Child health for AMC MCQ

A 3 year old refuses to weight bear on one leg, holds the hip flexed and externally rotated, and cries when it is moved. He has a fever of 38.8C and looks unwell. His inflammatory markers are markedly raised. He will not let anyone touch the hip. He had been well until two days ago. What is the most likely diagnosis?

1. Transient synovitis An irritable hip in a well child after a viral illness, a diagnosis of exclusion. A hot, held, immobile hip with fever and refusal to weight bear makes exclusion matter.
2. Childhood hip/leg disorders (including Perthes' disease, slipped upper femoral epiphyses, developmental dysplasia of the hip) Hip or leg problems varying by age. A hot, held, immobile hip with fever and refusal to weight bear fits.
3. Slipped upper femoral epiphysis Hip or knee pain with external rotation in an adolescent. A hot, held, immobile hip with fever and refusal to weight bear raises it.
4. Septic arthritis correct Correct. A hot, held, immobile hip with fever, refusal to weight bear and raised inflammatory markers is septic arthritis.
5. Non-accidental injury An injury with an inconsistent history. A hot, held, immobile hip with fever and refusal to weight bear makes it essential to consider.

The point: Septic arthritis is the emergency in any limping child that must not be missed. Fever, refusal to weight bear, a joint held still and immobile, and raised inflammatory markers point to it, and the Kocher criteria help stratify risk. The joint is aspirated and washed out urgently with antibiotics, because a septic joint is destroyed within days. It is always excluded before an irritable hip is labelled transient synovitis, which is the benign diagnosis of exclusion in a well, afebrile child.

Source: Royal Children's Hospital Melbourne — Clinical practice guideline: the limping child Royal Children's Hospital Melbourne · tier 2, specialty society or college

A 3 year old refuses to weight bear on one leg, holds the hip flexed and externally rotated, and cries when it is moved. He has a fever of 38.8C and looks unwell. His inflammatory markers are markedly raised. He will not let anyone touch the hip. He had been well until two days ago. What is the most appropriate initial investigation?

1. Joint aspiration where septic arthritis is suspected Confirms and treats a septic joint. A hot, held, immobile hip with fever and refusal to weight bear indicates it.
2. Assessment matched to the child's age The age narrows the likely diagnosis. A hot, held, immobile hip with fever and refusal to weight bear makes it central.
3. Hip and pelvis radiograph For Perthes disease and a slipped epiphysis. A hot, held, immobile hip with fever and refusal to weight bear makes it key.
4. Examination of the hip in a child with knee pain Knee pain can be referred from the hip. A hot, held, immobile hip with fever and refusal to weight bear makes it a rule.
5. Exclusion of septic arthritis correct Correct. The fever, inability to weight bear and raised markers are exactly the features that identify it and mandate action.

The point: Septic arthritis is the emergency in any limping child that must not be missed. Fever, refusal to weight bear, a joint held still and immobile, and raised inflammatory markers point to it, and the Kocher criteria help stratify risk. The joint is aspirated and washed out urgently with antibiotics, because a septic joint is destroyed within days. It is always excluded before an irritable hip is labelled transient synovitis, which is the benign diagnosis of exclusion in a well, afebrile child.

Source: Royal Children's Hospital Melbourne — Clinical practice guideline: the limping child Royal Children's Hospital Melbourne · tier 2, specialty society or college

A 3 year old refuses to weight bear on one leg, holds the hip flexed and externally rotated, and cries when it is moved. He has a fever of 38.8C and looks unwell. His inflammatory markers are markedly raised. He will not let anyone touch the hip. He had been well until two days ago. What is the most appropriate next step in management?

1. Harness or referral for developmental dysplasia A Pavlik harness or specialist management. A hot, held, immobile hip with fever and refusal to weight bear makes it standard.
2. Urgent management of septic arthritis correct Correct. It needs urgent joint washout and antibiotics before the joint is destroyed.
3. Examine the hip in a child with knee pain Because knee pain is often referred. A hot, held, immobile hip with fever and refusal to weight bear makes it a rule.
4. Orthopaedic management of Perthes disease Observation, physiotherapy or surgery depending on severity. A hot, held, immobile hip with fever and refusal to weight bear makes it targeted.
5. Orthopaedic referral for structural hip disease For Perthes, a slipped epiphysis and dysplasia. A hot, held, immobile hip with fever and refusal to weight bear makes it comprehensive.

The point: Septic arthritis is the emergency in any limping child that must not be missed. Fever, refusal to weight bear, a joint held still and immobile, and raised inflammatory markers point to it, and the Kocher criteria help stratify risk. The joint is aspirated and washed out urgently with antibiotics, because a septic joint is destroyed within days. It is always excluded before an irritable hip is labelled transient synovitis, which is the benign diagnosis of exclusion in a well, afebrile child.

Source: Royal Children's Hospital Melbourne — Clinical practice guideline: the limping child Royal Children's Hospital Melbourne · tier 2, specialty society or college