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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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2
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Sinaei R, Pezeshki S, Parvaresh S, Sinaei R, Shiari R, Hassas Yeganeh M, Bazargn N, Gharaei N. Post SARS-CoV-2 infection reactive arthritis: a brief report of two pediatric cases. Pediatr Rheumatol Online J 2021; 19:89. [PMID: 34118941 PMCID: PMC8196291 DOI: 10.1186/s12969-021-00555-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 04/16/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Although, preliminary reports of Severe Acute Respiratory Syndrome (SARS)-CoV-2 infection suggest that the infection causes a less severe illness in children, there is now growing evidence of other rare or even serious complications of disease. CASE PRESENTATION During the recent COVID-19 pandemic in Kerman, Iran, two children (an 8 year-old boy and a 6 year-old girl) were referred to outpatient Clinic of Pediatric Rheumatology with complaints of limping. Both children had experienced fever and mild respiratory tract infection. At the beginning of the second week of infection, they developed joint effusion. They both tested positive for coronavirus infection and were therefore diagnosed with post Coronavirus reactive arthritis. Both children were treated successfully with rest and Non-Steroidal Anti-Inflammatory Drugs (NSAID). They did not have any medical problems in the two months fallow up. CONCLUSIONS These two cases suggest that COVID-19 may be rheumatogenic. Highlighting the need for awareness of physicians, especially pediatricians, regarding the pathogenesis margins of this virus, as late presentations are of great importance.
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Affiliation(s)
- Reza Sinaei
- grid.412105.30000 0001 2092 9755Department of Pediatrics, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran ,grid.412105.30000 0001 2092 9755Endocrinology and Metabolism Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Sara Pezeshki
- Endocrinology and Metabolism Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran. .,Department of Internal Medicine, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran.
| | - Saeedeh Parvaresh
- Department of Pediatrics, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran.
| | - Roya Sinaei
- grid.412105.30000 0001 2092 9755Department of Pediatrics, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Reza Shiari
- grid.411600.2Department of Pediatric Rheumatology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Nasrin Bazargn
- grid.412105.30000 0001 2092 9755Department of Pediatrics, Afzalipour Medical Center, School of medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Nava Gharaei
- grid.38142.3c000000041936754XDepartment of Molecular and Cellular Biology, Harvard University, Cambridge, Massachusetts USA
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3
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Tu J, Gowdie P, Cassar J, Craig S. Test characteristics of history, examination and investigations in the evaluation for septic arthritis in the child presenting with acute non-traumatic limp. A systematic review. BMJ Open 2020; 10:e038088. [PMID: 33380476 PMCID: PMC7780717 DOI: 10.1136/bmjopen-2020-038088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Septic arthritis is an uncommon but potentially significant diagnosis to be considered when a child presents to the emergency department (ED) with non-traumatic limp. Our objective was to determine the diagnostic accuracy of clinical findings (history and examination) and investigation results (pathology tests and imaging) for the diagnosis of septic arthritis among children presenting with acute non-traumatic limp to the ED. METHODS Systematic review of the literature published between 1966 and June 2019 on MEDLINE and EMBASE databases. Studies were included if they evaluated children presenting with lower limb complaints and evaluated diagnostic performance of items from history, physical examination, laboratory testing or radiological examination. Data were independently extracted by two authors, and quality assessment was performed using the Quality Assessment Tool for Diagnostic Accuracy Studies 2 tool. RESULTS 18 studies were identified, and included 2672 children (560 with a final diagnosis of septic arthritis). There was substantial heterogeneity in inclusion criteria, study setting, definitions of specific variables and the gold standard used to confirm septic arthritis. Clinical and investigation findings were reported using varying definitions and cut-offs, and applied to differing study populations. Spectrum bias and poor-to-moderate study design quality limit their applicability to the ED setting.Single studies suggest that the presence of joint tenderness (n=189; positive likelihood ratio 11.4 (95% CI 5.9 to 22.0); negative likelihood ratio 0.2 (95% CI 0.0 to 1.2)) and joint effusion on ultrasound (n=127; positive likelihood ratio 8.4 (95% CI 4.1 to 17.1); negative likelihood ratio 0.2 (95% CI 0.1 to 0.3)) appear to be useful. Two promising clinical risk prediction tools were identified, however, their performance was notably lower when tested in external validation studies. DISCUSSION Differentiating children with septic arthritis from non-emergent disorders of non-traumatic limp remains a key diagnostic challenge for emergency physicians. There is a need for prospectively derived and validated ED-based clinical risk prediction tools.
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Affiliation(s)
- Jacky Tu
- Monash Health, Melbourne, Victoria, Australia
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Peter Gowdie
- Department of Paediatrics and Department of Paediatric Rheumatology, Monash Children's Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | | | - Simon Craig
- Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Pediatric Emergency Department, Monash Medical Centre, Emergency Service, Monash Health, Melbourne, Victoria, Australia
- Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
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4
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Irfan A, Rose A, Roberts B, Foster S, Huntley JS. Epidemiology of Irritable Hip in Western Scotland: A Follow-Up Study. Cureus 2020; 12:e10036. [PMID: 32983727 PMCID: PMC7515813 DOI: 10.7759/cureus.10036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background A ‘limping child’ commonly presents to the emergency department (ED). In the absence of trauma, many are diagnosed with irritable hip (IH). The aetiology of IH is not well understood and there may be geographical and seasonal variations. We previously established one year (2016) epidemiological data of IH presenting to the Royal Hospital for Children (RHCG) ED in Glasgow, Scotland. The sentinel findings in that year were (i) an age distribution shift to younger (peak at two years of age), (ii) no marked association with social class, and (iii) a spring preponderance. We sought to strengthen or refute these findings by repeating our study to obtain comparative data for 2017. Methods We performed a retrospective analysis of all children discharged from the RHCG ED from January to December 2017. Relevant discharge codes were determined, and patient records screened. Patients without a discharge code had their presenting complaint and medical record screened. These data were compared to that of the previously published study from the same ED (2016). Results Several findings were consistent with the conclusions of the 2016 study. The incidence was similar with 362 and 354 cases diagnosed in 2017 and 2016 respectively. The boy-girl ratio was consistent across both data-sets, 2:1 and 1.9:1 respectively. The mean age of presentation was similar (3.3 vs 3.5 years) across both years, with the same medians (three years) and peaks (two years). There was no overt difference in incidence or correlation to social deprivation. However, in 2016, a spring preponderance was seen whereas there was an autumn preponderance in 2017. Pooling data from the two cohorts, 93% (n=668) of patients were managed exclusively by ED physicians, with 70% (n=504) not requiring any further follow-up. The majority of patients who required follow-up were seen in ED clinics (169/212, 79.7%). No patient initially diagnosed as IH was found to have septic arthritis (SA). Conclusion In this follow-up study, we again found (i) a younger age profile than other studies, and (ii) no overt association with social deprivation. The major difference between the previous (2016) and current (2017) study was the apparent seasonal peaks: spring (2016), and autumn (2017). This difference does not negate the 'antecedent infection' hypothesis, but any aetiological proposal should be capable of accounting for this discrepancy. Additionally, our studies highlight that the majority of these patients can be managed in the ED alone.
