvis radiograph

[image]local://2287/571291D5B09C41BD9635EF611C5F6AE3.JPG[/image]



jma -> RE: case 5 (August 8, 2007 9:16:19 PM)

In the boy's history, was he born prematurely? Is their a leg length discrepancy? A (+) Trendelemberg?  Left hip seems to be a bit farther out of the socket than the left. There also seems to be something going on in the acetabular area as it is not clear.



SJBird55 -> RE: case 5 (August 9, 2007 7:06:26 AM)

He's got a low grade fever.... we might not be looking at a typical orthopaedic condition for kids his age.  Wags, if you could... that image is quite small on my screen.  I can't see details at all.  The pubic or ischial area or acetabular is too difficult for me to really see very well (I just know it is brigher in that region) - it's making my eyes water. 



Dr.Wagner -> RE: case 5 (August 9, 2007 8:50:07 AM)

bigger and better


[image]local://2287/B63EB2DAADED41EF97E5ABBA80EE759F.gif[/image]



FLAOrthoPT -> RE: case 5 (August 9, 2007 9:49:06 AM)

juvy ra?



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