Limping Child - Essential GP Revision

Differentials of a child presenting with a limp for GP exam preparation.

Video version: https://youtu.be/wGZGGx2La70

Notes, questions and flashcards: https://zerotogp.com/ 

Physical book: https://zerotofinalsshop.com/products/zero-to-gp-akt-revision-book-for-gp-trainees

Physical flashcards: https://zerotofinalsshop.com/products/zero-to-akt-gp-revision-flashcards

AKT Revision Course: https://zerotofinals.com/courses/zerotoakt/

Zero to Finals Notes: https://zerotofinals.com/paediatrics/ortho/

Transcript

SPEAKER_01 0:00

Hi, this is Tom, and welcome to the Zero to GP Podcast. In this episode, we're going to be covering the content you need to know regarding children presenting in primary care with a limp. As always, the format of these episodes is I'm going to present cases and ask you questions. Your job is to come up with an answer, ideally write it down or say it out loud, try to commit to an answer if you can, and then we're going to go through an explanation. If you head over to zero2finalshop.com, you'll find the AKT Revision book. And this is the ideal book to use for preparing for your AKT exam if you're setting the RCGP AKT exam for GP trainees. There's also the AKT revision flashcards, which are perfect for rapidly testing your knowledge and training your memory on the key facts that you need for that exam. And there's zero2gp.com where you can find short answer questions, a fact trainer tool, which is very much like ANCI, where you drill the key facts you need for your exam using spaced repetition to help them stay in your long-term memory. There's also a traditional multiple choice question bank for practicing MCQs for the AKT exam and digital flashcards. But for now, let's get straight into this episode on limps in children. So the first case is a 14-year-old girl, and her parents report she's been limping ever since she started walking. She was previously breach presentation during pregnancy. And on examination you can see a leg length discrepancy. So one of her legs is slightly longer than the other.

SPEAKER_00 1:53

In this case, what's your suspected diagnosis?

SPEAKER_01 2:04

In this case, you should be suspecting developmental dysplasia of the hip, or DDH. And with developmental dysplasia of the hip compared with normal, the socket, the acetabulum, where the head of the femur inserts into the socket in the hip joint, is shallow and abnormally abnormally developed, which means because it's shallow and the head of the femur doesn't properly fit inside that hip socket, it means there can be some wiggling around and there's a risk of subluxation or dislocation of the hip joint. And also there's going to be a lot of wear and tear and discomfort, which can lead to kind of premature osteoarthritis and degenerative changes. The next question regarding developmental dysplasia of the hip is what screening examination tests would we use to look for this during the six to eight week newborn baby check. So the CLEA test that we would do is the Ottolani test and the Barlow test. The Ottilani test involves kind of uh pulling the hips forward and um and the Barlow test is pushing the hips backwards. And the purpose of doing these tests is to feel for any clunking in the hips. And if there's clunking in the hips during that newborn baby test, um then we would be uh concerned about developmental dysplasia of the hip. So the next question is let's say you're doing a screening test and you feel some clunking in the hips or you're worried about developmental dysplasia, what's the diagnostic test?

SPEAKER_00 3:59

What test are you going to send this patient off to have? The key test is an ultrasound of the hips.

SPEAKER_01 4:11

So if a baby has risk factors, for example, breach presentation or family history of developmental dysplasia of the hip, then or you find these uh abnormal findings on examination, then they need an ultrasound of the hip to diagnose it. Okay, on to a new case. The new case is a three-year-old boy who's had a recent viral upper respiratory tract infection. He presents with a new limp, and his mum's brought him in and says he's had this limp for the last five hours. However, he's systemically well, he's still walking around, he's just limping slightly, he's he's got no temperature, observations are all normal, he otherwise seems fine.

SPEAKER_00 4:55

In this case, what's your suspected diagnosis? The suspected diagnosis here is transient synovitis.

SPEAKER_01 5:12

And this is where the synovial lining of the joint, particularly, for example, the hip, becomes temporarily inflamed and is transient, so it often just settles on its own. The next question is what's the essential differential diagnosis that needs to be excluded in a case like this?

SPEAKER_00 5:36

The key differential is septic arthritis.

SPEAKER_01 5:40

So particularly need to exclude a fever or any kind of red flags that the patient is systemically unwell, in which case they need emergency admission because septic arthritis is a medical emergency. So let's say you've got this patient, this exact case that we have, he's systemically well, new lymph for the last five hours.

