Imaging

Appropriate use criteria of transthoracic echocardiography for suspected pediatric heart disease in outpatient settings have been issued for the first time.

The criteria, a collaboration of nine societies, will appear on the websites of the American College of Cardiology, American Society of Echocardiography, and Society for Cardiovascular Angiography and Interventions.

“Of the various diagnostic modalities, echocardiography remains the most readily available, noninvasive, and highly diagnostic tool for assessing cardiac structure, function and hemodynamics in those with suspected cardiac disease,” said Dr. Robert Campbell of Emory University, Atlanta, and his associates. Of the 113 potential indications for first-time use of outpatient transthoracic echocardiography in children and adolescents that they considered, 53 were considered appropriate, 28 possibly appropriate, and 32 rarely appropriate (J. Am. Coll. Cardiol. 2014 Sept. 30 [doi:10.1016/j.jacc.2014.08.003]). The report addressed conditions such as arrhythmias and palpitations, syncope, murmurs, and systemic disorders.

The group collaborated with an Appropriate Use Criteria (AUC) task force and an independent rating panel to produce the report. The criteria do not address posttest follow-up, inpatient pediatric echocardiography, or the assessment of children with known cardiac abnormalities, the authors said.

The writing group reported no funding sources or conflicts of interest. Three members of the rating panel and one member of the AUC task force reported financial relationships with Siemens Medical Systems or Excellus BCBS.

Appropriate use criteria of transthoracic echocardiography for suspected pediatric heart disease in outpatient settings have been issued for the first time.

The criteria, a collaboration of nine societies, will appear on the websites of the American College of Cardiology, American Society of Echocardiography, and Society for Cardiovascular Angiography and Interventions.

“Of the various diagnostic modalities, echocardiography remains the most readily available, noninvasive, and highly diagnostic tool for assessing cardiac structure, function and hemodynamics in those with suspected cardiac disease,” said Dr. Robert Campbell of Emory University, Atlanta, and his associates. Of the 113 potential indications for first-time use of outpatient transthoracic echocardiography in children and adolescents that they considered, 53 were considered appropriate, 28 possibly appropriate, and 32 rarely appropriate (J. Am. Coll. Cardiol. 2014 Sept. 30 [doi:10.1016/j.jacc.2014.08.003]). The report addressed conditions such as arrhythmias and palpitations, syncope, murmurs, and systemic disorders.

The group collaborated with an Appropriate Use Criteria (AUC) task force and an independent rating panel to produce the report. The criteria do not address posttest follow-up, inpatient pediatric echocardiography, or the assessment of children with known cardiac abnormalities, the authors said.

The writing group reported no funding sources or conflicts of interest. Three members of the rating panel and one member of the AUC task force reported financial relationships with Siemens Medical Systems or Excellus BCBS.

Appropriate use criteria of transthoracic echocardiography for suspected pediatric heart disease in outpatient settings have been issued for the first time.

The criteria, a collaboration of nine societies, will appear on the websites of the American College of Cardiology, American Society of Echocardiography, and Society for Cardiovascular Angiography and Interventions.

“Of the various diagnostic modalities, echocardiography remains the most readily available, noninvasive, and highly diagnostic tool for assessing cardiac structure, function and hemodynamics in those with suspected cardiac disease,” said Dr. Robert Campbell of Emory University, Atlanta, and his associates. Of the 113 potential indications for first-time use of outpatient transthoracic echocardiography in children and adolescents that they considered, 53 were considered appropriate, 28 possibly appropriate, and 32 rarely appropriate (J. Am. Coll. Cardiol. 2014 Sept. 30 [doi:10.1016/j.jacc.2014.08.003]). The report addressed conditions such as arrhythmias and palpitations, syncope, murmurs, and systemic disorders.

The group collaborated with an Appropriate Use Criteria (AUC) task force and an independent rating panel to produce the report. The criteria do not address posttest follow-up, inpatient pediatric echocardiography, or the assessment of children with known cardiac abnormalities, the authors said.

The writing group reported no funding sources or conflicts of interest. Three members of the rating panel and one member of the AUC task force reported financial relationships with Siemens Medical Systems or Excellus BCBS.

On July 17, Jack Campanile, age 16 years, a patient at the Hospital for Sick Children (SickKids) in Toronto, was the first teen to undergo a specialized procedure using magnetic resonance imaging (MRI) and ultrasound technology to destroy a tumor in his leg without piercing the skin. The lesion had caused the teen excruciating pain prior to electing to have this non-invasive procedure.

“With high-intensity focused ultrasound, we are moving from minimally invasive to non-invasive therapy, significantly reducing risk to the patient and fast-tracking recovery,” said interventional radiologist Michael Temple, MD, Associate Professor of Medical Imaging at the University of Toronto, who led the team that performed the surgery.

During the 30-minute procedure, the team used the MRI to pinpoint the exact location of the osteoid osteoma and to help target the ultrasound waves to burn the whole tumor. Using an MRI also afforded the team the opportunity to monitor the temperature induced by the ultrasound to ensure that there was no unexpected increase in heat in surrounding tissue.

Hours after undergoing this procedure Jack was discharged. He initially experienced a few hours of pain, and then he was totally pain-free. Overall, he recovered quickly and smoothly; there also have been no reported complications. That night he had uninterrupted sleep for the first time in months. Most of his normal activities also were resumed 2 days after surgery.

“The osteoid osteoma tumor was chosen as our pilot study because the lesion is easily accessible and while the procedure is sophisticated, it is relatively straightforward. The success of this first case is great news for Jack, and exciting for our team as we look at developing more complex incisionless treatments in the future,” said Dr. Temple.

On July 17, Jack Campanile, age 16 years, a patient at the Hospital for Sick Children (SickKids) in Toronto, was the first teen to undergo a specialized procedure using magnetic resonance imaging (MRI) and ultrasound technology to destroy a tumor in his leg without piercing the skin. The lesion had caused the teen excruciating pain prior to electing to have this non-invasive procedure.

“With high-intensity focused ultrasound, we are moving from minimally invasive to non-invasive therapy, significantly reducing risk to the patient and fast-tracking recovery,” said interventional radiologist Michael Temple, MD, Associate Professor of Medical Imaging at the University of Toronto, who led the team that performed the surgery.

During the 30-minute procedure, the team used the MRI to pinpoint the exact location of the osteoid osteoma and to help target the ultrasound waves to burn the whole tumor. Using an MRI also afforded the team the opportunity to monitor the temperature induced by the ultrasound to ensure that there was no unexpected increase in heat in surrounding tissue.

Hours after undergoing this procedure Jack was discharged. He initially experienced a few hours of pain, and then he was totally pain-free. Overall, he recovered quickly and smoothly; there also have been no reported complications. That night he had uninterrupted sleep for the first time in months. Most of his normal activities also were resumed 2 days after surgery.

“The osteoid osteoma tumor was chosen as our pilot study because the lesion is easily accessible and while the procedure is sophisticated, it is relatively straightforward. The success of this first case is great news for Jack, and exciting for our team as we look at developing more complex incisionless treatments in the future,” said Dr. Temple.

On July 17, Jack Campanile, age 16 years, a patient at the Hospital for Sick Children (SickKids) in Toronto, was the first teen to undergo a specialized procedure using magnetic resonance imaging (MRI) and ultrasound technology to destroy a tumor in his leg without piercing the skin. The lesion had caused the teen excruciating pain prior to electing to have this non-invasive procedure.

“With high-intensity focused ultrasound, we are moving from minimally invasive to non-invasive therapy, significantly reducing risk to the patient and fast-tracking recovery,” said interventional radiologist Michael Temple, MD, Associate Professor of Medical Imaging at the University of Toronto, who led the team that performed the surgery.

During the 30-minute procedure, the team used the MRI to pinpoint the exact location of the osteoid osteoma and to help target the ultrasound waves to burn the whole tumor. Using an MRI also afforded the team the opportunity to monitor the temperature induced by the ultrasound to ensure that there was no unexpected increase in heat in surrounding tissue.

Hours after undergoing this procedure Jack was discharged. He initially experienced a few hours of pain, and then he was totally pain-free. Overall, he recovered quickly and smoothly; there also have been no reported complications. That night he had uninterrupted sleep for the first time in months. Most of his normal activities also were resumed 2 days after surgery.

“The osteoid osteoma tumor was chosen as our pilot study because the lesion is easily accessible and while the procedure is sophisticated, it is relatively straightforward. The success of this first case is great news for Jack, and exciting for our team as we look at developing more complex incisionless treatments in the future,” said Dr. Temple.

Ultrasonography is known to be less sensitive than computed tomography for diagnosing kidney stones. But the initial use of ultrasonography, followed by CT imaging if indicated, results in less cumulative radiation exposure for patients without increasing the risk of adverse clinical outcomes or missed diagnoses, according to findings published online Sept 18 in the New England Journal of Medicine (doi:10.1056/NEJMoa1404446).

The multicenter study, led by Dr. Rebecca Smith-Bindman of the University of California, San Francisco, and colleagues, randomized 2,759 patients presenting in hospital emergency departments with symptoms of nephrolithiasis to receive initial ultrasonography performed by an emergency physician (n = 908); ultrasonography performed by a radiologist (n = 893), or abdominal CT (n = 958), with all further diagnostic and management decisions left up to the physician.

©decade3d/thinkstockphotos.com

High-risk diagnoses with complications within 30 days of initial imaging occurred infrequently across the groups (0.4% for all three, n = 11), with no significant differences seen among the groups (P = .30). Within 6 months, serious adverse advents occurred in 12.4% of patients assigned initial ED ultrasonography, 10.8% in those assigned radiology ultrasonography, and 11.2% of those assigned to CT (P = .50) with no significant differences in pain scores, return emergency department visits, or hospitalizations. Cumulative radiation exposure at 6 months, however, was significantly higher for the CT arm than for the two ultrasonography arms (P < .001).

Dr. Smith-Bindman and colleagues emphasized in their analysis that their results do not imply that patients with suspected nephrolithiasis should undergo only ultrasound imaging, “but rather that ultrasonography should be used as the initial diagnostic imaging test, with further imaging studies performed at the discretion of the physician on the basis of clinical judgment.” Patients with nephrolithiasis often undergo repeat imaging over time, the researchers observed, and “replacing initial CT with ultrasonography for this often-recurring disease reduced overall radiation exposure.”

Dr. Smith-Bindman and colleagues noted as a limitation of their study the fact that treatment assignment could not be blinded. The study was funded by the Agency for Healthcare Research and Quality; none of its authors declared financial conflicts of interest.

Ultrasonography is known to be less sensitive than computed tomography for diagnosing kidney stones. But the initial use of ultrasonography, followed by CT imaging if indicated, results in less cumulative radiation exposure for patients without increasing the risk of adverse clinical outcomes or missed diagnoses, according to findings published online Sept 18 in the New England Journal of Medicine (doi:10.1056/NEJMoa1404446).

The multicenter study, led by Dr. Rebecca Smith-Bindman of the University of California, San Francisco, and colleagues, randomized 2,759 patients presenting in hospital emergency departments with symptoms of nephrolithiasis to receive initial ultrasonography performed by an emergency physician (n = 908); ultrasonography performed by a radiologist (n = 893), or abdominal CT (n = 958), with all further diagnostic and management decisions left up to the physician.

©decade3d/thinkstockphotos.com

High-risk diagnoses with complications within 30 days of initial imaging occurred infrequently across the groups (0.4% for all three, n = 11), with no significant differences seen among the groups (P = .30). Within 6 months, serious adverse advents occurred in 12.4% of patients assigned initial ED ultrasonography, 10.8% in those assigned radiology ultrasonography, and 11.2% of those assigned to CT (P = .50) with no significant differences in pain scores, return emergency department visits, or hospitalizations. Cumulative radiation exposure at 6 months, however, was significantly higher for the CT arm than for the two ultrasonography arms (P < .001).

Dr. Smith-Bindman and colleagues emphasized in their analysis that their results do not imply that patients with suspected nephrolithiasis should undergo only ultrasound imaging, “but rather that ultrasonography should be used as the initial diagnostic imaging test, with further imaging studies performed at the discretion of the physician on the basis of clinical judgment.” Patients with nephrolithiasis often undergo repeat imaging over time, the researchers observed, and “replacing initial CT with ultrasonography for this often-recurring disease reduced overall radiation exposure.”

Dr. Smith-Bindman and colleagues noted as a limitation of their study the fact that treatment assignment could not be blinded. The study was funded by the Agency for Healthcare Research and Quality; none of its authors declared financial conflicts of interest.