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Affiliation(s)
- Ahmer Irfan
- Department of Surgery, Johns Hopkins Hospital, Baltimore, USA
| | - Anna Rose
- Department of Surgery, Queen Elizabeth University Hospital, Glasgow, GBR
| | - Bryn Roberts
- Department of Surgery, Queen Elizabeth University Hospital, Glasgow, GBR.,Critical Care, University Hospital Crosshouse, Kilmarnock, GBR
| | - Steven Foster
- Department of Paediatric Emergency Medicine, Royal Hospital for Children, Glasgow, GBR.,Department of Emergency Medicine, Royal Hospital for Sick Children, Glasgow, GBR
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5
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Toner E, Khaled A, Nakhuda Y, Mohil R. The Limping Child, a Rare Differential: Pyomyositis of the Iliacus Muscle -A Case Report. J Orthop Case Rep 2019; 9:21-25. [PMID: 31534927 PMCID: PMC6727460 DOI: 10.13107/jocr.2250-0685.1352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: The presentation of an unwell child with a short history of a limp is not an uncommon referral to the orthopaedic on-call team. In the acute setting, this is most commonly secondary to trauma or infection. An unusual differential that clinicians should be aware of is pyomyositis of the muscles around the hip joint. The rarity of our case makes this a very interesting one, with only a few other recorded cases within the UK. Case Report: A 3-year-old Caucasian girl presented to the Paediatric ED, with 6 days’ history of general malaise, vomiting, and intermittent pyrexia. 5 days before prior to attendance, she also developed a limp, which progressively worsened until she refused to weight bear on the left side with obvious distress and pain. No history of trauma was reported. According to the parents, she had become more irritable each day. The patient had no significant medical history and no family history of congenital or developmental hip disorders. Her vital signs were in keeping with sepsis as she was tachycardiac (154) and pyrexial (38.1°). The referring GP also recorded a high temperature of 38.9°. Physical examination proved difficult, due to pain. No obvious erythema or swelling was noted around either groin or lower limb. When asked to walk, she held the left hip in flexion and refused to weight bear. Conclusion: Treatment of pyomyositis is essential to prevent subsequent life-threatening sepsis. Intravenous antibiotics, radiologically guided or surgical drainage of the collection, or debridement may be indicated in the management. Good understanding of the anatomy surrounding the hip joint is vital. The iliopsoas muscle inserts into the lesser trochanter of the hip joint. Therefore, inflammation in the origin or along the track of the muscle can mimic a septic arthritis picture. Radiological modalities, including ultrasound and magnetic resonance imaging, should be considered, particularly when diagnostic doubt exists. Overall, making surgical decisions in such a case can be challenging. We advocate multii-disciplinary approach and seeking further opinions from colleagues if in doubt which should help in providing the best care possible for a child.
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Affiliation(s)
- Ethan Toner
- Department of Trauma and Orthopaedic, Royal Blackburn Hospital, Blackburn, BB2 3HH, England, United Kingdom
| | - Ahmad Khaled
- Department of Trauma and Orthopaedic, Royal Blackburn Hospital, Blackburn, BB2 3HH, England, United Kingdom
| | - Yacoob Nakhuda
- Department of Radiology, Royal Blackburn Hospital, Blackburn BB2 3HH, England, United Kingdom
| | - Randeep Mohil
- Department of Trauma and Orthopaedic, Royal Blackburn Hospital, Blackburn, BB2 3HH, England, United Kingdom
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6
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Rossiter DJ, Ahluwalia A, Vo P, Mapara R. The limping child: a systematic approach to assessment and management. Br J Hosp Med (Lond) 2019; 79:C150-C153. [PMID: 30290754 DOI: 10.12968/hmed.2018.79.10.c150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel J Rossiter
- Orthopaedic Registrar, Department of Trauma and Orthopaedics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX
| | - Aashish Ahluwalia
- Core Surgical Trainee 1, Department of Trauma and Orthopaedics, University College London Hospital, London
| | - Phien Vo
- Senior House Officer, Department of Paediatrics, Kingston Hospital, London
| | - Rahee Mapara
- Core Surgical Trainee 1, Department of General Surgery, NHS Greater Glasgow and Clyde, Glasgow
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7
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Trochanteric Fractures in Young Children. Pediatr Emerg Care 2019; 35:e84-e85. [PMID: 30998653 DOI: 10.1097/pec.0000000000001825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Isolated avulsion fractures of the greater and lesser trochanter are usually seen in adolescents prior to the fusion of the apophysis. Greater trochanter fractures in adults have a high incidence of intertrochanteric extension and lesser trochanter fractures are regarded as a pathognomonic sign of metastatic disease. These fractures are very rare among children. METHODS We report five cases of trochanteric fractures in children of less than two years of age three of which were unrecognized initially in the accident and emergency department. RESULTS Early and complete recovery ensued following immobilization and symptomatic treatment. Surgical intervention was not required. CONCLUSIONS There needs to be a high index of suspicion to diagnose these fractures in children and plain radiographs need to be carefully examined when assessing a limping child. Our experience shows when correctly diagnosed these injuries can be treated successfully with supportive treatment and no need for surgical intervention. LEVEL OF EVIDENCE IV Case series.