SPEAKER_00 6:02

How are you going to manage this in primary care? So the first thing, as we discussed, is you need to exclude red flags.

SPEAKER_01 6:22

So make sure, you know, he's afebrile, he's systemically well, there's no signs of septic arthritis, and there's no other signs of other conditions, for example, uh a fracture or non-accidental injury or something going on a bit longer and suspecting some other differential diagnosis. So if it's a clear-cut, simple case and you're suspecting transient synovitis, the next step is just simple analgesia, so paracetamol, ibuprofen, and safety net advice, which is really important. So tell the parents if uh head straight to AE, if they become feverish or unwell or there's any other concerns, and then follow up the patient in 48 to 72 hours to make sure everything is settling and they're back to normal. Okay, let's move on to another case, which is a six-year-old boy. This six-year-old boy has a gradual onset, developing over weeks, of unilateral groin pain. And on examination, there's restricted hip range of motion.

SPEAKER_00 7:27

In this case, what's your suspected diagnosis?

SPEAKER_01 7:39

Here we're suspecting Perthes disease, and Perth's disease is avascular necrosis of the femoral head, and it's idiopathic, meaning we don't know why it's happened. So if you've got a patient about six years old who develops this gradual onset of groin pain, think about Perth's disease. Often they can be managed conservatively, but you in this case in primary care you're going to refer to orthopedics, get a diagnosis, and allow that, let them manage it. Okay, onto a new case. You've got a 12-year-old boy who's obese, and he has a sudden onset of unilateral groin pain. On examination, there's restricted range of motion in his hip. Interestingly, this started after a minor fall. So let's say he's just playing in the park, trips over, it's a minor fall. In a 12-year-old, you wouldn't expect any sort of repercussions of a simple fall like that. But here he's got this persistent groin pain.

SPEAKER_00 8:42

In this case, what's your suspected diagnosis?

SPEAKER_01 8:55

Here you might be suspecting slipped upper femoral epiphysis or Sufi. This is where the growth plate in the hip actually slips. So it's kind of like a um a hip dislocation, but on the growth plate, where the top of the femoral head remains in the hip joint, and the the rest of the femur at the growth plate has slipped away from that. In this case, again, you're going to be referring straight to hospital. They need to have x-rays, diagnosis, and specialist management. Okay, on to the next case. The next case is a 13-year-old male. He's a keen basketball player, and he presents with pain and tenderness and a lump at the right tibial tuberosity.

SPEAKER_00 9:45

So in this case, what's your suspected diagnosis? Here we're suspecting Osgood Schlatter disease.

SPEAKER_01 10:01

And this is where the patella tendon is pulling at the tibial tuberosity, and it's actually causing small fractures at the tibial tuberosity as it pulls the at the bone there. And this causes tenderness, pain, a lump, it's more painful with movement, and it should be okay at rest. And here you can make this diagnosis clinically if you've excluded any concerning differential diagnoses. And um, but you can do an X-ray if there's any concerns or or suspicions of some differential diagnosis. These uh really settle just with rest, and um the prognosis is good long term, although they can be left with a permanent lump at the tibial tuberosity. Okay, on to the final case that we have, which is a 14-year-old female, and she's had a recent growth spurt, so she's she's shot up in height, and there's distal thigh pain and swelling on one side, on the left side. This has been a gradual onset, and she also comments that her pain is worse at night time, sometimes keeps her awake at night.

SPEAKER_00 11:14

What's your suspected diagnosis in this case?

SPEAKER_01 11:27

Here we've got to suspect the worst case scenario, which would be osteosarcoma, so a bone tumor, a bone sarcoma in the distal femur. The final question is what would be the next step in management if you saw this uh 14, 14-year-old girl in primary care?

SPEAKER_00 11:48

What are you gonna do next?

SPEAKER_01 11:57

So the nice guidelines on suspected cancer say if you're suspecting osteosarcoma, so unexplained bone pain or swelling, then uh in a child or a young person, then they need a very urgent x-ray within 48 hours. And then if that x-ray comes back suggesting possible uh sarcoma, then they're gonna need a very urgent referral to be seen by a specialist within another 48 hours. So I hope that helps uh that episode on childhood limp was helpful. Um, do leave me a comment or send me a message if you have any specific requests about videos you'd like to see in the future. And I'll see you in the next video, which will be in about a week's time.