Ultrasonography is known to be less sensitive than computed tomography for diagnosing kidney stones. But the initial use of ultrasonography, followed by CT imaging if indicated, results in less cumulative radiation exposure for patients without increasing the risk of adverse clinical outcomes or missed diagnoses, according to findings published online Sept 18 in the New England Journal of Medicine (doi:10.1056/NEJMoa1404446).

The multicenter study, led by Dr. Rebecca Smith-Bindman of the University of California, San Francisco, and colleagues, randomized 2,759 patients presenting in hospital emergency departments with symptoms of nephrolithiasis to receive initial ultrasonography performed by an emergency physician (n = 908); ultrasonography performed by a radiologist (n = 893), or abdominal CT (n = 958), with all further diagnostic and management decisions left up to the physician.

©decade3d/thinkstockphotos.com

High-risk diagnoses with complications within 30 days of initial imaging occurred infrequently across the groups (0.4% for all three, n = 11), with no significant differences seen among the groups (P = .30). Within 6 months, serious adverse advents occurred in 12.4% of patients assigned initial ED ultrasonography, 10.8% in those assigned radiology ultrasonography, and 11.2% of those assigned to CT (P = .50) with no significant differences in pain scores, return emergency department visits, or hospitalizations. Cumulative radiation exposure at 6 months, however, was significantly higher for the CT arm than for the two ultrasonography arms (P < .001).

Dr. Smith-Bindman and colleagues emphasized in their analysis that their results do not imply that patients with suspected nephrolithiasis should undergo only ultrasound imaging, “but rather that ultrasonography should be used as the initial diagnostic imaging test, with further imaging studies performed at the discretion of the physician on the basis of clinical judgment.” Patients with nephrolithiasis often undergo repeat imaging over time, the researchers observed, and “replacing initial CT with ultrasonography for this often-recurring disease reduced overall radiation exposure.”

Dr. Smith-Bindman and colleagues noted as a limitation of their study the fact that treatment assignment could not be blinded. The study was funded by the Agency for Healthcare Research and Quality; none of its authors declared financial conflicts of interest.

Case

A 2-year-old girl was carried into the ED after falling off her bed earlier in the evening. The parents did not see the child fall, but heard her crying in her room. On physical examination, the patient was in a lot of pain, would not move her left arm, and had a left elbow effusion. The radial pulse was strong, and she was able to move all of her fingers but would not move her elbow. A lateral X-ray taken of the left elbow is shown below (Figure 1).  

Supracondylar Fractures

Supracondylar fractures are the most common pediatric elbow injury and disposition can range from outpatient follow-up to urgent surgical intervention. The average age of presentation is between 3 to 10 years, and the injury typically results from a fall on an outstretched hand (FOOSH) with hyperextension of the elbow. Supracondylar fractures may also occur after a direct blow to the elbow or hyperflexion.¹

The supracondylar area in children,  the distal portion of the humerus, is thin and weak. The force transmitted to this region by a direct blow or FOOSH injury can fracture the humerus. The brachial artery runs along the anterior humerus and can easily sustain injury. Median, ulnar, or radial nerve injuries are also common and can result in permanent disability.² Immediate neurovascular examination is mandatory, and diminished or absent pulses, poor perfusion, and pallor are signs of ischemia. Examination should include assessment of the radial pulse and the sensory and motor function of the median, radial, and ulnar nerves.  To test the median nerve (via the anterior interosseous branch), ask the patient make an “OK” sign with his or her fingers; to test the radial nerve, instruct the child to make a “thumb’s up” sign; and to test the ulnar nerve, have  the child hold his or her fingers spread-out against resistance. In addition, sensation of the palmer and dorsal surfaces and in between the fingers should be confirmed.

Plain radiographs, including anteroposterior (AP), oblique, and true lateral views, should be obtained. Interpretation of pediatric elbow films can be difficult, and the stages of ossification must be considered. The helpful acronym for remembering the order of bone ossification is CRITOE (capitellum, radial head, internal [medial] epicondyle, trochlea, olecranon, and external [lateral] epicondyle) (Table 1).

If the anterior humeral line—a line drawn through the anterior cortex of the humerus—fails to intersect the capitellum in its middle third, fracture of the distal humerus is present (Figure 2). The radial head should be aligned with the capitellum. Close inspection for a posterior fat pad, or “sail sign” is imperative as it indicates hemorrhage, joint effusion, or occult fracture. The presence of an anterior fat pad can be a normal variant; however, if the pad is wide and creates a “sail sign” then fracture must be assumed.¹

Fracture Types

Pediatric supracondylar frac­tures are classified into three types (Table 2). Type I fractures may be subtle on X-ray, evident only by a posterior fat pad or only seen on an oblique view. These nondisplaced fractures may be splinted with a long-arm splint. Type II fractures are angulated yet the posterior cortex remains intact. Typically the anterior humeral line is displaced, anteriorly intersecting the anterior third of the capitellum or missing it entirely. These cases require urgent orthopedic consultation for either closed reduction with splinting or open reduction with percutaneous pin placement. 

Type III supracondylar fractures are completely displaced with a fracture through the anterior and posterior cortex. Since a high-risk of injury to the upper extremity vessels and nerves is associated with these very unstable fractures, routine neurovascular checks (while awaiting operative repair) are required. Supracondylar fractures are often associated with forearm or distal radius fractures; therefore, forearm radiographs should also be obtained.³

Diskitis

Diskitis is defined as inflammation or infection of the intervertebral disk. Though etiology is debated, Staphylococcus aureus is confirmed in up to 60% of cases.⁴ This infection has been described by some as being on the spectrum of vertebral osteomyelitis. Though rare, delayed diagnosis of diskitis can result in significant morbidity. Incidence peaks in early childhood between ages 3 to 5 years but may present at any age with back pain, limp, or refusal to walk. Most commonly, the lower lumbar disks are affected. Examination may reveal decreased muscle strength or reflexes, refusal to bend forward, hip pain, or tenderness of the spine. Although white blood cell (WBC) count is typically normal, more than 90% of patients with diskitis have an elevated erythrocyte sedimentation rate. X-rays usually appear normal until 2 to 3 weeks after symptoms begin, at which time narrowing of the joint space can be seen. Magnetic resonance imaging is required for diagnosis (Figure 3), and orthopedics should be consulted for possible aspiration for culture. Empiric antibiotic therapy includes an antistaphylococcal agent (eg, nafcillin/oxacillin, clindamycin, vancomycin) and a third-generation cephalosporin (eg, cefotaxime, ceftriaxone).⁵ 

 

Tumors

Back or bone pain can be a subtle early presenting symptom of cancer or tumors of the bone or bone marrow. The most common malignant bone tumors in children are osteosarcoma and Ewing sarcoma.⁶ Both types may present with intermittent pain or pain that worsens over weeks to months. Fever also may be present, which can lead to a misdiagnosis of osteomyelitis. Acute leukemia presenting with bone/back pain and a history of nighttime pain combined with low WBC, platelets, or hemoglobin is highly suggestive of this diagnosis. Physical examination should identify lymphadenopathy, hepatomegaly, or splenomegaly. The child with back pain in whom there is concern for mass should have laboratory evaluation, including a complete blood cell count, erythrocyte sedimentation rate, C-reactive protein, alkaline phosphatase, and lactate dehydrogenase. Plain radiographs may demonstrate “onion skinning” or the “sunburst” pattern, indicating periosteal reaction, and is highly suggestive of malignancy (Figure 4). Benign tumors of childhood may present initially as back pain as well. Osteoid osteoma is a common benign tumor which presents with pain that becomes worse at night and may respond to nonsteroidal anti-inflammatory drugs.⁷

Spondylolysis

Spondylolysis, also known as “pars defect,” is a unilateral or bilateral fracture of the vertebral pars interarticularis—typically of the lower lumbar vertebrae, most commonly L5. Spondylolysis occurs after repetitive microtrauma. Spondylolisthesis is the slipping of one vertebra over another one. These diagnoses should be suspected in adolescents, especially athletic patients presenting with acute low-back pain. The pain associated with these conditions often extends into the posterior thigh and is relieved by rest. Examination findings include lumbosacral tenderness, particularly with extension or lateral bending. Radiographs should include AP, lateral, and oblique views and may demonstrate fracture, displacement of the vertebrae, or the classic “Scotty dog” sign with the crack (collar) on the neck of dog (Figure 5). Treatment consists of immobilization, activity restriction, and physiotherapy. Referral to orthopedics is advised for follow-up X-rays and monitoring. If conservative treatment fails to relieve pain or if slippage progressively worsens, spinal fusion is necessary.⁸

Pediatric Cervical Spine Clearance

Thankfully, cervical spine injuries are rare, occurring in approximately 1% of children after blunt trauma.⁹ Left unrecognized, however, these injuries may result in permanent neurological disability. Children younger than 8 years of age are more likely to injure the upper cervical spine (C1 to C3) than older children and adults. This is because children have relatively larger heads than bodies and weaker cervical muscles and ligaments, making the upper cervical spine more mobile. The Emergency X-Radiography Utilization Study (NEXUS) criteria have been validated in adults; however, criteria for clearing the pediatric cervical spine are poorly studied. Because of limited data, there are few evidence-based guidelines for the clearance of the pediatric cervical spine. A study in 2001 found that the NEXUS guidelines where helpful in reducing imaging in 20% of children, but due to the low numbers of infants in this study, caution is advised when applying the NEXUS criteria to children under 2 years of age.⁹

Midline posterior cervical tenderness, evidence of intoxication, altered level of consciousness, abnormal neurological examination, or distracting painful injury are indications for AP, lateral, and odontoid X-rays. After blunt trauma, if a patient is receiving an urgent computed tomography (CT) scan for another area of injury such as the head or abdomen, he or she should also receive a CT scan of the cervical spine. Additionally, those with significant mechanism of injury, focal neurological findings, significant altered level of consciousness, and/or significant posterior midline neck pain should also have a cervical spine CT scan.¹⁰ Neurosurgical service consultation is necessary in cases of abnormal cervical spine radiographs (plain films and/or CT scan), abnormal neurological examination (focal neurological findings or altered level of consciousness), or continued significant posterior midline cervical spine pain/tenderness, history, and resolution of focal neurological findings despite normal radiographs. Clearance of the cervical spine is possible if the patient has no posterior midline cervical tenderness; has a normal neurological examination; is not intoxicated; has no altered level of consciousness; has no painful distracting injury and normal radiographs; and has resolution of significant midline tenderness and/or altered level of consciousness when either one of these was the criteria that necessitated the radiographs (Table 3).¹¹

Nonaccidental Trauma: Abuse

Orthopedic injury due to nonaccidental trauma (NAT) can be difficult to distinguish from normal childhood injuries. Identification of high-risk presentations is key in diagnosing these injuries and hopefully preventing further abuse. Femur fractures in children younger than age 1 year have a high likelihood of being nonaccidental, with between 60% to 80% of femoral shaft fractures resulting from abuse. No particular pattern of fracture is pathognomonic for NAT. The American Academy of Orthopaedic Surgeons recommends that children younger than age 36 months with a diaphyseal femur fracture be evaluated for child abuse.¹²

 

Spiral fractures and transverse fractures of long bones also raise suspicion for NAT. Injury to the metaphysis of long bones, especially in nonambulatory children, is considered highly suggestive of child abuse. The classic metaphyseal lesion, called a “corner” or “bucket-handle” fracture, occurs when the extremity (usually the forearm) is pulled or twisted forcibly, or the child is shaken. X-ray will demonstrate a disruption of the metaphysis with lucency. As the developing ribs are flexible and difficult to break with minor injuries, a child with a rib fracture and no history of severe trauma, such as a motor vehicle crash or fall from a significant height, has a high likelihood of being a victim of child abuse. Skull fractures caused from accidental injury and abuse may have similar presentations. The history and mechanism are important to correlate with physical examination findings for potential inconsistencies.¹³

Case Conclusion

The child in this case sustained a type II supracondylar fracture. Orthopedic surgery was consulted, and the patient was taken to the operating room for closed reduction and percutaneous pinning. She was placed in a cast, and pins were removed at follow-up 4 weeks later. No residual pain or deficits remained, and she regained full function of her arm.

Dr Hewett is a pediatric emergency medicine fellow, College of Medicine, Medical University of South Carolina, Charleston.
Dr Titus is vice chair, pediatric fellowships, and fellowship director, pediatric emergency medicine; and an associate professor of pediatrics, Medical University of South Carolina, Charleston.

Case

A 2-year-old girl was carried into the ED after falling off her bed earlier in the evening. The parents did not see the child fall, but heard her crying in her room. On physical examination, the patient was in a lot of pain, would not move her left arm, and had a left elbow effusion. The radial pulse was strong, and she was able to move all of her fingers but would not move her elbow. A lateral X-ray taken of the left elbow is shown below (Figure 1).  