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8
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Irfan A, Starr RJ, Foster S, Smith ID, Huntley JS. "Irritable Hip": Diagnosis in the Emergency Department. A Descriptive Study Over One Year. Cureus 2018; 10:e3481. [PMID: 30613443 PMCID: PMC6314824 DOI: 10.7759/cureus.3481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background A ‘limping child’ commonly presents to the emergency department (ED), often without a history of trauma. It is important that serious underlying pathology is ruled out before a diagnosis of benign irritable hip (IH). The aetiology of IH is not well understood and there may be geographical and seasonal variation. The aim of this study was to determine the basic epidemiology of IH in the Glasgow Population. Methods A retrospective analysis was carried out of all children discharged from the Glasgow Children’s Emergency Department from January to December 2016. Relevant discharge codes were determined and patient records screened. Any patient who did not have a discharge code had their presenting complaint and medical record screened. Results A total of 354 patients were diagnosed with IH, of which 319 and 189 were in the Greater Glasgow and Clyde and City of Glasgow catchment areas, respectively. The majority of these patients (n = 254) were diagnosed clinically. The incidence of IH was 177.7 per 100,000 children with a boy:girl ratio of 1.9:1 (209:110). The mean age of presentation was 3.5 years and the recurrence rate was 5.9% (n = 18). There was an increased incidence in spring (n = 111), especially in March (n = 42) and April (n = 40). There was no incidence variation or influence discernible by social deprivation. Conclusion In this population, IH has: (i) an atypical age profile (age distribution shift to younger), (ii) no marked association with social deprivation (in contrast to other studies), and (iii) a 'spring preponderance'. We suggest that most cases can safely be managed in the ED without recourse to further investigations or speciality referral.
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Affiliation(s)
- Ahmer Irfan
- Department of Surgery, Johns Hopkins Hospital, Baltimore, USA
| | - Robert J Starr
- Department of Anaesthesiology, Aberdeen Royal Infirmary, Aberdeen, GBR
| | - Steven Foster
- Department of Paediatric Emergency Medicine, Royal Hospital for Children, Glasgow, GBR
| | - Innes D Smith
- Department of Trauma and Orthopaedics, Queen Elizabeth University Hospital, Glasgow, GBR
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9
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Owen R, Ramlakhan S, Saatchi R, Burke D. Development of a high-resolution infrared thermographic imaging method as a diagnostic tool for acute undifferentiated limp in young children. Med Biol Eng Comput 2018; 56:1115-1125. [PMID: 29181625 PMCID: PMC5978821 DOI: 10.1007/s11517-017-1749-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 11/03/2017] [Indexed: 11/15/2022]
Abstract
Acute limp is a common presenting condition in the paediatric emergency department. There are a number of causes of acute limp that include traumatic injury, infection and malignancy. These causes in young children are not easily distinguished. In this pilot study, an infrared thermographic imaging technique to diagnose acute undifferentiated limp in young children was developed. Following required ethics approval, 30 children (mean age = 5.2 years, standard deviation = 3.3 years) were recruited. The exposed lower limbs of participants were imaged using a high-resolution thermal camera. Using predefined regions of interest (ROI), any skin surface temperature difference between the healthy and affected legs was statistically analysed, with the aim of identifying limp. In all examined ROIs, the median skin surface temperature for the affected limb was higher than that of the healthy limb. The small sample size recruited for each group, however, meant that the statistical tests of significant difference need to be interpreted in this context. Thermal imaging showed potential in helping with the diagnosis of acute limp in children. Repeating a similar study with a larger sample size will be beneficial to establish reproducibility of the results. Graphical abstract A young child with an acute undifferentiated limp undergoes thermal imaging and the follow on image analysis assists the limp diagnosis.
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Affiliation(s)
- R Owen
- The University of Sheffield Medical School, Sheffield, UK.
| | - S Ramlakhan
- Sheffield Children's NHS Foundation Trust, Sheffield, UK
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, W.I., Trinidad and Tobago
| | - R Saatchi
- Materials and Engineering Research Institute, Sheffield Hallam University, Sheffield, UK
| | - D Burke
- Sheffield Children's NHS Foundation Trust, Sheffield, UK
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10
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Davis T, Lawton B, Klein K, Goldstein H, Tagg A. Walking in circles: The limping child. Emerg Med Australas 2017; 29:380-382. [PMID: 28681516 DOI: 10.1111/1742-6723.12830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Tessa Davis
- Accident and Emergency, Chelsea and Westminster Hospital, London, UK
| | - Ben Lawton
- Emergency Department, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Emergency Department, Logan Hospital, Brisbane, Queensland, Australia
| | - Kristina Klein
- Emergency Department, Logan Hospital, Brisbane, Queensland, Australia.,LifeFlight, Brisbane, Queensland, Australia
| | - Henry Goldstein
- Emergency Department, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Andrew Tagg
- Emergency Department, Footscray Hospital, Melbourne, Victoria, Australia
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11
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Patel R, Monem M, Sherief T. Unilateral infective sacroiliitis in a boy presenting with a limp. BMJ Case Rep 2017; 2017:bcr-2017-219279. [PMID: 28478389 DOI: 10.1136/bcr-2017-219279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 9-year-old boy admitted to a district general hospital with a 1-week history of fever and a 2-day history of right hip pain. Initial workup revealed raised inflammatory markers and unremarkable imaging studies. After clinical review, there was minimal improvement of the patient's condition 5 days after presentation; therefore, an MRI of the pelvis/hips was carried out, which supported a clinical diagnosis of right-sided infective sacroiliitis. Infective sacroiliitis is rare and only represents 1%-2% of septic arthritis in children. The condition still remains a diagnostic challenge first due to poor localisation of symptoms with referred pain to the hip, thigh and lower back and second due to a lack of awareness by non-specialist clinicians. Early diagnosis is a key to avoid sequelae such as an abscess, degenerative changes of the sacroiliac joint and can be achieved by a thorough clinical examination, monitoring inflammatory markers and MRI.
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Affiliation(s)
| | - Mohammed Monem
- Otolaryngology, East and North Hertfordshire NHS Trust, Stevenage, UK
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12
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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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13
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Suter B, Jones Y. The Curious Case of the Limping Toddler. Clin Pediatr (Phila) 2016; 55:574-6. [PMID: 26239919 DOI: 10.1177/0009922815598862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Blair Suter
- West Virginia University School of Medicine, Morgantown, WV, USA
| | - Yemisi Jones
- University of Cincinnati College of Medicine, Oh, USA
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14
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Imaging of Hip Pain: From Radiography to Cross-Sectional Imaging Techniques. Radiol Res Pract 2016; 2016:6369237. [PMID: 26885391 PMCID: PMC4738697 DOI: 10.1155/2016/6369237] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 12/17/2015] [Accepted: 12/20/2015] [Indexed: 12/16/2022] Open
Abstract
Hip pain can have multiple causes, including intra-articular, juxta-articular, and referred pain, mainly from spine or sacroiliac joints. In this review, we discuss the causes of intra-articular hip pain from childhood to adulthood and the role of the appropriate imaging techniques according to clinical suspicion and age of the patient. Stress is put on the findings of radiographs, currently considered the first imaging technique, not only in older people with degenerative disease but also in young people without osteoarthritis. In this case plain radiography allows categorization of the hip as normal or dysplastic or with impingement signs, pincer, cam, or a combination of both.
