Pediatric emergency medicine trisk 0910 0910

be measured for asymmetry. The neurologic examination should include
inspection of the spine for lumbosacral hair or dimple (indicating possible spinal
dysraphism), and testing of strength, sensation, and reflexes. The abdomen and
external genitalia should be examined for tenderness or masses and the skin for
rashes. A rectal examination may be indicated if sacral pathology is suspected.
Finally, wear patterns on the child’s shoes may provide clues to the nature and
duration of the limp.

Laboratory and Imaging
Plain radiographs remain a mainstay of the workup of a limping child. They
provide an excellent means of screening for fracture, effusion, lytic lesions,
periosteal reaction, and avascular necrosis. In a child with an obvious focus of
pain, the radiographs may be obtained with views specific to that area, noting that
children with knee pain may have hip pathology. The need for comparative views
(of the contralateral normal extremity) depends on the experience of the physician
interpreting the films. Some radiographic findings can be subtle, and comparison
with the opposite side may be helpful. Although the goal is to focus imaging on
areas of greatest concern, in a young child or a child lacking obvious focus for the
limp, anteroposterior and lateral tibia/fibula radiographs of both extremities
should be ordered. If tibia/fibula films are negative, imaging of the pelvis, femur,
and ankle/foot may be considered. In children in whom hip pathology is
suspected, anteroposterior and frog-leg lateral views of the pelvis are required.
The frog-leg lateral view, obtained with the hips abducted and externally rotated,
allows excellent visualization of the femoral heads. These radiographs should
always include both hips to enable comparison of the femoral heads and width of
the joint spaces. Radiographs of the spine are necessary if the child has
neurologic signs or symptoms.
In children whose limp is associated with fever or systemic illness, laboratory
studies, including a complete blood cell count, C-reactive protein (CRP) level,
and an erythrocyte sedimentation rate (ESR), are indicated. These studies serve as
screens for infection, inflammation, malignancy, and hemoglobinopathy.

Significant overlap may exist in the clinical and laboratory presentations of
infectious and inflammatory arthritis. There is currently no single noninvasive
test that distinguishes hip septic arthritis from transient synovitis or Lyme disease
in the acute setting. Algorithms based on variables such as the inability to bear
weight, fever, white blood cell count, CRP, and ESR have been created to aid
clinicians in their clinical decision making. Unfortunately, these algorithms have
not been shown to be generalizable across all populations. In addition, there is an
increasing recognition of Kingella kingae as an etiology for joint infections in