Supracondylar Fractures

Supracondylar fractures are the most common pediatric elbow injury and disposition can range from outpatient follow-up to urgent surgical intervention. The average age of presentation is between 3 to 10 years, and the injury typically results from a fall on an outstretched hand (FOOSH) with hyperextension of the elbow. Supracondylar fractures may also occur after a direct blow to the elbow or hyperflexion.¹

The supracondylar area in children,  the distal portion of the humerus, is thin and weak. The force transmitted to this region by a direct blow or FOOSH injury can fracture the humerus. The brachial artery runs along the anterior humerus and can easily sustain injury. Median, ulnar, or radial nerve injuries are also common and can result in permanent disability.² Immediate neurovascular examination is mandatory, and diminished or absent pulses, poor perfusion, and pallor are signs of ischemia. Examination should include assessment of the radial pulse and the sensory and motor function of the median, radial, and ulnar nerves.  To test the median nerve (via the anterior interosseous branch), ask the patient make an “OK” sign with his or her fingers; to test the radial nerve, instruct the child to make a “thumb’s up” sign; and to test the ulnar nerve, have  the child hold his or her fingers spread-out against resistance. In addition, sensation of the palmer and dorsal surfaces and in between the fingers should be confirmed.

Plain radiographs, including anteroposterior (AP), oblique, and true lateral views, should be obtained. Interpretation of pediatric elbow films can be difficult, and the stages of ossification must be considered. The helpful acronym for remembering the order of bone ossification is CRITOE (capitellum, radial head, internal [medial] epicondyle, trochlea, olecranon, and external [lateral] epicondyle) (Table 1).

If the anterior humeral line—a line drawn through the anterior cortex of the humerus—fails to intersect the capitellum in its middle third, fracture of the distal humerus is present (Figure 2). The radial head should be aligned with the capitellum. Close inspection for a posterior fat pad, or “sail sign” is imperative as it indicates hemorrhage, joint effusion, or occult fracture. The presence of an anterior fat pad can be a normal variant; however, if the pad is wide and creates a “sail sign” then fracture must be assumed.¹

Fracture Types

Pediatric supracondylar frac­tures are classified into three types (Table 2). Type I fractures may be subtle on X-ray, evident only by a posterior fat pad or only seen on an oblique view. These nondisplaced fractures may be splinted with a long-arm splint. Type II fractures are angulated yet the posterior cortex remains intact. Typically the anterior humeral line is displaced, anteriorly intersecting the anterior third of the capitellum or missing it entirely. These cases require urgent orthopedic consultation for either closed reduction with splinting or open reduction with percutaneous pin placement. 

Type III supracondylar fractures are completely displaced with a fracture through the anterior and posterior cortex. Since a high-risk of injury to the upper extremity vessels and nerves is associated with these very unstable fractures, routine neurovascular checks (while awaiting operative repair) are required. Supracondylar fractures are often associated with forearm or distal radius fractures; therefore, forearm radiographs should also be obtained.³

Diskitis

Diskitis is defined as inflammation or infection of the intervertebral disk. Though etiology is debated, Staphylococcus aureus is confirmed in up to 60% of cases.⁴ This infection has been described by some as being on the spectrum of vertebral osteomyelitis. Though rare, delayed diagnosis of diskitis can result in significant morbidity. Incidence peaks in early childhood between ages 3 to 5 years but may present at any age with back pain, limp, or refusal to walk. Most commonly, the lower lumbar disks are affected. Examination may reveal decreased muscle strength or reflexes, refusal to bend forward, hip pain, or tenderness of the spine. Although white blood cell (WBC) count is typically normal, more than 90% of patients with diskitis have an elevated erythrocyte sedimentation rate. X-rays usually appear normal until 2 to 3 weeks after symptoms begin, at which time narrowing of the joint space can be seen. Magnetic resonance imaging is required for diagnosis (Figure 3), and orthopedics should be consulted for possible aspiration for culture. Empiric antibiotic therapy includes an antistaphylococcal agent (eg, nafcillin/oxacillin, clindamycin, vancomycin) and a third-generation cephalosporin (eg, cefotaxime, ceftriaxone).⁵ 

 

Tumors

Back or bone pain can be a subtle early presenting symptom of cancer or tumors of the bone or bone marrow. The most common malignant bone tumors in children are osteosarcoma and Ewing sarcoma.⁶ Both types may present with intermittent pain or pain that worsens over weeks to months. Fever also may be present, which can lead to a misdiagnosis of osteomyelitis. Acute leukemia presenting with bone/back pain and a history of nighttime pain combined with low WBC, platelets, or hemoglobin is highly suggestive of this diagnosis. Physical examination should identify lymphadenopathy, hepatomegaly, or splenomegaly. The child with back pain in whom there is concern for mass should have laboratory evaluation, including a complete blood cell count, erythrocyte sedimentation rate, C-reactive protein, alkaline phosphatase, and lactate dehydrogenase. Plain radiographs may demonstrate “onion skinning” or the “sunburst” pattern, indicating periosteal reaction, and is highly suggestive of malignancy (Figure 4). Benign tumors of childhood may present initially as back pain as well. Osteoid osteoma is a common benign tumor which presents with pain that becomes worse at night and may respond to nonsteroidal anti-inflammatory drugs.⁷

Spondylolysis

Spondylolysis, also known as “pars defect,” is a unilateral or bilateral fracture of the vertebral pars interarticularis—typically of the lower lumbar vertebrae, most commonly L5. Spondylolysis occurs after repetitive microtrauma. Spondylolisthesis is the slipping of one vertebra over another one. These diagnoses should be suspected in adolescents, especially athletic patients presenting with acute low-back pain. The pain associated with these conditions often extends into the posterior thigh and is relieved by rest. Examination findings include lumbosacral tenderness, particularly with extension or lateral bending. Radiographs should include AP, lateral, and oblique views and may demonstrate fracture, displacement of the vertebrae, or the classic “Scotty dog” sign with the crack (collar) on the neck of dog (Figure 5). Treatment consists of immobilization, activity restriction, and physiotherapy. Referral to orthopedics is advised for follow-up X-rays and monitoring. If conservative treatment fails to relieve pain or if slippage progressively worsens, spinal fusion is necessary.⁸

Pediatric Cervical Spine Clearance

Thankfully, cervical spine injuries are rare, occurring in approximately 1% of children after blunt trauma.⁹ Left unrecognized, however, these injuries may result in permanent neurological disability. Children younger than 8 years of age are more likely to injure the upper cervical spine (C1 to C3) than older children and adults. This is because children have relatively larger heads than bodies and weaker cervical muscles and ligaments, making the upper cervical spine more mobile. The Emergency X-Radiography Utilization Study (NEXUS) criteria have been validated in adults; however, criteria for clearing the pediatric cervical spine are poorly studied. Because of limited data, there are few evidence-based guidelines for the clearance of the pediatric cervical spine. A study in 2001 found that the NEXUS guidelines where helpful in reducing imaging in 20% of children, but due to the low numbers of infants in this study, caution is advised when applying the NEXUS criteria to children under 2 years of age.⁹

Midline posterior cervical tenderness, evidence of intoxication, altered level of consciousness, abnormal neurological examination, or distracting painful injury are indications for AP, lateral, and odontoid X-rays. After blunt trauma, if a patient is receiving an urgent computed tomography (CT) scan for another area of injury such as the head or abdomen, he or she should also receive a CT scan of the cervical spine. Additionally, those with significant mechanism of injury, focal neurological findings, significant altered level of consciousness, and/or significant posterior midline neck pain should also have a cervical spine CT scan.¹⁰ Neurosurgical service consultation is necessary in cases of abnormal cervical spine radiographs (plain films and/or CT scan), abnormal neurological examination (focal neurological findings or altered level of consciousness), or continued significant posterior midline cervical spine pain/tenderness, history, and resolution of focal neurological findings despite normal radiographs. Clearance of the cervical spine is possible if the patient has no posterior midline cervical tenderness; has a normal neurological examination; is not intoxicated; has no altered level of consciousness; has no painful distracting injury and normal radiographs; and has resolution of significant midline tenderness and/or altered level of consciousness when either one of these was the criteria that necessitated the radiographs (Table 3).¹¹

Nonaccidental Trauma: Abuse

Orthopedic injury due to nonaccidental trauma (NAT) can be difficult to distinguish from normal childhood injuries. Identification of high-risk presentations is key in diagnosing these injuries and hopefully preventing further abuse. Femur fractures in children younger than age 1 year have a high likelihood of being nonaccidental, with between 60% to 80% of femoral shaft fractures resulting from abuse. No particular pattern of fracture is pathognomonic for NAT. The American Academy of Orthopaedic Surgeons recommends that children younger than age 36 months with a diaphyseal femur fracture be evaluated for child abuse.¹²

 

Spiral fractures and transverse fractures of long bones also raise suspicion for NAT. Injury to the metaphysis of long bones, especially in nonambulatory children, is considered highly suggestive of child abuse. The classic metaphyseal lesion, called a “corner” or “bucket-handle” fracture, occurs when the extremity (usually the forearm) is pulled or twisted forcibly, or the child is shaken. X-ray will demonstrate a disruption of the metaphysis with lucency. As the developing ribs are flexible and difficult to break with minor injuries, a child with a rib fracture and no history of severe trauma, such as a motor vehicle crash or fall from a significant height, has a high likelihood of being a victim of child abuse. Skull fractures caused from accidental injury and abuse may have similar presentations. The history and mechanism are important to correlate with physical examination findings for potential inconsistencies.¹³

Case Conclusion

The child in this case sustained a type II supracondylar fracture. Orthopedic surgery was consulted, and the patient was taken to the operating room for closed reduction and percutaneous pinning. She was placed in a cast, and pins were removed at follow-up 4 weeks later. No residual pain or deficits remained, and she regained full function of her arm.

Dr Hewett is a pediatric emergency medicine fellow, College of Medicine, Medical University of South Carolina, Charleston.
Dr Titus is vice chair, pediatric fellowships, and fellowship director, pediatric emergency medicine; and an associate professor of pediatrics, Medical University of South Carolina, Charleston.

Case

A 2-year-old girl was carried into the ED after falling off her bed earlier in the evening. The parents did not see the child fall, but heard her crying in her room. On physical examination, the patient was in a lot of pain, would not move her left arm, and had a left elbow effusion. The radial pulse was strong, and she was able to move all of her fingers but would not move her elbow. A lateral X-ray taken of the left elbow is shown below (Figure 1).  

Supracondylar Fractures

Supracondylar fractures are the most common pediatric elbow injury and disposition can range from outpatient follow-up to urgent surgical intervention. The average age of presentation is between 3 to 10 years, and the injury typically results from a fall on an outstretched hand (FOOSH) with hyperextension of the elbow. Supracondylar fractures may also occur after a direct blow to the elbow or hyperflexion.¹

The supracondylar area in children,  the distal portion of the humerus, is thin and weak. The force transmitted to this region by a direct blow or FOOSH injury can fracture the humerus. The brachial artery runs along the anterior humerus and can easily sustain injury. Median, ulnar, or radial nerve injuries are also common and can result in permanent disability.² Immediate neurovascular examination is mandatory, and diminished or absent pulses, poor perfusion, and pallor are signs of ischemia. Examination should include assessment of the radial pulse and the sensory and motor function of the median, radial, and ulnar nerves.  To test the median nerve (via the anterior interosseous branch), ask the patient make an “OK” sign with his or her fingers; to test the radial nerve, instruct the child to make a “thumb’s up” sign; and to test the ulnar nerve, have  the child hold his or her fingers spread-out against resistance. In addition, sensation of the palmer and dorsal surfaces and in between the fingers should be confirmed.

Plain radiographs, including anteroposterior (AP), oblique, and true lateral views, should be obtained. Interpretation of pediatric elbow films can be difficult, and the stages of ossification must be considered. The helpful acronym for remembering the order of bone ossification is CRITOE (capitellum, radial head, internal [medial] epicondyle, trochlea, olecranon, and external [lateral] epicondyle) (Table 1).

If the anterior humeral line—a line drawn through the anterior cortex of the humerus—fails to intersect the capitellum in its middle third, fracture of the distal humerus is present (Figure 2). The radial head should be aligned with the capitellum. Close inspection for a posterior fat pad, or “sail sign” is imperative as it indicates hemorrhage, joint effusion, or occult fracture. The presence of an anterior fat pad can be a normal variant; however, if the pad is wide and creates a “sail sign” then fracture must be assumed.¹

Fracture Types

Pediatric supracondylar frac­tures are classified into three types (Table 2). Type I fractures may be subtle on X-ray, evident only by a posterior fat pad or only seen on an oblique view. These nondisplaced fractures may be splinted with a long-arm splint. Type II fractures are angulated yet the posterior cortex remains intact. Typically the anterior humeral line is displaced, anteriorly intersecting the anterior third of the capitellum or missing it entirely. These cases require urgent orthopedic consultation for either closed reduction with splinting or open reduction with percutaneous pin placement. 