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15
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Abstract
Limping in children is a common complaint at pediatric, pediatric orthopaedic offices and in emergency rooms. There are several causes for this condition, and identifying them is a challenge. The older the patient, the better the anamnesis and more detailed the physical examination will be, enabling an easier medical assessment for searching the source of the disorder. In order to make the approach easier, three age groups can and should be considered. Among infants (1 to 3 years old), diagnosis will most likely be: transitory synovitis, septic arthritis, neurological disorders (mild brain palsy (BP) and muscular dystrophy), congenital hip dislocation (CHD), varus thigh, juvenile rheumatoid arthritis (JRA) and neoplasias (osteoid osteoma, leukemia); in the scholar age group, between 4 and 10 years old, in addition to the diagnoses above, Legg-Calvé-Perthes disease, discoid meniscus, inferior limbs discrepancy and unspecific muscular pain; in adolescents (11 to 15 years old): slipped capital femoral epiphysis, congenital hip dislocation, chondrolysis, overuse syndromes, dissecans osteochondritis, and tarsal coalition. The purpose of this study is to provide an update on how to approach pediatric patients presenting with limping, and to discuss its potential causes.
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Affiliation(s)
- Cláudio Santili
- Department of Orthopedics and Traumatology, Faculdade de Ciências Médicas, Santa Casa de Sao Paulo; Assistant Physician, Pediatric Orthopedics and Traumatology Group, Irmandade da Santa Casa de Misericórdia de Sao Paulo, Sao Paulo, Brazil
- Correspondence: Dr. Cláudio Santili, Departamento de Ortopedia e Traumatologia da Santa Casa de São Paulo-Grupo de Ortopedia e Traumatologia Pediátrica, Rua Cesário Mota Junior, 112-01277-900-São Paulo, SPCorrespondence: Dr. Cláudio SantiliDepartamento de Ortopedia e Traumatologia da Santa Casa de São Paulo-Grupo de Ortopedia e Traumatologia PediátricaRua Cesário Mota Junior112-01277-900-São Paulo, SP.
| | - Wilson Lino Júnior
- Pediatric Orthopedics and Traumatology Group, Irmandade da Santa Casa de Misericórdia de Sao Paulo, Sao Paulo, Brazil
| | - Ellen de Oliveira Goiano
- Interning Physician, Pediatric Orthopedics and Traumatology Group, Irmandade da Santa Casa de Misericórdia de Sao Paulo, Sao Paulo, Brazil
| | - Romero Antunes Barreto Lins
- Resident (R3) Physician, Department of Orthopedics and Traumatology, Faculdade de Ciências Médicas, Santa Casa de Sao Paulo, Sao Paulo, Brazil
| | - Gilberto Waisberg
- Pediatric Orthopedics and Traumatology Group, Irmandade da Santa Casa de Misericórdia de Sao Paulo, Sao Paulo, Brazil
| | - Susana dos Reis Braga
- Master in Orthopedics, Faculdade de Ciências Médicas, Santa Casa de Sao Paulo; Physician, Pediatric Orthopedics and Traumatology Group, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Miguel Akkari
- Head, Pediatric Orthopedics and Traumatology Group, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
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Abstract
"Limp" is a common complaint of children presenting to the emergency department or physician's office. For most patients presenting with limp, the diagnosis and management can be completed in the physician's office or emergency department by gathering a detailed history, performing a careful physical examination, and requesting a few laboratory and imaging studies. This article reviews common causes of atraumatic limp in children and discusses the evaluation and management of these conditions.
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17
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Abstract
Joint pains are a common reason for children to present to primary care. The differential diagnosis is large including some diseases that do not primarily affect the musculoskeletal system. Although the cause for many patients will be benign and self-resolving, in rare cases the diagnosis is associated with long-term morbidity and mortality if not detected early and appropriately treated. These include primary and secondary malignancies, septic arthritis, osteomyelitis, inflammatory arthritis, slipped upper femoral epiphysis (SUFE) and non-accidental injury. We highlight the importance of a thorough history and directed yet comprehensive examination. A diagnostic algorithm is provided to direct primary care physicians' clinical assessment and investigation with the evidence base where available. In many cases, tests are not required, but if there is suspicion of malignancy, infection or inflammatory conditions, laboratory tests including full blood count, blood film, erythrocyte sedimentation rate, C-reactive protein and lactate dehydrogenase help to support or exclude the diagnosis. Autoimmune tests, such as antinuclear antibodies and rheumatoid factor, have no diagnostic role in juvenile idiopathic arthritis; therefore, we advise against any form of 'rheumatological/autoimmune disease screen' in primary care. Imaging does have a place in the diagnosis of joint pains in children, with plain radiographs being most appropriate for suspected fractures and SUFE, whilst ultrasound is better for the detection of inflammatory or infective effusions. The appropriate referral of children to paediatric rheumatologists, oncologists, orthopaedic surgeons and the emergency department are discussed.
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Affiliation(s)
- E S Sen
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK; School of Clinical Sciences, University of Bristol, Bristol, UK
| | - S L N Clarke
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK; School of Clinical Sciences, University of Bristol, Bristol, UK
| | - A V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK.
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Thornton MD, Della-Giustina K, Aronson PL. Emergency department evaluation and treatment of pediatric orthopedic injuries. Emerg Med Clin North Am 2015; 33:423-49. [PMID: 25892730 DOI: 10.1016/j.emc.2014.12.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Orthopedic injuries in children are unique when compared to those of adults because of the physiologic differences, especially the growth plates, stronger periosteum, and dynamic state of growth. The approach to the orthopedically injured child requires a gentle yet thorough focus with consideration of the growth plates as a primary area of weakness and growth when the child sustains an injury. Understanding the developmental stages of bones is paramount to being able to manage any injuries. Finally, what appears to be a benign injury may portend more serious issues, because nonaccidental trauma must always be considered in the evaluation of the injured child.
