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Cristaldi S, Boni A, Ferro V, Musolino A, Della Vecchia N, Boccuzzi E, Bellelli E, Biagiarelli FS, Aulisa AG, Cirillo M, Raucci U, Villani A. Atraumatic Limping Child, a Challenge for Pediatricians: An Observational Age-Related Study in a Pediatric Emergency Department. CHILDREN (BASEL, SWITZERLAND) 2024; 11:185. [PMID: 38397297 PMCID: PMC10887381 DOI: 10.3390/children11020185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/19/2024] [Accepted: 01/30/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Atraumatic limping is a frequent cause of consultation in Pediatric Emergency Departments (PED) and often represents a challenge for pediatricians for its variability in etiology ranging from benign causes to potential crippling conditions. The aims of this research are to illustrate the clinical features of acute limping children (LC) and to identify the possible red flags that could help to make a diagnosis of severe pathologies. METHODS We carried out a retrospective study about non-traumatic limping children referred to the PED of Bambino Gesù Children's Hospital over a 2-year period. We divided the cohort into three groups based on the patient's age: toddlers, children and adolescents. We considered crippling conditions: oncologic etiologies, bone or neurological infections, epiphysiolysis, Perthes disease, Guillain Barrè syndrome and non-accidental injuries. RESULTS We analyzed 485 patients. At clinical evaluation, 19.5% of the patients presented at least one sign and/or symptom of red flags. Crippling conditions (6.2% of the total population) showed red flags in 36.7%. Transient synovitis of the hip was the most frequent diagnosis. We found crippling conditions in 30 patients, mostly represented by toddlers. CONCLUSIONS Our data suggest that toddlers and patients presenting red flags should be evaluated with particular suspicion because they have an increased risk of underlying severe conditions.
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Affiliation(s)
- Sebastian Cristaldi
- General Pediatrics and ED 2nd Level, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.C.); (V.F.); (N.D.V.); (E.B.); (E.B.); (F.S.B.); (A.V.)
| | - Alessandra Boni
- Pneumology and Cystic Fibrosis, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Valentina Ferro
- General Pediatrics and ED 2nd Level, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.C.); (V.F.); (N.D.V.); (E.B.); (E.B.); (F.S.B.); (A.V.)
| | - Antonio Musolino
- Residency School of Pediatrics, University of Rome Tor Vergata, 00133 Rome, Italy;
| | - Nicoletta Della Vecchia
- General Pediatrics and ED 2nd Level, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.C.); (V.F.); (N.D.V.); (E.B.); (E.B.); (F.S.B.); (A.V.)
| | - Elena Boccuzzi
- General Pediatrics and ED 2nd Level, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.C.); (V.F.); (N.D.V.); (E.B.); (E.B.); (F.S.B.); (A.V.)
| | - Elena Bellelli
- General Pediatrics and ED 2nd Level, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.C.); (V.F.); (N.D.V.); (E.B.); (E.B.); (F.S.B.); (A.V.)
| | - Francesco Saverio Biagiarelli
- General Pediatrics and ED 2nd Level, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.C.); (V.F.); (N.D.V.); (E.B.); (E.B.); (F.S.B.); (A.V.)
| | - Angelo Gabriele Aulisa
- Orthopaedics and Traumatology Division, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Marco Cirillo
- Department of Radiology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Umberto Raucci
- General Pediatrics and ED 2nd Level, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.C.); (V.F.); (N.D.V.); (E.B.); (E.B.); (F.S.B.); (A.V.)
| | - Alberto Villani
- General Pediatrics and ED 2nd Level, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.C.); (V.F.); (N.D.V.); (E.B.); (E.B.); (F.S.B.); (A.V.)