Type III supracondylar fractures are completely displaced with a fracture through the anterior and posterior cortex. Since a high-risk of injury to the upper extremity vessels and nerves is associated with these very unstable fractures, routine neurovascular checks (while awaiting operative repair) are required. Supracondylar fractures are often associated with forearm or distal radius fractures; therefore, forearm radiographs should also be obtained.³

Diskitis

Diskitis is defined as inflammation or infection of the intervertebral disk. Though etiology is debated, Staphylococcus aureus is confirmed in up to 60% of cases.⁴ This infection has been described by some as being on the spectrum of vertebral osteomyelitis. Though rare, delayed diagnosis of diskitis can result in significant morbidity. Incidence peaks in early childhood between ages 3 to 5 years but may present at any age with back pain, limp, or refusal to walk. Most commonly, the lower lumbar disks are affected. Examination may reveal decreased muscle strength or reflexes, refusal to bend forward, hip pain, or tenderness of the spine. Although white blood cell (WBC) count is typically normal, more than 90% of patients with diskitis have an elevated erythrocyte sedimentation rate. X-rays usually appear normal until 2 to 3 weeks after symptoms begin, at which time narrowing of the joint space can be seen. Magnetic resonance imaging is required for diagnosis (Figure 3), and orthopedics should be consulted for possible aspiration for culture. Empiric antibiotic therapy includes an antistaphylococcal agent (eg, nafcillin/oxacillin, clindamycin, vancomycin) and a third-generation cephalosporin (eg, cefotaxime, ceftriaxone).⁵ 

 

Tumors

Back or bone pain can be a subtle early presenting symptom of cancer or tumors of the bone or bone marrow. The most common malignant bone tumors in children are osteosarcoma and Ewing sarcoma.⁶ Both types may present with intermittent pain or pain that worsens over weeks to months. Fever also may be present, which can lead to a misdiagnosis of osteomyelitis. Acute leukemia presenting with bone/back pain and a history of nighttime pain combined with low WBC, platelets, or hemoglobin is highly suggestive of this diagnosis. Physical examination should identify lymphadenopathy, hepatomegaly, or splenomegaly. The child with back pain in whom there is concern for mass should have laboratory evaluation, including a complete blood cell count, erythrocyte sedimentation rate, C-reactive protein, alkaline phosphatase, and lactate dehydrogenase. Plain radiographs may demonstrate “onion skinning” or the “sunburst” pattern, indicating periosteal reaction, and is highly suggestive of malignancy (Figure 4). Benign tumors of childhood may present initially as back pain as well. Osteoid osteoma is a common benign tumor which presents with pain that becomes worse at night and may respond to nonsteroidal anti-inflammatory drugs.⁷

Spondylolysis

Spondylolysis, also known as “pars defect,” is a unilateral or bilateral fracture of the vertebral pars interarticularis—typically of the lower lumbar vertebrae, most commonly L5. Spondylolysis occurs after repetitive microtrauma. Spondylolisthesis is the slipping of one vertebra over another one. These diagnoses should be suspected in adolescents, especially athletic patients presenting with acute low-back pain. The pain associated with these conditions often extends into the posterior thigh and is relieved by rest. Examination findings include lumbosacral tenderness, particularly with extension or lateral bending. Radiographs should include AP, lateral, and oblique views and may demonstrate fracture, displacement of the vertebrae, or the classic “Scotty dog” sign with the crack (collar) on the neck of dog (Figure 5). Treatment consists of immobilization, activity restriction, and physiotherapy. Referral to orthopedics is advised for follow-up X-rays and monitoring. If conservative treatment fails to relieve pain or if slippage progressively worsens, spinal fusion is necessary.⁸

Pediatric Cervical Spine Clearance

Thankfully, cervical spine injuries are rare, occurring in approximately 1% of children after blunt trauma.⁹ Left unrecognized, however, these injuries may result in permanent neurological disability. Children younger than 8 years of age are more likely to injure the upper cervical spine (C1 to C3) than older children and adults. This is because children have relatively larger heads than bodies and weaker cervical muscles and ligaments, making the upper cervical spine more mobile. The Emergency X-Radiography Utilization Study (NEXUS) criteria have been validated in adults; however, criteria for clearing the pediatric cervical spine are poorly studied. Because of limited data, there are few evidence-based guidelines for the clearance of the pediatric cervical spine. A study in 2001 found that the NEXUS guidelines where helpful in reducing imaging in 20% of children, but due to the low numbers of infants in this study, caution is advised when applying the NEXUS criteria to children under 2 years of age.⁹

Midline posterior cervical tenderness, evidence of intoxication, altered level of consciousness, abnormal neurological examination, or distracting painful injury are indications for AP, lateral, and odontoid X-rays. After blunt trauma, if a patient is receiving an urgent computed tomography (CT) scan for another area of injury such as the head or abdomen, he or she should also receive a CT scan of the cervical spine. Additionally, those with significant mechanism of injury, focal neurological findings, significant altered level of consciousness, and/or significant posterior midline neck pain should also have a cervical spine CT scan.¹⁰ Neurosurgical service consultation is necessary in cases of abnormal cervical spine radiographs (plain films and/or CT scan), abnormal neurological examination (focal neurological findings or altered level of consciousness), or continued significant posterior midline cervical spine pain/tenderness, history, and resolution of focal neurological findings despite normal radiographs. Clearance of the cervical spine is possible if the patient has no posterior midline cervical tenderness; has a normal neurological examination; is not intoxicated; has no altered level of consciousness; has no painful distracting injury and normal radiographs; and has resolution of significant midline tenderness and/or altered level of consciousness when either one of these was the criteria that necessitated the radiographs (Table 3).¹¹

Nonaccidental Trauma: Abuse

Orthopedic injury due to nonaccidental trauma (NAT) can be difficult to distinguish from normal childhood injuries. Identification of high-risk presentations is key in diagnosing these injuries and hopefully preventing further abuse. Femur fractures in children younger than age 1 year have a high likelihood of being nonaccidental, with between 60% to 80% of femoral shaft fractures resulting from abuse. No particular pattern of fracture is pathognomonic for NAT. The American Academy of Orthopaedic Surgeons recommends that children younger than age 36 months with a diaphyseal femur fracture be evaluated for child abuse.¹²

 

Spiral fractures and transverse fractures of long bones also raise suspicion for NAT. Injury to the metaphysis of long bones, especially in nonambulatory children, is considered highly suggestive of child abuse. The classic metaphyseal lesion, called a “corner” or “bucket-handle” fracture, occurs when the extremity (usually the forearm) is pulled or twisted forcibly, or the child is shaken. X-ray will demonstrate a disruption of the metaphysis with lucency. As the developing ribs are flexible and difficult to break with minor injuries, a child with a rib fracture and no history of severe trauma, such as a motor vehicle crash or fall from a significant height, has a high likelihood of being a victim of child abuse. Skull fractures caused from accidental injury and abuse may have similar presentations. The history and mechanism are important to correlate with physical examination findings for potential inconsistencies.¹³

Case Conclusion

The child in this case sustained a type II supracondylar fracture. Orthopedic surgery was consulted, and the patient was taken to the operating room for closed reduction and percutaneous pinning. She was placed in a cast, and pins were removed at follow-up 4 weeks later. No residual pain or deficits remained, and she regained full function of her arm.

Dr Hewett is a pediatric emergency medicine fellow, College of Medicine, Medical University of South Carolina, Charleston.
Dr Titus is vice chair, pediatric fellowships, and fellowship director, pediatric emergency medicine; and an associate professor of pediatrics, Medical University of South Carolina, Charleston.

The child with limp represents a common scenario in the pediatric ED. Evaluation of such patients may be difficult due to vague clinical histories and nonspecific physical examination findings. The differential diagnosis is broad and includes mild self-limited processes (eg, toxic synovitis), as well as potentially limb and life-threatening etiologies (eg, osteomyelitis, malignancy). Careful attention to historical clues and a focused physical examination are often suggestive of a diagnosis, but laboratory and radiographic studies are necessary in most cases.

While trauma is the most common source of limp in children, infectious, inflammatory, and anatomic causes are also frequently encountered. This review focuses on several of the most important etiologies of limp in children: toxic synovitis, septic arthritis, osteomyelitis, Perthes disease, slipped capital femoral epiphysis (SCFE), and Osgood-Schlatter disease.

Case Presentation

Kailey, a 28-month-old girl, was brought to the ED by her parents, who stated that their child “isn’t walking right.” They noted that their daughter’s right leg had been bothering her for about a week, but that the limp had become more noticeable. Aside from a cold a week before presentation, both parents stated that the child has been healthy; they also denied any trauma or systemic symptoms such as rash, weight loss, vomiting, or diarrhea. The mother believed Kailey may have had a low-grade fever earlier in the week. There were no sick contacts at home, but the child did attend daycare.

On examination, Kailey was well-appearing on her mother’s lap. Her vital signs were unremarkable and she was afebrile. She was able to bear weight on the right leg but walked with a slightly antalgic gait, which became more apparent when she was asked to run across the room to her mother. Her right leg was normal appearing on examination with normal reflexes; however, the child appeared to wince when passively ranging her right hip and right knee joint. The emergency physician (EP) was not able to determine any particular areas of point tenderness. The remainder of the examination, including neurological and musculoskeletal examinations, was normal.

Regarding further history, the child’s parents informed the EP that they had taken their daughter to an urgent care clinic earlier in the week.  X-rays taken of the girl’s right knee and hip at this visit were both normal; however, the girl’s limp had been getting worse.

Overview

Limp is a common presenting complaint in the pediatric ED, and its evaluation is often challenging as the clinical course of limp in a child varies from benign and self-limited to serious and limb-threatening. However, with careful attention to the history and physical examination, appropriate laboratory evaluation, and focused imaging studies, a diagnosis can be made in most cases and treatment initiated. Of paramount importance for clinicians is to remember that limp in a child nearly always represents an organic disease.^1,2

While trauma is the most common cause of limp in children, infectious, inflammatory, and anatomic processes are other potential etiologies. A clue to the diagnosis may also be inferred from the patient’s age, as certain conditions such as fracture, Perthes disease, and transient synovitis are seen in younger children, while SCFE and Osgood-Schlatter are more common in children older than 10 years of age. Other serious conditions such as septic hip or osteomyelitis may be encountered at any age.

Initial Management

A thorough history and physical examination provide the basis for subsequent laboratory and radiographic testing of children presenting with a limp. The duration and localization of symptoms should be elicited; traumatic or infectious causes are more common among those presenting with acute (<2 weeks) complaints. The presence of systemic symptoms (eg, fever, weight loss, chills, rashes, recurrent arthralgias) increases the likelihood of underlying oncologic or rheumatologic process. Examination of the child begins with a full physical examination to uncover other possible etiologic clues such as other involved joints (juvenile idiopathic arthritis), signs of old bruising (nonaccidental trauma), firm lymph nodes (malignancy), abdominal pain (eg, appendicitis, psoas abscess, constipation), or limb-length discrepancy (developmental dysplasia of the hip).

Focused assessment of the limp itself involves watching the child walk or run; different variations of limp may also offer a clue to the diagnosis. An antalgic gait simply refers to one in which the affected leg spends less time in the weight-bearing stage, and it is most commonly seen with infection and trauma. Trendelenburg gait, frequently seen with SCFE and Perthes disease, is characterized by a downward tilt of the pelvis away from the affected side while the affected leg is bearing weight.

In many cases, it may be difficult to accurately characterize a limp due to a patient’s pain or lack of compliance. Evaluation of any limp should also focus on the joint above and below the child’s apparent main source of pain. This is particularly true of knee complaints as referred pain from the hip may often present as isolated thigh or knee pain. Areas of point tenderness, erythema, joint effusion, and warmth strongly point to an infectious source but are frequently absent early in disease presentation. While swelling and severe pain with passive movement of a joint indicate septic arthritis, limitation of joint movement at the hip can be seen with SCFE and Perthes disease.