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Affiliation(s)
- Matthew D Thornton
- Department of Emergency Medicine, Bay State Medical Center, 759 Chestnut Street, Springfield, MA 01199, USA
| | - Karen Della-Giustina
- Department of Emergency Medicine, Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06610, USA.
| | - Paul L Aronson
- Department of Pediatric Emergency Medicine, Yale New Haven Childrens Hospital, 100 York Street, Suite 1F, New Haven, CT 06511, USA
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19
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Abstract
BACKGROUND The epidemiology of transient synovitis is poorly understood, and the aetiology is unknown, although a suggestion of a viral association predominates. PURPOSE This population-based study investigated the epidemiology in order to formulate aetiological theories of pathogenesis. PATIENT AND METHODS Cases in Merseyside were identified between 2004 and 2009. Incidence rates were determined and analysed by age, sex, season and region of residence. Socioeconomic deprivation scores were generated using the Index of Multiple Deprivation, allocated by postcode. Poisson confidence intervals were calculated and Poisson regression was used to check for trends. RESULTS Two hundred and fifty-nine cases were identified over 5.5 years. The annual incidence was 25.1 (95 % CI 22.1-28.5) per 100,000 0-14 year-olds. Male to female ratio was 3.2:1 (p < 0.001). Mean age at presentation was 5.4 years (95 % CI 5.0-5.8), which demonstrated a near-normal distribution. No relationship was identified between seasonality and incidence (p = 0.64). A correlation was identified with socioeconomic deprivation in Merseyside: incidence rate ratio 1.16 (95 % CI 1.06-1.26, p < 0.001), although further analysis within the subregion of Liverpool did not confirm this finding (p = 0.35). CONCLUSIONS The normal distribution for age at disease presentation suggests a specific disease entity. The absence of seasonality casts some doubt on the popular theory of a viral aetiology. The absence of a consistent socioeconomic gradient in both Merseyside and Liverpool challenges a previous suggestion of an association with Perthes' disease. This paper provides ecological evidence that may challenge existing aetiological theories, though transient synovitis remains an enigma.
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Asche SS, van Rijn RM, Bessems JH, Krul M, Bierma-Zeinstra SM. What is the clinical course of transient synovitis in children: a systematic review of the literature. Chiropr Man Therap 2013; 21:39. [PMID: 24229447 PMCID: PMC3831260 DOI: 10.1186/2045-709x-21-39] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 09/30/2013] [Indexed: 11/10/2022] Open
Abstract
Background Transient synovitis of the hip (TS) is considered to be a self-limiting disease in childhood. However, because the etiology is unclear and some cases precede Legg-Perthes’ disease, data on follow-up are important. Our aim was to summarize the knowledge on the clinical course of TS in children. Methods The study design was a systematic review and a literature search was conducted in Medline and Embase. Studies describing short and/or long-term follow-up of TS in children were included. Case reports, reviews and studies describing traumatic hip pain were excluded. Study quality was scored and data extraction was performed. The main outcome measures were short-term and long-term clinical course, and recurrence of symptoms. Results A total of 25 studies were included of which 14 were of high quality. At two-week follow-up, almost all children with TS were symptom free. Those with symptoms persisting for over one month were more prone to develop other hip pathology, such as Legg-Perthes’ disease. The recurrence rate of TS ranged from 0–26.3%. At long-term follow-up, 0-10% of the children diagnosed with TS developed Legg-Perthes’ disease. Hip pain after intensive physical effort and limited range of motion of the hip at long-term follow-up was reported in 12-28% and in 0-18% of the children, respectively. Conclusions The majority of the studies indicate that children with TS recover within two weeks; recurrence was seen in 0-26% of the cases. Children with TS should be followed at least six months to increase the likelihood of not missing Legg-Perthes’ disease.
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Affiliation(s)
| | | | | | | | - Sita Ma Bierma-Zeinstra
- Department of General Practice, Erasmus MC-University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
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21
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Affiliation(s)
- Manuele Lampasi
- Divisione di Ortopedia e Traumatologia Pediatrica, Rizzoli Orthopaedic Institute, Bologna, Italy.
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22
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ACR Appropriateness Criteria® Limping Child—Ages 0 to 5 Years. J Am Coll Radiol 2012; 9:545-53. [DOI: 10.1016/j.jacr.2012.04.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Indexed: 12/21/2022]
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23
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A Complicated Limp: When Occam's Razor Fails. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2012. [DOI: 10.1016/j.cpem.2012.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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24
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Murias S, Remesal A, Quiles M, Merino R. Características de los pacientes con cojera en Reumatología. An Pediatr (Barc) 2012; 76:290-3. [DOI: 10.1016/j.anpedi.2011.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 10/05/2011] [Accepted: 10/27/2011] [Indexed: 01/24/2023] Open
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Seyahi A, Uludag S, Altıntaş B, Demirhan M. Tibial torus and toddler's fractures misdiagnosed as transient synovitis: a case series. J Med Case Rep 2011; 5:305. [PMID: 21752248 PMCID: PMC3142521 DOI: 10.1186/1752-1947-5-305] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Accepted: 07/13/2011] [Indexed: 01/24/2023] Open
Abstract
Introduction The high incidence of transient synovitis in early childhood makes it the first suspected pathology in a limping child. Trauma, which has long been regarded as a causative factor for transient synovitis, may be underestimated in a non-cooperative toddler. After excluding most serious conditions, such as septic arthritis, a speculative diagnosis of transient synovitis can be made, and this can easily mask a subtle musculoskeletal injury. Case presentations We report the cases of three Caucasian patients (two boys, aged 20-months- and three-years-old, and one girl, aged two-years-old), with tibial torus and toddler's fractures which were late-diagnosed due to an initial misdiagnosis of transient synovitis of the hip. Conclusion In a non-cooperative child musculoskeletal trauma can be mistaken as a simple causative factor for transient synovitis of the hip and this can easily prevent further investigation for a possible subtle musculoskeletal injury of the lower extremities. Our experience with the presented cases suggests the need to be more vigilant in the differential diagnosis of transient synovitis in young children.
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Affiliation(s)
- Aksel Seyahi
- American Hospital, Department of Orthopaedics and Traumatology, Istanbul, Turkey.