- Systems Medicine Department, University of Rome Tor Vergata, 00133 Rome, Italy
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Tu J, Haines M, Gowdie P, Craig S. Paediatric acute non-traumatic limp presenting to the emergency department: a retrospective observational study. Emerg Med J 2023; 40:182-188. [PMID: 36414323 DOI: 10.1136/emermed-2022-212624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 10/27/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acute non-traumatic limp in children has many causes, ranging from common benign and self-limiting disease to serious time-sensitive emergencies such as septic arthritis. We aimed to (1) describe the epidemiology and workup of paediatric acute non-traumatic limp presentation in three Australian EDs and (2) compare investigations and treatment between a tertiary paediatric centre and two non-tertiary centres. METHODS A retrospective chart review of children aged 0-16 years, with an initial presentation of non-traumatic limp to three EDs in Melbourne, Australia. Data on presentation, management and outcomes was systematically collected on all eligible patients. RESULTS Of 63 941 presentations over a 12-month period, 475 (0.7%) met inclusion criteria. The median (IQR) age of presentation was 5 (3-8) years, with a male predominance (61%). Blood tests and imaging were performed in 39% and 51%, respectively. 34% of presentations had no investigations. The most frequent ED diagnoses were transient synovitis (37%) and viral myositis (16%). 84% were discharged home after ED evaluation. Compared with the two non-tertiary hospitals, children who presented to the tertiary centre were less likely to have any investigation performed (OR=0.41, 95% CI: 0.27 to 0.62, p<0.001) and more likely to be discharged home after evaluation (OR=4.67, 95% CI: 2.79 to 7.81, p<0.001). CONCLUSION Although mostly due to benign disorders, an important number of limping children who presented to the ED had serious disease, with approximately one-third of these not diagnosed at the initial ED visit. There is large variation in workup including blood test, imaging and decisions regarding ED disposition.
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Affiliation(s)
- Jacky Tu
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Mitchell Haines
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Peter Gowdie
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
- Department of Paediatrics and Department of Paediatric Rheumatology, Monash Children's Hospital, Clayton, Victoria, Australia
| | - Simon Craig
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
- Paediatric Emergency Department, Monash Medical Centre, Clayton, Victoria, Australia
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Differential MRI findings of transient synovitis of the hip in children when septic arthritis is suspected according to symptom duration. J Pediatr Orthop B 2020; 29:297-303. [PMID: 31503109 DOI: 10.1097/bpb.0000000000000671] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
We investigated the differential MRI findings in children with transient synovitis of the hip in whom septic arthritis was suspected. Under the hypothesis that disease progression can alter representative MRI findings, we stratified these findings in accordance with symptom duration as this can correlate with disease progression. We analyzed 65 children who underwent MRI for acute hip pain and who were suspected of having a septic condition (i.e. presented with fever or increased inflammatory markers) when the imaging was performed. Symptom duration was defined as the interval from the first presentation of hip pain to the MRI scan. We divided the patients into two subgroups according to symptom duration: patients with short symptom duration (≤2 days, short-term subgroup, n = 30) and those with long symptom duration (≥3 days, long-term subgroup, n = 35). Twenty-eight (43.1%) of the study subjects were diagnosed with septic arthritis. Whereas only a high-grade joint effusion was a significant MRI finding differentiating septic arthritis from transient synovitis in the whole cohort, the presence of contralateral joint effusion in the short-term subgroup (P = 0.024) and the absence of a change/enhancement of the signal intensity of soft tissue in the long-term subgroup (P < 0.001) were significant predictors of transient synovitis. The significances of differential MRI findings for septic arthritis and transient synovitis seem to change according to symptom duration. We suggest that symptom duration, which may correlate with disease progression, should also be considered when interpreting MRIs of children under suspicion of septic arthritis.