 

Laboratory Studies

In most children presenting with limp, extensive laboratory testing is not needed for the diagnosis but is helpful when infectious, oncologic, and rheumatologic causes are considered. Inflammatory markers such as the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are elevated in most acute infectious processes. A complete blood count (CBC) should also be obtained in cases of suspected infection to evaluate the white blood cell count (WBC). Due to the high prevalence of joint infections and postinfectious processes caused by group A streptococcus (GAS), an antistreptolysin titer (ASO), throat culture, and rapid streptococcal antigen swab should be considered. If infection is suspected and a joint effusion is present, cell counts, gram stain, and culture from the synovial fluid should be sent to assist with diagnosis and antibiotic management. If a child appears septic, a blood culture should be obtained as well. With suspected osteomyelitis, cultures of the bone should be taken in the operating room in addition to a peripheral blood culture. Ideally, antibiotics should be withheld until cultures are sent unless the child appears acutely ill.

Diagnostic Imaging

In most cases, plain films of the affected area are ordered to screen for fracture or mass. The possibility of referred pain from the hip to the knee or vice versa should be considered in any child presenting with a limp appearing to originate from these areas. Pelvic X-ray with anteroposterior (AP) and frog-leg views is preferred over a unilateral hip series because this allows for comparison views of the unaffected side. For other areas of the lower extremities, AP and lateral views of the affected side are generally sufficient. Ultrasound is a useful modality when a hip effusion is suspected (Figure 1). Unlike effusions of the knee joint, hip effusions are difficult to detect based on physical examination and plain radiography alone. Among children with poorly localizing symptoms, a radionuclide bone scan may be used to guide further imaging studies. Magnetic resonance imaging (MRI) is also a very sensitive tool for the detection of inflammation or infection and is the modality of choice for the diagnosis of osteomyelitis and early Perthes disease. However, its use may be limited by availability and the need for sedation in young children.

Toxic Synovitis and Septic Arthritis

Clinicians may have difficulty differentiating between toxic synovitis (also known as transient synovitis) and septic arthritis of the hip in pediatric patients. In both toxic synovitis and septic arthritis, the child is unable to bear weight on the affected side, and ultrasound may demonstrate effusion.^3,4

Toxic synovitis is thought to be a viral or postviral phenomenon, though the exact agent responsible for initiating the inflammatory cascade is not known. It has a relatively benign course and generally responds over 3 to 10 days to rest and nonsteroidal anti-inflammatory drugs (NSAIDs).^5,6

Septic arthritis, however, is a serious infection with the capacity to cause permanent joint damage as well as spread into the blood or bone. Staphylococcal and streptococcal bacteria, including GAS and methicillin-resistant staphylococcus aureus (MRSA) are the most common causes of septic arthritis in the pediatric population.⁷ However, Kingella kingae, a gram-negative organism, is an increasingly recognized cause of septic arthritis in children younger than 3 years of age. Commonly found in the posterior pharynx, Kingella is very difficult to culture but may be detected by polymerase chain reaction (PCR) assays.⁸ The spectrum of GAS-related joint infections ranges from a postinfectious type that may be indistinguishable from toxic synovitis (but with evidence of recent GAS pharyngitis) to typical bacterial septic arthritis.⁹

Multiple clinical prediction rules and algorithms have been developed to assist with the management of these cases. The Kocher criteria, which include history of fever >101.3˚F, nonweight-bearing status, ESR >40 mm/hour, and WBC >12,000 cells/mm³ were found to be independent clinical predictors for the differentiation between transient arthritis and septic arthritis. Children with none of the risk factors had a 0.2% chance of septic arthritis while those with two risk factors had a 40% chance of septic arthritis. Subsequent validation studies among pediatric populations with a lower prevalence of septic arthritis found the positive predictive values to be lower; nevertheless, the Kocher criteria remain useful in guiding management.^3,4

If a diagnosis of septic arthritis remains a consideration after the history, physical examination, and plain radiography, laboratory studies should be obtained, including a CBC, ESR, CRP,  blood culture, rapid streptococcal assay, throat culture, and ASO titer. An ultrasound should also be performed to assess for the presence of a hip effusion.

Elevated inflammatory markers (ESR >40 mm/hour, CRP >20 mg/L, WBC >12,000 cells/mm³) and an effusion should prompt orthopedic consultation and arthrocentesis for synovial fluid-cell counts, gram stain, and culture. Synovial fluid WBC counts >50,000 cells/mm³ or a positive gram stain or culture is diagnostic of septic arthritis and requires treatment with intravenous (IV) antibiotics and likely operative intervention. The absence of an effusion on ultrasound, synovial fluid WBC counts <50,000 cells/mm³, and inflammatory markers that are not significantly elevated indicate an alternative diagnosis such as toxic synovitis. However, there may be cases in which the diagnosis is not clear due to ambiguous laboratory values from the blood or synovial fluid; in these cases the decision to proceed with IV antibiotics must be made in consultation with an orthopedist.¹⁰

 

Empiric antibiotic therapy in patients with septic arthritis should take into account the prevalence of MRSA in the community. Clindamycin is a popular choice due to its high oral bioavailability, which facilitates transition to a home regimen. Vancomycin is another option and can be reserved for more severely ill children. Empiric coverage for suspected septic arthritis in children younger than 3 years of age should also include an anti-gram negative agent, such as a cephalosporin, to treat Kingella.⁷

Osteomyelitis

Acute osteomyelitis is a common cause of limp among children and is usually caused by the hematogenous spread of bacteria. Staphylococcus aureus, including MRSA, is responsible for up to 90% of cases of osteomyelitis, though recent studies have identified Kingella as an etiologic agent among children younger age 3 years.⁷ The highly vascular metaphysis of the tibia and femur in children can become infected during times of otherwise asymptomatic bacteremia in healthy patients.⁸ Among younger children with less well-developed anatomic separation between the bone and joint space, it is possible for infection to spread into the joint space. Younger children with osteomyelitis may present with poorly localized pain with or without systemic symptoms; older children and those with more advanced disease may describe point tenderness on the bone. In many cases it may be difficult clinically to distinguish osteomyelitis from septic arthritis; excessive pain with passive range of motion of the joint is more indicative of septic arthritis. 

Evaluation of suspected osteomyelitis begins with plain radiographs, CBC, ESR, and CRP. Elevated inflammatory markers are sensitive but not specific for osteomyelitis and may be followed serially to determine response to treatment. Blood cultures should also be obtained and are positive in up to 50% of cases of acute osteomyelitis. Plain radiographs are frequently nondiagnostic early in the course of disease and should primarily be used to evaluate for other causes of joint pain such as fracture or malignancy. The imaging modality of choice is MRI as it is capable of detecting early inflammatory changes in the bone; fast sequence MRIs are now used to screen for osteomyelitis in an attempt to reduce the need for sedation in young children (Figure 2).¹¹

Ideally, antibiotic therapy should be deferred until cultures from the site of infection are obtained operatively or via aspiration. The local staphylococcus aureus resistance pattern should guide empiric antibiotic therapy. With the rise of MRSA, clindamycin has become first-line therapy with vancomycin as an alternative for severely-ill or clindamycin-allergic patients. For children younger than 3 years of age with a more subacute presentation, the possibility of Kingella infection should be considered and treated with a cephalosporin. Some children with osteomyelitis will require operative debridement, though
many can be treated with antibiotics alone. The standard duration of antibiotic treatment is 4 to 6 weeks, with transition to an oral regimen once the patient is afebrile with downtrending inflammatory markers.^7,8,11

Perthes Disease

Perthes disease (also called Legg-Calve-Perthes disease) is an idiopathic process that involves avascular necrosis and revascularization of the blood supply of the femoral head. The condition is most common in children ages 3 to 12 years and has a 4:1 male to female predominance. The remodeling takes place over the course of 2 to 4 years. During this process, the epiphysis of the femoral head is weakened and undergoes irreversible deformation that, if uncorrected, will persist throughout life. Severe degenerative arthritis may result and ultimately require hip replacement.¹²

Perthes disease typically presents as a subacute limp, sometimes with referred pain to the groin, thigh, or knee of the affected side. Range of motion of the hip may be limited, particularly in abduction and internal rotation. Plain films demonstrate necrotic avascular areas of the distal femoral head during active disease; after the remodeling process is complete, the femoral head often shows residual deformities. Magnetic resonance imaging is useful in cases in which plain film findings are subtle, particularly early in the course of the disease.^12,13

Management of Perthes disease depends on the age of the child and clinical factors such as radiographic progression and range of motion of the hip. The goal of therapy is to limit damage to the femoral head during the revascularization process. In children younger than 5 years of age, nonsurgical management with an abduction splint to keep the femoral head contained and protected within the acetabulum may be used. Surgical osteotomies are used in older and more severely affected children to artificially contain the femoral head during the healing process.¹³

Slipped Capital Femoral Epiphysis

A common cause of limp among older children, the average age of presentation for SCFE is 13.5 years for boys and 12 years for girls. This condition occurs when the proximal femoral epiphysis slides posteriorly and inferiorly relative to the metaphysis. Epidemiological studies have established a connection between SCFE and obesity. Although the precise pathogenesis remains unknown, it is hypothesized that increased mechanical forces during a time of rapid pubertal growth lead to weakness at the physis. Among children who develop SCFE outside of the usual age distribution, endocrinopathies such as hypothyroidism, hypogonadism, and panhypopituitarism are often discovered.¹⁴

 

As with Perthes disease, SCFE may present as a chronic, subacute, or acute limp with referred pain to the groin, thigh, or knee. The patient with SCFE often has severe pain with internal rotation of the affected hip and will hold the hip in obligatory external rotation if it is flexed. Patients unable to bear weight on the affected side have unstable SCFE.

All patients with suspected SCFE should have an AP and frog leg view of the pelvis performed to allow for comparison due to the incidence of bilateral disease in up to one-third of patients. The classic radiographic finding of SCFE is the “melting ice cream cone” sign showing the relative displacement of the proximal femoral epiphysis (ice cream) to the femoral neck (cone) (Figure 3). The degree of slippage can be quantified by Klein’s line; on the AP view, a line drawn through the superior edge of the femoral neck should intersect the edge of the proximal femoral epiphysis.¹⁴

All patients with SCFE should be made nonweight bearing on the affected hip to prevent further slippage of the epiphysis. Definitive treatment involves in-situ fixation of the femoral neck with the proximal femoral epiphysis. Close orthopedic follow up is essential as roughly 50% of children with unilateral SCFE will go on to develop SCFE in the contralateral hip. Long-term complications of SCFE include osteonecrosis, joint space narrowing, and osteoarthritis.^14,15

Osgood-Schlatter Disease

Osgood-Schlatter disease is a relatively benign cause of limp that is thought to occur due to repetitive trauma to the secondary ossification center tibial tubercle. Over time, the strong pull of the quadriceps muscle group on the patellar tendon causes a chronic avulsion at the site of the patellar tendon insertion on the tibial tuberosity. It most commonly develops in early puberty from ages 9 to 14 years. Affected children develop tenderness over the tibial tuberosity that is made worse with activity. On examination, pain can be elicited by having the child extend the knee against resistance or kneel. Lateral radiographs of the knee may be normal or demonstrate swelling, irregularity, or elevation of the tibial tubercle. Treatment consists of NSAIDs, ice, and physical therapy; activity restriction is generally unnecessary. Most cases resolve over 6 to 18 months as the growth plate at the secondary ossification center ossifies.¹⁶

Case Conclusion

Initial examination confirmed the presence of a limp; the differential in this age group includes toxic synovitis, septic arthritis, and osteomyelitis. Although Kailey appeared relatively well on examination, her history of recent fever and the worsening symptoms over the past week were concerning. The workup began with plain films of the pelvis and the right knee because of the possibility of referred pain and the lack of localizing signs on examination. In addition, laboratory evaluation was performed, including CBC, CRP, and ESR. Due to her young age, a rapid streptococcal assay, throat culture, or an ASO titer was not necessary.

Plain films of the pelvis and the right knee were normal. The patient’s WBC was unremarkable, but her ESR was 50 mm/hour and CRP was 25 mg/L. Given these elevated inflammatory markers, ultrasound of the right hip was ordered, which revealed a small effusion. An orthopedic specialist was consulted, who performed a sedated joint aspiration. Cell counts from the joint aspirate were sent for evaluation, as well as culture, gram stain, and a PCR for Kingella.

After joint aspiration, Kailey was admitted to the hospital overnight and was started on empiric treatment with IV clindamycin and ceftriaxone. The synovial fluid gram stain was negative, but the WBC was 65,000 cells/mm³. Over the next several days, her inflammatory markers trended downward, she remained afebrile, and her gait slowly improved. The synovial fluid culture remained negative, but the PCR was positive for Kingella. Kailey was discharged on hospital day 3 with a 21-day course of oral cephalexin.

Dr Kane is a fellow in the department of pediatrics, division of pediatric emergency medicine, Vanderbilt Children’s Hospital, Nashville, Tennessee. Dr McMorrow is an assistant professor of emergency medicine and assistant professor of pediatrics, department of pediatrics, division of pediatric emergency medicine, Vanderbilt Children’s Hospital, Nashville, Tennessee.