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26
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Baunin C, Vial J, Labarre D, Domenech-Fontenel C, Railhac J, Sans N. [The chronically limping child]. JOURNAL DE RADIOLOGIE 2011; 92:506-514. [PMID: 21704246 DOI: 10.1016/j.jradio.2011.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 04/11/2011] [Indexed: 05/31/2023]
Abstract
Chronic limping in children usually indicates the presence of an underlying organic lesion. Clinical evaluation establishes the site and type of limping. It may suggest a neurological or mechanical lesion or locoregional etiology at the level of the hip or pelvis. Plain radiographs and ultrasound are firstline imaging techniques. The diagnosis may be delayed either due to ignorance of age-specific entities or false positive or negative results on plain films and ultrasound. MRI now plays a major role for diagnosis. Multiple potential underlying etiologies including trauma, infections, arthritides or tumors are best evaluated with MRI. The MRI examination should not be limited only to the hip joint.
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Affiliation(s)
- C Baunin
- Imagerie Pédiatrique, Hôpital des Enfants, 330 Avenue de Grande-Bretagne, 31059 Toulouse cedex 9, France.
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27
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Rosa JRP, Kojima CM, Fernandes LFL, Hehn BJ, Santili C. Fluxograma diferencial entre a artrite séptica e sinovite transitória do quadril em crianças. ACTA ORTOPEDICA BRASILEIRA 2011. [DOI: 10.1590/s1413-78522011000400006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
O diagnóstico diferencial entre a artrite séptica e a sinovite transitória do quadril não é fácil de ser realizado, pois não há um exame que seja simples, nem satisfatoriamente sensível e específico para diferenciá-las. Sendo assim, é muitas vezes utilizada uma propedêutica armada de exames que demanda maior custo e requer melhor infra-estrutura da instituição de saúde. Perante isso, torna-se evidente a necessidade de uma análise multifatorial dos dados clínicos e laboratoriais envolvidos para a proposição de um fluxograma em que se possa racionalizar exames visando a correta abordagem e evitar a indicação de procedimentos, muitas vezes, desnecessários como a ressonância magnética ou mais invasivos como a artrocentese e a própria drenagem cirúrgica. Realizamos uma ampla revisão da literatura nas bases de dados do Pubmed e Cochrane até maio de 2009 em que foi analisada a importância do exame clínico, dos testes laboratoriais e de imagem para a diferenciação entre as duas afecções. Mediante o cruzamento dos dados foi elaborado um fluxograma para o diagnóstico e conduta na criança e no adolescente, com idade de seis meses a dezoito anos, com sintoma de dor no quadril, na suspeita de quadro inflamatório. Nivel de Evidência III, estudos diagnósticos, investigação de um exame para diagnóstico.
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Krul M, van der Wouden JC, Schellevis FG, van Suijlekom-Smit LWA, Koes BW. Acute non-traumatic hip pathology in children: incidence and presentation in family practice. Fam Pract 2010; 27:166-70. [PMID: 20026553 DOI: 10.1093/fampra/cmp092] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The differential diagnosis of children with acute non-traumatic hip pathology varies from quite harmless conditions such as transient synovitis of the hip to more severe problems like Perthes' disease, slipped capital femoral epiphysis (SCFE) and life-threatening conditions such as septic arthritis of the hip. OBJECTIVE To provide population-based data on symptom presentation and incidence rates of non-traumatic acute hip pathology in family practice. METHODS We analysed data from a large national survey of family practice (104 practices), which was carried out by the Netherlands Institute for Health Services Research (NIVEL) in 2001. We included all children aged 0-14 years. Incidence rates were calculated by dividing the total number of cases (numerator) by the average study population at risk (denominator). RESULTS Our study population consisted of 73 954 children aged 0-14 years, yielding 68 202 person-years. These children presented with 101 episodes of acute non-traumatic hip pathology. The presenting feature in 81.5% of the children was pain, in 8.6% limping and 9.9% presented with both symptoms. Only 27% of the participating family practitioners (FPs) reported whether the child had a fever. The incidence rate for all acute non-traumatic hip pathology was 148.1 per 100 000 person-years, and for transient synovitis, this was 76.2 per 100 000 person-years. CONCLUSION In family practice, most children with acute non-traumatic hip pathology present with pain as the initial symptom. FPs need to be more aware that fever is the main distinguishing factor between a harmless condition and a life-threatening condition. Transient synovitis is the diagnosis with the highest incidence rate.
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Affiliation(s)
- Marjolein Krul
- Department of General Practice, Erasmus MC-University Medical Center Rotterdam, Room Ff304, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
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30
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Jung S, Borland S, Matewski D. Early diagnostic procedures in primary care and hospital for children with a painful hip. A prospective study. Eur J Gen Pract 2009; 15:226-30. [DOI: 10.3109/13814780903447564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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31
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Abstract
Pediatric patients often present to the emergency department with orthopedic pathology that can challenge the emergency department physician. This article focuses on key diagnoses that are frequently mismanaged. These diagnoses require specific knowledge to execute appropriate treatment. Pediatric fractures, compartmental syndrome, bone and joint infection, limp and non-accidental trauma are reviewed. Approach to the workup of these patients and treatment algorithms are discussed.
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Affiliation(s)
- Jennifer C Laine
- Department of Orthopaedic Surgery, University of California-San Francisco, 500 Parnassus Avenue, San Francisco, CA 94143, USA
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32
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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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Baskett A, Hosking J, Aickin R. Hip radiography for the investigation of nontraumatic, short duration hip pain presenting to a children's emergency department. Pediatr Emerg Care 2009; 25:78-82. [PMID: 19194345 DOI: 10.1097/pec.0b013e318196ea43] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the diagnostic accuracy of routine hip x-ray in 2- to 11-year-old children presenting to the emergency department with recent onset, nontraumatic hip pain and to assess the predictive value of other clinical presenting variables. METHODS Retrospective chart review of children with hip pain of less than 2 weeks duration, presenting to a metropolitan children's emergency department in New Zealand. Data were extracted on radiography results, diagnosis on final discharge from hospital, and other clinical details. Diagnostic categories were divided into urgent pathology (those requiring immediate treatment) and nonurgent pathology (those requiring follow up and those requiring no treatment or follow up). Contingency analysis and logistic regression were performed on variables to assess ability to predict urgent pathology. RESULTS Hip x-rays were performed in 99% of 310 eligible patients. Of these, 3% had some degree of significant abnormality reported on hip x-ray. Final diagnoses were transient synovitis in 86% of patients, osteomyelitis or other significant musculoskeletal sepsis in 8%, slipped upper femoral epiphysis in 1%, and other musculoskeletal disorder in 4%, with no cases of septic arthritis. In children 9 years or older, the likelihood ratio with a positive x-ray was 17, compared with 6 in children younger than 9 years. Fever, weight-bearing status, and age were the most important predictors of urgent pathology. CONCLUSIONS In children younger than 9 years presenting with recent onset, nontraumatic hip pain, hip x-ray is of limited value. In children 9 years or older, hip x-ray may be useful to exclude slipped upper femoral epiphysis. Fever, weight bearing status, and age may better predict urgent pathology.