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Lee JH, Park MS, Kwon H, Chung CY, Lee KM, Kim YJ, Kim K. A guideline for differential diagnosis between septic arthritis and transient synovitis in the ED: a Delphi survey. Am J Emerg Med 2016; 34:1631-6. [PMID: 27321938 DOI: 10.1016/j.ajem.2016.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 06/01/2016] [Accepted: 06/02/2016] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Among the causes of limping gait in children, septic arthritis (SA) and transient synovitis (TS) are the 2 most likely etiologies. The aim of this study was to determine the medical histories, physical examinations, and other studies to use to create a clinical guideline for differential diagnosis between SA and TS in children in the emergency department (ED). The pediatric orthopedic emergency committee of our institution addressed the issue of developing a guideline for differential diagnosis. METHODS Two rounds of the modified Delphi survey were conducted, and a face-to-face committee meeting was held after each survey round. Delphi survey panelists included 10 pediatric orthopedic surgeons and 8 emergency physicians including 3 pediatric emergency physicians. RESULTS Response rates were 100% in each round. The panelists used a 6-point Likert scale to rate the clinical diagnostic guideline contents as having high (5 or 6), moderate (3 or 4), or low importance (1 or 2). Twenty-eight questionnaire items were included in the first round; and 18 items, in the second round. Factors for concern were selected, and a flowchart of the diagnostic guideline development process was based on the results of the survey. CONCLUSION A diagnostic guideline for evaluating SA and TS in children in the ED was achieved using combined empirical evidence together with expert opinion, potentially resulting in a diagnostic strategy to be incorporated into existing guidelines or used on its own.
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Affiliation(s)
- Jin Hee Lee
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Moon Seok Park
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Hyuksool Kwon
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea.
| | - Chin Youb Chung
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Kyoung Min Lee
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Yu Jin Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
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Harris JC, Caesar DH, Davison C, Phibbs R, Than MP. Review article: How useful are laboratory investigations in the Emergency Department evaluation of possible osteomyelitis? Emerg Med Australas 2011; 23:317-30. [DOI: 10.1111/j.1742-6723.2011.01413.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kang SN, Sanghera T, Mangwani J, Paterson JMH, Ramachandran M. The management of septic arthritis in children. ACTA ACUST UNITED AC 2009; 91:1127-33. [DOI: 10.1302/0301-620x.91b9.22530] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We performed a systematic review of the optimal management of septic arthritis in children as recommended in the current English literature using MEDLINE, EMBASE, CINAHL, the Cochrane Library and reference lists of retrieved articles without date restrictions up to 31 January 2009. From 2236 citations, 227 relevant full-text articles were screened in detail; 154 papers fulfilled the inclusion criteria, from which conclusions were drawn on the management of infected joints in children. Our review showed that no single investigation, including joint aspiration, is sufficiently reliable to diagnose conclusively joint infection. The roles of aspiration, arthrotomy and arthroscopy in treatment are not clear cut, and the ideal duration of antibiotic therapy is not yet fully defined. These issues are discussed. Further large-scale, multi-centre studies are needed to delineate the optimal management of paediatric septic arthritis.
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Affiliation(s)
- S.-N. Kang
- Department of Trauma and Orthopaedics, The Royal London Hospitals, Barts and The London NHS Trust, Whitechapel Road, Whitechapel, London E1 1BB, UK
| | - T. Sanghera
- University of Nottingham Medical School, Queen’s Medical Centre, Nottingham NG7 2UH, UK
| | - J. Mangwani
- Department of Trauma and Orthopaedics, The Royal London Hospitals, Barts and The London NHS Trust, Whitechapel Road, Whitechapel, London E1 1BB, UK
| | - J. M. H. Paterson
- Department of Trauma and Orthopaedics, The Royal London Hospitals, Barts and The London NHS Trust, Whitechapel Road, Whitechapel, London E1 1BB, UK
| | - M. Ramachandran
- Department of Trauma and Orthopaedics, The Royal London Hospitals, Barts and The London NHS Trust, Whitechapel Road, Whitechapel, London E1 1BB, UK
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Reed L, Baskett A, Watkins N. Managing children with acute non-traumatic limp: the utility of clinical findings, laboratory inflammatory markers and X-rays. Emerg Med Australas 2009; 21:136-42. [DOI: 10.1111/j.1742-6723.2008.01144.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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