The child with limp represents a common scenario in the pediatric ED. Evaluation of such patients may be difficult due to vague clinical histories and nonspecific physical examination findings. The differential diagnosis is broad and includes mild self-limited processes (eg, toxic synovitis), as well as potentially limb and life-threatening etiologies (eg, osteomyelitis, malignancy). Careful attention to historical clues and a focused physical examination are often suggestive of a diagnosis, but laboratory and radiographic studies are necessary in most cases.

While trauma is the most common source of limp in children, infectious, inflammatory, and anatomic causes are also frequently encountered. This review focuses on several of the most important etiologies of limp in children: toxic synovitis, septic arthritis, osteomyelitis, Perthes disease, slipped capital femoral epiphysis (SCFE), and Osgood-Schlatter disease.

Case Presentation

Kailey, a 28-month-old girl, was brought to the ED by her parents, who stated that their child “isn’t walking right.” They noted that their daughter’s right leg had been bothering her for about a week, but that the limp had become more noticeable. Aside from a cold a week before presentation, both parents stated that the child has been healthy; they also denied any trauma or systemic symptoms such as rash, weight loss, vomiting, or diarrhea. The mother believed Kailey may have had a low-grade fever earlier in the week. There were no sick contacts at home, but the child did attend daycare.

On examination, Kailey was well-appearing on her mother’s lap. Her vital signs were unremarkable and she was afebrile. She was able to bear weight on the right leg but walked with a slightly antalgic gait, which became more apparent when she was asked to run across the room to her mother. Her right leg was normal appearing on examination with normal reflexes; however, the child appeared to wince when passively ranging her right hip and right knee joint. The emergency physician (EP) was not able to determine any particular areas of point tenderness. The remainder of the examination, including neurological and musculoskeletal examinations, was normal.

Regarding further history, the child’s parents informed the EP that they had taken their daughter to an urgent care clinic earlier in the week.  X-rays taken of the girl’s right knee and hip at this visit were both normal; however, the girl’s limp had been getting worse.

Overview

Limp is a common presenting complaint in the pediatric ED, and its evaluation is often challenging as the clinical course of limp in a child varies from benign and self-limited to serious and limb-threatening. However, with careful attention to the history and physical examination, appropriate laboratory evaluation, and focused imaging studies, a diagnosis can be made in most cases and treatment initiated. Of paramount importance for clinicians is to remember that limp in a child nearly always represents an organic disease.^1,2

While trauma is the most common cause of limp in children, infectious, inflammatory, and anatomic processes are other potential etiologies. A clue to the diagnosis may also be inferred from the patient’s age, as certain conditions such as fracture, Perthes disease, and transient synovitis are seen in younger children, while SCFE and Osgood-Schlatter are more common in children older than 10 years of age. Other serious conditions such as septic hip or osteomyelitis may be encountered at any age.

Initial Management

A thorough history and physical examination provide the basis for subsequent laboratory and radiographic testing of children presenting with a limp. The duration and localization of symptoms should be elicited; traumatic or infectious causes are more common among those presenting with acute (<2 weeks) complaints. The presence of systemic symptoms (eg, fever, weight loss, chills, rashes, recurrent arthralgias) increases the likelihood of underlying oncologic or rheumatologic process. Examination of the child begins with a full physical examination to uncover other possible etiologic clues such as other involved joints (juvenile idiopathic arthritis), signs of old bruising (nonaccidental trauma), firm lymph nodes (malignancy), abdominal pain (eg, appendicitis, psoas abscess, constipation), or limb-length discrepancy (developmental dysplasia of the hip).

Focused assessment of the limp itself involves watching the child walk or run; different variations of limp may also offer a clue to the diagnosis. An antalgic gait simply refers to one in which the affected leg spends less time in the weight-bearing stage, and it is most commonly seen with infection and trauma. Trendelenburg gait, frequently seen with SCFE and Perthes disease, is characterized by a downward tilt of the pelvis away from the affected side while the affected leg is bearing weight.

In many cases, it may be difficult to accurately characterize a limp due to a patient’s pain or lack of compliance. Evaluation of any limp should also focus on the joint above and below the child’s apparent main source of pain. This is particularly true of knee complaints as referred pain from the hip may often present as isolated thigh or knee pain. Areas of point tenderness, erythema, joint effusion, and warmth strongly point to an infectious source but are frequently absent early in disease presentation. While swelling and severe pain with passive movement of a joint indicate septic arthritis, limitation of joint movement at the hip can be seen with SCFE and Perthes disease.

 

Laboratory Studies

In most children presenting with limp, extensive laboratory testing is not needed for the diagnosis but is helpful when infectious, oncologic, and rheumatologic causes are considered. Inflammatory markers such as the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are elevated in most acute infectious processes. A complete blood count (CBC) should also be obtained in cases of suspected infection to evaluate the white blood cell count (WBC). Due to the high prevalence of joint infections and postinfectious processes caused by group A streptococcus (GAS), an antistreptolysin titer (ASO), throat culture, and rapid streptococcal antigen swab should be considered. If infection is suspected and a joint effusion is present, cell counts, gram stain, and culture from the synovial fluid should be sent to assist with diagnosis and antibiotic management. If a child appears septic, a blood culture should be obtained as well. With suspected osteomyelitis, cultures of the bone should be taken in the operating room in addition to a peripheral blood culture. Ideally, antibiotics should be withheld until cultures are sent unless the child appears acutely ill.

Diagnostic Imaging

In most cases, plain films of the affected area are ordered to screen for fracture or mass. The possibility of referred pain from the hip to the knee or vice versa should be considered in any child presenting with a limp appearing to originate from these areas. Pelvic X-ray with anteroposterior (AP) and frog-leg views is preferred over a unilateral hip series because this allows for comparison views of the unaffected side. For other areas of the lower extremities, AP and lateral views of the affected side are generally sufficient. Ultrasound is a useful modality when a hip effusion is suspected (Figure 1). Unlike effusions of the knee joint, hip effusions are difficult to detect based on physical examination and plain radiography alone. Among children with poorly localizing symptoms, a radionuclide bone scan may be used to guide further imaging studies. Magnetic resonance imaging (MRI) is also a very sensitive tool for the detection of inflammation or infection and is the modality of choice for the diagnosis of osteomyelitis and early Perthes disease. However, its use may be limited by availability and the need for sedation in young children.

Toxic Synovitis and Septic Arthritis

Clinicians may have difficulty differentiating between toxic synovitis (also known as transient synovitis) and septic arthritis of the hip in pediatric patients. In both toxic synovitis and septic arthritis, the child is unable to bear weight on the affected side, and ultrasound may demonstrate effusion.^3,4

Toxic synovitis is thought to be a viral or postviral phenomenon, though the exact agent responsible for initiating the inflammatory cascade is not known. It has a relatively benign course and generally responds over 3 to 10 days to rest and nonsteroidal anti-inflammatory drugs (NSAIDs).^5,6

Septic arthritis, however, is a serious infection with the capacity to cause permanent joint damage as well as spread into the blood or bone. Staphylococcal and streptococcal bacteria, including GAS and methicillin-resistant staphylococcus aureus (MRSA) are the most common causes of septic arthritis in the pediatric population.⁷ However, Kingella kingae, a gram-negative organism, is an increasingly recognized cause of septic arthritis in children younger than 3 years of age. Commonly found in the posterior pharynx, Kingella is very difficult to culture but may be detected by polymerase chain reaction (PCR) assays.⁸ The spectrum of GAS-related joint infections ranges from a postinfectious type that may be indistinguishable from toxic synovitis (but with evidence of recent GAS pharyngitis) to typical bacterial septic arthritis.⁹

Multiple clinical prediction rules and algorithms have been developed to assist with the management of these cases. The Kocher criteria, which include history of fever >101.3˚F, nonweight-bearing status, ESR >40 mm/hour, and WBC >12,000 cells/mm³ were found to be independent clinical predictors for the differentiation between transient arthritis and septic arthritis. Children with none of the risk factors had a 0.2% chance of septic arthritis while those with two risk factors had a 40% chance of septic arthritis. Subsequent validation studies among pediatric populations with a lower prevalence of septic arthritis found the positive predictive values to be lower; nevertheless, the Kocher criteria remain useful in guiding management.^3,4

If a diagnosis of septic arthritis remains a consideration after the history, physical examination, and plain radiography, laboratory studies should be obtained, including a CBC, ESR, CRP,  blood culture, rapid streptococcal assay, throat culture, and ASO titer. An ultrasound should also be performed to assess for the presence of a hip effusion.

Elevated inflammatory markers (ESR >40 mm/hour, CRP >20 mg/L, WBC >12,000 cells/mm³) and an effusion should prompt orthopedic consultation and arthrocentesis for synovial fluid-cell counts, gram stain, and culture. Synovial fluid WBC counts >50,000 cells/mm³ or a positive gram stain or culture is diagnostic of septic arthritis and requires treatment with intravenous (IV) antibiotics and likely operative intervention. The absence of an effusion on ultrasound, synovial fluid WBC counts <50,000 cells/mm³, and inflammatory markers that are not significantly elevated indicate an alternative diagnosis such as toxic synovitis. However, there may be cases in which the diagnosis is not clear due to ambiguous laboratory values from the blood or synovial fluid; in these cases the decision to proceed with IV antibiotics must be made in consultation with an orthopedist.¹⁰

 

Empiric antibiotic therapy in patients with septic arthritis should take into account the prevalence of MRSA in the community. Clindamycin is a popular choice due to its high oral bioavailability, which facilitates transition to a home regimen. Vancomycin is another option and can be reserved for more severely ill children. Empiric coverage for suspected septic arthritis in children younger than 3 years of age should also include an anti-gram negative agent, such as a cephalosporin, to treat Kingella.⁷

Osteomyelitis

Acute osteomyelitis is a common cause of limp among children and is usually caused by the hematogenous spread of bacteria. Staphylococcus aureus, including MRSA, is responsible for up to 90% of cases of osteomyelitis, though recent studies have identified Kingella as an etiologic agent among children younger age 3 years.⁷ The highly vascular metaphysis of the tibia and femur in children can become infected during times of otherwise asymptomatic bacteremia in healthy patients.⁸ Among younger children with less well-developed anatomic separation between the bone and joint space, it is possible for infection to spread into the joint space. Younger children with osteomyelitis may present with poorly localized pain with or without systemic symptoms; older children and those with more advanced disease may describe point tenderness on the bone. In many cases it may be difficult clinically to distinguish osteomyelitis from septic arthritis; excessive pain with passive range of motion of the joint is more indicative of septic arthritis. 

Evaluation of suspected osteomyelitis begins with plain radiographs, CBC, ESR, and CRP. Elevated inflammatory markers are sensitive but not specific for osteomyelitis and may be followed serially to determine response to treatment. Blood cultures should also be obtained and are positive in up to 50% of cases of acute osteomyelitis. Plain radiographs are frequently nondiagnostic early in the course of disease and should primarily be used to evaluate for other causes of joint pain such as fracture or malignancy. The imaging modality of choice is MRI as it is capable of detecting early inflammatory changes in the bone; fast sequence MRIs are now used to screen for osteomyelitis in an attempt to reduce the need for sedation in young children (Figure 2).¹¹

Ideally, antibiotic therapy should be deferred until cultures from the site of infection are obtained operatively or via aspiration. The local staphylococcus aureus resistance pattern should guide empiric antibiotic therapy. With the rise of MRSA, clindamycin has become first-line therapy with vancomycin as an alternative for severely-ill or clindamycin-allergic patients. For children younger than 3 years of age with a more subacute presentation, the possibility of Kingella infection should be considered and treated with a cephalosporin. Some children with osteomyelitis will require operative debridement, though
many can be treated with antibiotics alone. The standard duration of antibiotic treatment is 4 to 6 weeks, with transition to an oral regimen once the patient is afebrile with downtrending inflammatory markers.^7,8,11

Perthes Disease

Perthes disease (also called Legg-Calve-Perthes disease) is an idiopathic process that involves avascular necrosis and revascularization of the blood supply of the femoral head. The condition is most common in children ages 3 to 12 years and has a 4:1 male to female predominance. The remodeling takes place over the course of 2 to 4 years. During this process, the epiphysis of the femoral head is weakened and undergoes irreversible deformation that, if uncorrected, will persist throughout life. Severe degenerative arthritis may result and ultimately require hip replacement.¹²

Perthes disease typically presents as a subacute limp, sometimes with referred pain to the groin, thigh, or knee of the affected side. Range of motion of the hip may be limited, particularly in abduction and internal rotation. Plain films demonstrate necrotic avascular areas of the distal femoral head during active disease; after the remodeling process is complete, the femoral head often shows residual deformities. Magnetic resonance imaging is useful in cases in which plain film findings are subtle, particularly early in the course of the disease.^12,13

Management of Perthes disease depends on the age of the child and clinical factors such as radiographic progression and range of motion of the hip. The goal of therapy is to limit damage to the femoral head during the revascularization process. In children younger than 5 years of age, nonsurgical management with an abduction splint to keep the femoral head contained and protected within the acetabulum may be used. Surgical osteotomies are used in older and more severely affected children to artificially contain the femoral head during the healing process.¹³

Slipped Capital Femoral Epiphysis

A common cause of limp among older children, the average age of presentation for SCFE is 13.5 years for boys and 12 years for girls. This condition occurs when the proximal femoral epiphysis slides posteriorly and inferiorly relative to the metaphysis. Epidemiological studies have established a connection between SCFE and obesity. Although the precise pathogenesis remains unknown, it is hypothesized that increased mechanical forces during a time of rapid pubertal growth lead to weakness at the physis. Among children who develop SCFE outside of the usual age distribution, endocrinopathies such as hypothyroidism, hypogonadism, and panhypopituitarism are often discovered.¹⁴

 

As with Perthes disease, SCFE may present as a chronic, subacute, or acute limp with referred pain to the groin, thigh, or knee. The patient with SCFE often has severe pain with internal rotation of the affected hip and will hold the hip in obligatory external rotation if it is flexed. Patients unable to bear weight on the affected side have unstable SCFE.