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Affiliation(s)
- Abby Baskett
- Advanced Trainee, Paediatric Emergency Medicine, Children's Emergency Department, Starship Children's Health, Auckland, New Zealand.
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34
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Pediatric leukemia revealed by a limping episode: a report of four cases. Orthop Traumatol Surg Res 2009; 95:77-81. [PMID: 19251241 DOI: 10.1016/j.otsr.2008.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2008] [Accepted: 09/30/2008] [Indexed: 02/02/2023]
Abstract
Acute limping in children is a common reason for consultation in pediatric emergency units. Acute leukemia is a rarely encountered disease in the orthopedic surgeon's activity. In addition, its clinical presentation is not typical and therefore is a source of possible diagnostic delay. For such reasons, there is a definite risk of undiagnosing the actual etiology of the limping episode. We report our experience with four cases of children initially seen in the pediatric emergency department for limping, as their revealing presentation of acute leukemia. The limb pain was highly variable. The radiographic work-up was always normal. Peripheral blood abnormalities were initially absent in one case and blastic cells were absent in two cases. The physician in charge should remember that paraclinical work-up normal results do not exclude a diagnosis of acute leukemia, that any drop in hematopoietic cell counts should call for a myelogram and that paraclinical exams, including the hemogram, should be repeated until a diagnosis and improvement or confirmed cure is achieved over time.
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Delaney RA, Lenehan B, O'sullivan L, McGuinness AJ, Street JT. The limping child: an algorithm to outrule musculoskeletal sepsis. Ir J Med Sci 2007; 176:181-7. [PMID: 17624502 DOI: 10.1007/s11845-007-0061-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2006] [Accepted: 06/20/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND The acutely limping child presents a significant diagnostic challenge. AIM The purpose of this study was to create a clinically useful algorithm to allow exclusion of 'musculoskeletal sepsis' as a differential diagnosis in the child presenting with limp. METHODS Data were collected on all 286 limping children admitted to our centre over a 3-year-period. Using logistic regression analysis, the predictive model was constructed, to exclude infection. RESULTS Duration of symptoms, constitutional symptoms, temperature, white cell count and ESR were significantly different in children with musculoskeletal infection (P < 0.05). Multivariate analysis demonstrated that when all three variables of duration of symptoms >1, <5 days; temperature >37.0 degrees C; and ESR >35 mm/h were present, the predicted probability of infection was 0.66, falling to 0.01 when none were present. CONCLUSION This multivariate model enables us to rule out musculoskeletal infection with 99% certainty in limping children with none of these three presenting variables.
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Affiliation(s)
- R A Delaney
- Department of Trauma and Orthopaedics, Cork University Hospital, Cork, Ireland.
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36
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Abstract
Acute limp in childhood is associated with considerable anxiety for parents and clinicians alike. It can be a diagnostic challenge in the uncooperative child and any delay in diagnosis can result in significant morbidity and even mortality. A thorough clinical evaluation is of utmost importance. This review revisits the clinical assessment of a limping child and explores the relevant literature.
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Affiliation(s)
- Ali Abbassian
- North-West Thames Rotation, Charing Cross Hospital, London W6 8RF
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37
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Bienvenu-Perrard M, de Suremain N, Wicart P, Moulin F, Benosman A, Kalifa G, Coste J, Adamsbaum C. [Benefit of hip ultrasound in management of the limping child]. ACTA ACUST UNITED AC 2007; 88:377-83. [PMID: 17457269 DOI: 10.1016/s0221-0363(07)89834-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the contribution of sonography of the hip in the management of nontraumatic limping in children. PATIENTS AND METHODS Prospective study including children consulting for nontraumatic limping (n=93). These children had a clinical examination, a biological and imaging workup (pelvis x-rays (n=88), initial sonograph of the hip (n=93), and follow-up sonograph of the hip (n=29)). RESULTS Ninety-three children (69 boys, 24 girls) aged from 10 months to 13 years (median, 4 years) were included and divided into two groups: The sensitivity and specificity of sonography in establishing a serious diagnosis was 57% and 59%, respectively. CONCLUSION The advantage of systematic hip sonography is challenged in this study because of low sensitivity and specificity. Its main advantage seems to be in its negative results, which prompt other investigations.
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Affiliation(s)
- M Bienvenu-Perrard
- Service de Radiologie, Université Paris Descartes, Feculté de Médecine, AP-HP, Hôpital Saint Vincent de Paul, Paris, France
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Foster HE, Cabral DA. Is musculoskeletal history and examination so different in paediatrics? Best Pract Res Clin Rheumatol 2006; 20:241-62. [PMID: 16546055 DOI: 10.1016/j.berh.2005.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Musculoskeletal (MSK) complaints in children and adolescents are common. The differential diagnosis is broad and based predominantly on clinical assessment. The skills both for eliciting history and for examination require understanding of the child/young person's specific emotional and cognitive developmental stage; interpretation of the findings requires knowledge of normal (and abnormal) motor and musculoskeletal growth and development. We specifically describe the different approach, unique skills and knowledge required by all clinicians who assess children and adolescents with MSK complaints; children and adolescents are not 'just little adults'. We emphasize the importance of clinical competence in ensuring that patients with juvenile idiopathic arthritis are diagnosed early and referral to specialist centres is not delayed with consequential suboptimal management and outcome. There is evidence that physician clinical skills in MSK assessment are inadequate, probably as a result of systemic deficiencies in the education process. Current and proposed solutions are discussed.
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Affiliation(s)
- Helen E Foster
- Musculoskeletal Research Group, Medical School, University of Newcastle, Framlington Place, Catherine Cookson Building, NE2 4HH Newcastle, UK.