All patients with suspected SCFE should have an AP and frog leg view of the pelvis performed to allow for comparison due to the incidence of bilateral disease in up to one-third of patients. The classic radiographic finding of SCFE is the “melting ice cream cone” sign showing the relative displacement of the proximal femoral epiphysis (ice cream) to the femoral neck (cone) (Figure 3). The degree of slippage can be quantified by Klein’s line; on the AP view, a line drawn through the superior edge of the femoral neck should intersect the edge of the proximal femoral epiphysis.¹⁴

All patients with SCFE should be made nonweight bearing on the affected hip to prevent further slippage of the epiphysis. Definitive treatment involves in-situ fixation of the femoral neck with the proximal femoral epiphysis. Close orthopedic follow up is essential as roughly 50% of children with unilateral SCFE will go on to develop SCFE in the contralateral hip. Long-term complications of SCFE include osteonecrosis, joint space narrowing, and osteoarthritis.^14,15

Osgood-Schlatter Disease

Osgood-Schlatter disease is a relatively benign cause of limp that is thought to occur due to repetitive trauma to the secondary ossification center tibial tubercle. Over time, the strong pull of the quadriceps muscle group on the patellar tendon causes a chronic avulsion at the site of the patellar tendon insertion on the tibial tuberosity. It most commonly develops in early puberty from ages 9 to 14 years. Affected children develop tenderness over the tibial tuberosity that is made worse with activity. On examination, pain can be elicited by having the child extend the knee against resistance or kneel. Lateral radiographs of the knee may be normal or demonstrate swelling, irregularity, or elevation of the tibial tubercle. Treatment consists of NSAIDs, ice, and physical therapy; activity restriction is generally unnecessary. Most cases resolve over 6 to 18 months as the growth plate at the secondary ossification center ossifies.¹⁶

Case Conclusion

Initial examination confirmed the presence of a limp; the differential in this age group includes toxic synovitis, septic arthritis, and osteomyelitis. Although Kailey appeared relatively well on examination, her history of recent fever and the worsening symptoms over the past week were concerning. The workup began with plain films of the pelvis and the right knee because of the possibility of referred pain and the lack of localizing signs on examination. In addition, laboratory evaluation was performed, including CBC, CRP, and ESR. Due to her young age, a rapid streptococcal assay, throat culture, or an ASO titer was not necessary.

Plain films of the pelvis and the right knee were normal. The patient’s WBC was unremarkable, but her ESR was 50 mm/hour and CRP was 25 mg/L. Given these elevated inflammatory markers, ultrasound of the right hip was ordered, which revealed a small effusion. An orthopedic specialist was consulted, who performed a sedated joint aspiration. Cell counts from the joint aspirate were sent for evaluation, as well as culture, gram stain, and a PCR for Kingella.

After joint aspiration, Kailey was admitted to the hospital overnight and was started on empiric treatment with IV clindamycin and ceftriaxone. The synovial fluid gram stain was negative, but the WBC was 65,000 cells/mm³. Over the next several days, her inflammatory markers trended downward, she remained afebrile, and her gait slowly improved. The synovial fluid culture remained negative, but the PCR was positive for Kingella. Kailey was discharged on hospital day 3 with a 21-day course of oral cephalexin.

Dr Kane is a fellow in the department of pediatrics, division of pediatric emergency medicine, Vanderbilt Children’s Hospital, Nashville, Tennessee. Dr McMorrow is an assistant professor of emergency medicine and assistant professor of pediatrics, department of pediatrics, division of pediatric emergency medicine, Vanderbilt Children’s Hospital, Nashville, Tennessee.

The child with limp represents a common scenario in the pediatric ED. Evaluation of such patients may be difficult due to vague clinical histories and nonspecific physical examination findings. The differential diagnosis is broad and includes mild self-limited processes (eg, toxic synovitis), as well as potentially limb and life-threatening etiologies (eg, osteomyelitis, malignancy). Careful attention to historical clues and a focused physical examination are often suggestive of a diagnosis, but laboratory and radiographic studies are necessary in most cases.

While trauma is the most common source of limp in children, infectious, inflammatory, and anatomic causes are also frequently encountered. This review focuses on several of the most important etiologies of limp in children: toxic synovitis, septic arthritis, osteomyelitis, Perthes disease, slipped capital femoral epiphysis (SCFE), and Osgood-Schlatter disease.

Case Presentation

Kailey, a 28-month-old girl, was brought to the ED by her parents, who stated that their child “isn’t walking right.” They noted that their daughter’s right leg had been bothering her for about a week, but that the limp had become more noticeable. Aside from a cold a week before presentation, both parents stated that the child has been healthy; they also denied any trauma or systemic symptoms such as rash, weight loss, vomiting, or diarrhea. The mother believed Kailey may have had a low-grade fever earlier in the week. There were no sick contacts at home, but the child did attend daycare.

On examination, Kailey was well-appearing on her mother’s lap. Her vital signs were unremarkable and she was afebrile. She was able to bear weight on the right leg but walked with a slightly antalgic gait, which became more apparent when she was asked to run across the room to her mother. Her right leg was normal appearing on examination with normal reflexes; however, the child appeared to wince when passively ranging her right hip and right knee joint. The emergency physician (EP) was not able to determine any particular areas of point tenderness. The remainder of the examination, including neurological and musculoskeletal examinations, was normal.

Regarding further history, the child’s parents informed the EP that they had taken their daughter to an urgent care clinic earlier in the week.  X-rays taken of the girl’s right knee and hip at this visit were both normal; however, the girl’s limp had been getting worse.

Overview

Limp is a common presenting complaint in the pediatric ED, and its evaluation is often challenging as the clinical course of limp in a child varies from benign and self-limited to serious and limb-threatening. However, with careful attention to the history and physical examination, appropriate laboratory evaluation, and focused imaging studies, a diagnosis can be made in most cases and treatment initiated. Of paramount importance for clinicians is to remember that limp in a child nearly always represents an organic disease.^1,2

While trauma is the most common cause of limp in children, infectious, inflammatory, and anatomic processes are other potential etiologies. A clue to the diagnosis may also be inferred from the patient’s age, as certain conditions such as fracture, Perthes disease, and transient synovitis are seen in younger children, while SCFE and Osgood-Schlatter are more common in children older than 10 years of age. Other serious conditions such as septic hip or osteomyelitis may be encountered at any age.

Initial Management

A thorough history and physical examination provide the basis for subsequent laboratory and radiographic testing of children presenting with a limp. The duration and localization of symptoms should be elicited; traumatic or infectious causes are more common among those presenting with acute (<2 weeks) complaints. The presence of systemic symptoms (eg, fever, weight loss, chills, rashes, recurrent arthralgias) increases the likelihood of underlying oncologic or rheumatologic process. Examination of the child begins with a full physical examination to uncover other possible etiologic clues such as other involved joints (juvenile idiopathic arthritis), signs of old bruising (nonaccidental trauma), firm lymph nodes (malignancy), abdominal pain (eg, appendicitis, psoas abscess, constipation), or limb-length discrepancy (developmental dysplasia of the hip).

Focused assessment of the limp itself involves watching the child walk or run; different variations of limp may also offer a clue to the diagnosis. An antalgic gait simply refers to one in which the affected leg spends less time in the weight-bearing stage, and it is most commonly seen with infection and trauma. Trendelenburg gait, frequently seen with SCFE and Perthes disease, is characterized by a downward tilt of the pelvis away from the affected side while the affected leg is bearing weight.

In many cases, it may be difficult to accurately characterize a limp due to a patient’s pain or lack of compliance. Evaluation of any limp should also focus on the joint above and below the child’s apparent main source of pain. This is particularly true of knee complaints as referred pain from the hip may often present as isolated thigh or knee pain. Areas of point tenderness, erythema, joint effusion, and warmth strongly point to an infectious source but are frequently absent early in disease presentation. While swelling and severe pain with passive movement of a joint indicate septic arthritis, limitation of joint movement at the hip can be seen with SCFE and Perthes disease.

 

Laboratory Studies

In most children presenting with limp, extensive laboratory testing is not needed for the diagnosis but is helpful when infectious, oncologic, and rheumatologic causes are considered. Inflammatory markers such as the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are elevated in most acute infectious processes. A complete blood count (CBC) should also be obtained in cases of suspected infection to evaluate the white blood cell count (WBC). Due to the high prevalence of joint infections and postinfectious processes caused by group A streptococcus (GAS), an antistreptolysin titer (ASO), throat culture, and rapid streptococcal antigen swab should be considered. If infection is suspected and a joint effusion is present, cell counts, gram stain, and culture from the synovial fluid should be sent to assist with diagnosis and antibiotic management. If a child appears septic, a blood culture should be obtained as well. With suspected osteomyelitis, cultures of the bone should be taken in the operating room in addition to a peripheral blood culture. Ideally, antibiotics should be withheld until cultures are sent unless the child appears acutely ill.

Diagnostic Imaging

In most cases, plain films of the affected area are ordered to screen for fracture or mass. The possibility of referred pain from the hip to the knee or vice versa should be considered in any child presenting with a limp appearing to originate from these areas. Pelvic X-ray with anteroposterior (AP) and frog-leg views is preferred over a unilateral hip series because this allows for comparison views of the unaffected side. For other areas of the lower extremities, AP and lateral views of the affected side are generally sufficient. Ultrasound is a useful modality when a hip effusion is suspected (Figure 1). Unlike effusions of the knee joint, hip effusions are difficult to detect based on physical examination and plain radiography alone. Among children with poorly localizing symptoms, a radionuclide bone scan may be used to guide further imaging studies. Magnetic resonance imaging (MRI) is also a very sensitive tool for the detection of inflammation or infection and is the modality of choice for the diagnosis of osteomyelitis and early Perthes disease. However, its use may be limited by availability and the need for sedation in young children.

Toxic Synovitis and Septic Arthritis

Clinicians may have difficulty differentiating between toxic synovitis (also known as transient synovitis) and septic arthritis of the hip in pediatric patients. In both toxic synovitis and septic arthritis, the child is unable to bear weight on the affected side, and ultrasound may demonstrate effusion.^3,4

Toxic synovitis is thought to be a viral or postviral phenomenon, though the exact agent responsible for initiating the inflammatory cascade is not known. It has a relatively benign course and generally responds over 3 to 10 days to rest and nonsteroidal anti-inflammatory drugs (NSAIDs).^5,6

Septic arthritis, however, is a serious infection with the capacity to cause permanent joint damage as well as spread into the blood or bone. Staphylococcal and streptococcal bacteria, including GAS and methicillin-resistant staphylococcus aureus (MRSA) are the most common causes of septic arthritis in the pediatric population.⁷ However, Kingella kingae, a gram-negative organism, is an increasingly recognized cause of septic arthritis in children younger than 3 years of age. Commonly found in the posterior pharynx, Kingella is very difficult to culture but may be detected by polymerase chain reaction (PCR) assays.⁸ The spectrum of GAS-related joint infections ranges from a postinfectious type that may be indistinguishable from toxic synovitis (but with evidence of recent GAS pharyngitis) to typical bacterial septic arthritis.⁹

Multiple clinical prediction rules and algorithms have been developed to assist with the management of these cases. The Kocher criteria, which include history of fever >101.3˚F, nonweight-bearing status, ESR >40 mm/hour, and WBC >12,000 cells/mm³ were found to be independent clinical predictors for the differentiation between transient arthritis and septic arthritis. Children with none of the risk factors had a 0.2% chance of septic arthritis while those with two risk factors had a 40% chance of septic arthritis. Subsequent validation studies among pediatric populations with a lower prevalence of septic arthritis found the positive predictive values to be lower; nevertheless, the Kocher criteria remain useful in guiding management.^3,4

If a diagnosis of septic arthritis remains a consideration after the history, physical examination, and plain radiography, laboratory studies should be obtained, including a CBC, ESR, CRP,  blood culture, rapid streptococcal assay, throat culture, and ASO titer. An ultrasound should also be performed to assess for the presence of a hip effusion.