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39
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Shavit I, Eidelman M, Galbraith R. Sonography of the hip-joint by the emergency physician: its role in the evaluation of children presenting with acute limp. Pediatr Emerg Care 2006; 22:570-3. [PMID: 16912625 DOI: 10.1097/01.pec.0000230705.51151.40] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe a new imaging bedside test called Sonography of the Hip-joint by the Emergency Physician (SHEP) and to examine if its use as a triage tool for the presence of fluid in the hip joint can guide the emergency physician to the right diagnosis. METHODS Case series of 5 children presented to the ED with an acute onset of limp. In addition to a careful clinical history and physical examination, each child received SHEP. RESULTS Follow-up confirmed that the presumptive diagnosis made in the ED was correct. The SHEP tests were found helpful in diagnosing transient synovitis (3 cases), septic arthritis (1 case), and osteomyelitis of the femur (1 case). CONCLUSIONS The SHEP tests provided additional information that narrowed the differential diagnosis, and minimized unnecessary blood tests and diagnostic imaging studies.
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Affiliation(s)
- Itai Shavit
- Pediatric Emergency Department, Rambam Medical Center, Haifa, Israel.
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40
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Abstract
A wide range of conditions comes under the umbrella of paediatric rheumatology. These problems are common in childhood and cover a wide variety of presentations and outcomes. Many conditions are benign and self-limiting, others run a chronic relapsing and remitting course; some are fatal. Broadly, rheumatological problems can be subdivided into inflammatory, mechanical, and behaviourally or psychologically driven aetiologies, although these are not mutually exclusive. The majority of patients with rheumatological conditions will present with symptoms that are easily localized to the musculoskeletal system. Sometimes, however, a child with a rheumatological condition may present less specifically: for example with fatigue, deterioration in school performance or growth retardation. In this case a rheumatological aetiology may be overlooked unless it is specifically suspected and a careful assessment for musculoskeletal symptoms and signs is undertaken. In order to arrive at the correct diagnosis and plan appropriate further management, it is therefore important for the clinician both to have an effective system to ensure that musculoskeletal symptoms are appropriately determined and assessed, and to be aware of the wide range of conditions, which can cause such symptoms in childhood and adolescence. The keys to this lie in acquiring the clinical skills necessary to accurately assess such patients and awareness of the changing differential diagnosis with the age of the child. In this chapter, we aim to address these issues, initially by discussing the prevalence of musculoskeletal symptoms in children and adolescents and the various conditions which cause them, and subsequently by looking at common presentations of rheumatic disease in childhood and suggesting an approach to diagnosis in each case.
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Affiliation(s)
- Karen Davies
- Paediatric Rheumatology Department, New Cross Hospital, Wolverhampton, WV10 0QP, UK.
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41
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Abstract
A limp suggests an underlying pathology causing the abnormal gait pattern. There is a long list of possible causes. The challenge for the physician is to identify the cause and act accordingly. The purpose of this article is to instruct on the assessment of a child with a limp.
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Affiliation(s)
- Paul Gibbons
- Department of Orthopaedic Surgery, The Children’s Hospital at Westmead, Sydney, Australia,
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43
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Affiliation(s)
- L P Ferguson
- Department of Accident and Emergency Medicine, Royal Hospital for Sick Children, Edinburgh EH9 1LF
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44
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45
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Abstract
The current literature offers only sparse reports of the use of hip arthroscopy in the pediatric patient injured during athletics. In contrast, the role of this technique in the diagnosis and treatment of multiple childhood hip conditions including pyarthrosis, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis, coxa vara, juvenile chronic arthritis, chondrolysis, and avascular necrosis is well described. The application of this relatively uncommon technique to the young athlete has only recently become more attractive. The ability to examine and treat traumatic intra-articular pathology with minimal morbidity and prompt recovery is mandated by the young age of these patients and their demanding activity levels. Hip arthroscopists are now beginning to correlate preoperative physical exam findings and history with diagnosis and expectations for outcome. As our combined experience with this technique grows, the specific indications for its use in the young athlete become increasingly better defined. In pediatric and adolescent patients, the new onset of hip pain should warrant a high level of suspicion for the more common causes of pain such as infection, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis, or developmental dysplasia. When these have been evaluated, further differential diagnosis should include labral tears, loose bodies, synovitis, and chondral lesions. As this review begins to elucidate, these conditions are amenable to arthroscopic evaluation and treatment. At this time, the presence of reproducible mechanical symptoms after a twisting or axial loading injury during athletics should prompt the orthopaedic surgeon to consider arthroscopic examination of the hip if conservative therapy fails. Satisfying and reproducible results have been achieved when using hip arthroscopy within these parameters.
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Affiliation(s)
- K R Berend
- Division of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA.
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46
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Griffiths PV, Demellweek C, Fay N, Robinson PH, Davidson DC. Wechsler subscale IQ and subtest profile in early treated phenylketonuria. Arch Dis Child 2000; 82:209-15. [PMID: 10685922 PMCID: PMC1718264 DOI: 10.1136/adc.82.3.209] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM Mildly depressed IQ is common in treated phenylketonuria. This study explored whether a particular intellectual ability profile typifies early and continuously treated phenylketonuria and whether component skills comprising the IQ relate to socioeconomic and treatment factors. METHODS IQ scores were collected retrospectively from variants of the "Wechsler intelligence scale for children" performed at age 8 on 57 children with early treated, classic phenylketonuria. The mental ability pattern underlying IQ was investigated by analysing subscale and subtest scores and dietary factors, such as historical phenylalanine blood concentrations. RESULTS The children's mean full scale IQ of 91.11 was significantly below the healthy population norm. There was a significant discrepancy between their mean verbal IQ (94.65) and mean performance IQ (89.42), suggestive of a spatial deficit, but the data did not support a biochemical or sociological explanation. Individual Wechsler subtests had no distinctive pattern. Phenylalanine control at age 2 was predictive of overall IQ. At this age, children with annual median phenylalanine < 360 micromol/litre (recommended UK upper limit) had a mean IQ 10 points higher than those above. CONCLUSIONS Early and continuous treatment of phenylketonuria does not necessarily lead to normalisation of overall IQ. Verbal intelligence in the primary school years appears to normalise if blood phenylalanine is maintained below 360 micromol/litre in infancy, but spatial intelligence may remain poor. However, the discrepancy in skill development is not the result of social status or treatment variables. Perhaps weak spatial intelligence is an ancillary effect of a protective rearing style occasioned by the dietary treatment regimen.
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Affiliation(s)
- P V Griffiths
- Department of Psychology, University of Stirling and Royal Hospital for Sick Children, Glasgow G3 8SJ, UK.
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