Elevated inflammatory markers (ESR >40 mm/hour, CRP >20 mg/L, WBC >12,000 cells/mm³) and an effusion should prompt orthopedic consultation and arthrocentesis for synovial fluid-cell counts, gram stain, and culture. Synovial fluid WBC counts >50,000 cells/mm³ or a positive gram stain or culture is diagnostic of septic arthritis and requires treatment with intravenous (IV) antibiotics and likely operative intervention. The absence of an effusion on ultrasound, synovial fluid WBC counts <50,000 cells/mm³, and inflammatory markers that are not significantly elevated indicate an alternative diagnosis such as toxic synovitis. However, there may be cases in which the diagnosis is not clear due to ambiguous laboratory values from the blood or synovial fluid; in these cases the decision to proceed with IV antibiotics must be made in consultation with an orthopedist.¹⁰

 

Empiric antibiotic therapy in patients with septic arthritis should take into account the prevalence of MRSA in the community. Clindamycin is a popular choice due to its high oral bioavailability, which facilitates transition to a home regimen. Vancomycin is another option and can be reserved for more severely ill children. Empiric coverage for suspected septic arthritis in children younger than 3 years of age should also include an anti-gram negative agent, such as a cephalosporin, to treat Kingella.⁷

Osteomyelitis

Acute osteomyelitis is a common cause of limp among children and is usually caused by the hematogenous spread of bacteria. Staphylococcus aureus, including MRSA, is responsible for up to 90% of cases of osteomyelitis, though recent studies have identified Kingella as an etiologic agent among children younger age 3 years.⁷ The highly vascular metaphysis of the tibia and femur in children can become infected during times of otherwise asymptomatic bacteremia in healthy patients.⁸ Among younger children with less well-developed anatomic separation between the bone and joint space, it is possible for infection to spread into the joint space. Younger children with osteomyelitis may present with poorly localized pain with or without systemic symptoms; older children and those with more advanced disease may describe point tenderness on the bone. In many cases it may be difficult clinically to distinguish osteomyelitis from septic arthritis; excessive pain with passive range of motion of the joint is more indicative of septic arthritis. 

Evaluation of suspected osteomyelitis begins with plain radiographs, CBC, ESR, and CRP. Elevated inflammatory markers are sensitive but not specific for osteomyelitis and may be followed serially to determine response to treatment. Blood cultures should also be obtained and are positive in up to 50% of cases of acute osteomyelitis. Plain radiographs are frequently nondiagnostic early in the course of disease and should primarily be used to evaluate for other causes of joint pain such as fracture or malignancy. The imaging modality of choice is MRI as it is capable of detecting early inflammatory changes in the bone; fast sequence MRIs are now used to screen for osteomyelitis in an attempt to reduce the need for sedation in young children (Figure 2).¹¹

Ideally, antibiotic therapy should be deferred until cultures from the site of infection are obtained operatively or via aspiration. The local staphylococcus aureus resistance pattern should guide empiric antibiotic therapy. With the rise of MRSA, clindamycin has become first-line therapy with vancomycin as an alternative for severely-ill or clindamycin-allergic patients. For children younger than 3 years of age with a more subacute presentation, the possibility of Kingella infection should be considered and treated with a cephalosporin. Some children with osteomyelitis will require operative debridement, though
many can be treated with antibiotics alone. The standard duration of antibiotic treatment is 4 to 6 weeks, with transition to an oral regimen once the patient is afebrile with downtrending inflammatory markers.^7,8,11

Perthes Disease

Perthes disease (also called Legg-Calve-Perthes disease) is an idiopathic process that involves avascular necrosis and revascularization of the blood supply of the femoral head. The condition is most common in children ages 3 to 12 years and has a 4:1 male to female predominance. The remodeling takes place over the course of 2 to 4 years. During this process, the epiphysis of the femoral head is weakened and undergoes irreversible deformation that, if uncorrected, will persist throughout life. Severe degenerative arthritis may result and ultimately require hip replacement.¹²

Perthes disease typically presents as a subacute limp, sometimes with referred pain to the groin, thigh, or knee of the affected side. Range of motion of the hip may be limited, particularly in abduction and internal rotation. Plain films demonstrate necrotic avascular areas of the distal femoral head during active disease; after the remodeling process is complete, the femoral head often shows residual deformities. Magnetic resonance imaging is useful in cases in which plain film findings are subtle, particularly early in the course of the disease.^12,13

Management of Perthes disease depends on the age of the child and clinical factors such as radiographic progression and range of motion of the hip. The goal of therapy is to limit damage to the femoral head during the revascularization process. In children younger than 5 years of age, nonsurgical management with an abduction splint to keep the femoral head contained and protected within the acetabulum may be used. Surgical osteotomies are used in older and more severely affected children to artificially contain the femoral head during the healing process.¹³

Slipped Capital Femoral Epiphysis

A common cause of limp among older children, the average age of presentation for SCFE is 13.5 years for boys and 12 years for girls. This condition occurs when the proximal femoral epiphysis slides posteriorly and inferiorly relative to the metaphysis. Epidemiological studies have established a connection between SCFE and obesity. Although the precise pathogenesis remains unknown, it is hypothesized that increased mechanical forces during a time of rapid pubertal growth lead to weakness at the physis. Among children who develop SCFE outside of the usual age distribution, endocrinopathies such as hypothyroidism, hypogonadism, and panhypopituitarism are often discovered.¹⁴

 

As with Perthes disease, SCFE may present as a chronic, subacute, or acute limp with referred pain to the groin, thigh, or knee. The patient with SCFE often has severe pain with internal rotation of the affected hip and will hold the hip in obligatory external rotation if it is flexed. Patients unable to bear weight on the affected side have unstable SCFE.

All patients with suspected SCFE should have an AP and frog leg view of the pelvis performed to allow for comparison due to the incidence of bilateral disease in up to one-third of patients. The classic radiographic finding of SCFE is the “melting ice cream cone” sign showing the relative displacement of the proximal femoral epiphysis (ice cream) to the femoral neck (cone) (Figure 3). The degree of slippage can be quantified by Klein’s line; on the AP view, a line drawn through the superior edge of the femoral neck should intersect the edge of the proximal femoral epiphysis.¹⁴

All patients with SCFE should be made nonweight bearing on the affected hip to prevent further slippage of the epiphysis. Definitive treatment involves in-situ fixation of the femoral neck with the proximal femoral epiphysis. Close orthopedic follow up is essential as roughly 50% of children with unilateral SCFE will go on to develop SCFE in the contralateral hip. Long-term complications of SCFE include osteonecrosis, joint space narrowing, and osteoarthritis.^14,15

Osgood-Schlatter Disease

Osgood-Schlatter disease is a relatively benign cause of limp that is thought to occur due to repetitive trauma to the secondary ossification center tibial tubercle. Over time, the strong pull of the quadriceps muscle group on the patellar tendon causes a chronic avulsion at the site of the patellar tendon insertion on the tibial tuberosity. It most commonly develops in early puberty from ages 9 to 14 years. Affected children develop tenderness over the tibial tuberosity that is made worse with activity. On examination, pain can be elicited by having the child extend the knee against resistance or kneel. Lateral radiographs of the knee may be normal or demonstrate swelling, irregularity, or elevation of the tibial tubercle. Treatment consists of NSAIDs, ice, and physical therapy; activity restriction is generally unnecessary. Most cases resolve over 6 to 18 months as the growth plate at the secondary ossification center ossifies.¹⁶

Case Conclusion

Initial examination confirmed the presence of a limp; the differential in this age group includes toxic synovitis, septic arthritis, and osteomyelitis. Although Kailey appeared relatively well on examination, her history of recent fever and the worsening symptoms over the past week were concerning. The workup began with plain films of the pelvis and the right knee because of the possibility of referred pain and the lack of localizing signs on examination. In addition, laboratory evaluation was performed, including CBC, CRP, and ESR. Due to her young age, a rapid streptococcal assay, throat culture, or an ASO titer was not necessary.

Plain films of the pelvis and the right knee were normal. The patient’s WBC was unremarkable, but her ESR was 50 mm/hour and CRP was 25 mg/L. Given these elevated inflammatory markers, ultrasound of the right hip was ordered, which revealed a small effusion. An orthopedic specialist was consulted, who performed a sedated joint aspiration. Cell counts from the joint aspirate were sent for evaluation, as well as culture, gram stain, and a PCR for Kingella.

After joint aspiration, Kailey was admitted to the hospital overnight and was started on empiric treatment with IV clindamycin and ceftriaxone. The synovial fluid gram stain was negative, but the WBC was 65,000 cells/mm³. Over the next several days, her inflammatory markers trended downward, she remained afebrile, and her gait slowly improved. The synovial fluid culture remained negative, but the PCR was positive for Kingella. Kailey was discharged on hospital day 3 with a 21-day course of oral cephalexin.

Dr Kane is a fellow in the department of pediatrics, division of pediatric emergency medicine, Vanderbilt Children’s Hospital, Nashville, Tennessee. Dr McMorrow is an assistant professor of emergency medicine and assistant professor of pediatrics, department of pediatrics, division of pediatric emergency medicine, Vanderbilt Children’s Hospital, Nashville, Tennessee.

Case 1
A 2-year-old girl presented to the ED with arm pain. Her mother stated that her daughter was playing with a 5-year-old sibling when she heard the child cry- out in pain and noticed she was holding her right arm by her side, not wanting to move it. Neither child gave a reliable story of the injury.

Nursemaid’s Elbow
Nursemaid’s elbow, also known as pulled elbow, subluxation of the radial head, and most recently annular ligament displacement, is a common injury in children younger than age 6 years. One study estimates that the condition represented about 1% of injury-related ED visits in 2005.¹

Patients with nursemaid’s elbow typically present holding the injured arm at their side, slightly flexed and pronated. These patients appear relatively comfortable until moved actively or passively. The classic history of nursemaid’s elbow includes a traction mechanism, with the child being pulled up by one arm or being grabbed by the arm suddenly to keep him or her out of harm’s way.² Due to the laxity of connective tissues in children of this age, the head of the radius slips out of the annular ligament causing acute pain and decreased function.

Nursemaid’s elbow is usually diagnosed by history and examination alone, with special consideration to the mechanism of injury. There is rarely swelling or bruising.³ Passive flexion and extension at the elbow may be normal, but rotational maneuvers can be painful or fully resisted.

Reduction Techniques
In 2012, Cochrane updated its earlier review on nursemaid’s elbow and in 2013 followed up with an article in Pediatrics in Review.^3,4 Each covered research on reduction techniques, summarizing studies comparing supination-flexion (SF) versus hyperpronation (HP) as the initial reduction maneuver. Given that these maneuvers are difficult to camouflage, studies tend to be pseudorandomized with assessment by a nonblinded healthcare provider, decreasing the strength of the studies. In the Cochrane review, four different trials that included 379 children under age 7 years were selected for the review. In all four studies, pronation was found to have the least chance of failed first attempt, the chosen outcome for this meta-analysis. The risk ratio of failure of reduction for pronation was 0.45 (95% confidence interval [CI], 0.28-0.73).

There is some data supporting hyperpronation to be less painful as well; however, the Cochrane reviewers felt there may have been reporting bias.⁴ Since the time of each of these reviews, another study comprised of 150 children was conducted and also favored similar practice styles, as the hyperpronation maneuver had 95% success rate on first attempt versus 68% first-time success with supination and flexion.⁵

Complications and Recurrence
In a small study aimed at identifying recurrence rates for nursemaid’s elbow, Teach and Schultzman⁶ studied 93 children for 1 year after probable or definite diagnosis of nursemaid’s elbow. Of these children, 23.7% had recurrent radial head subluxation.  Children younger than age 2 years were found to have a relative risk of 2.6 (95% CI, 1.04-6.30) for one or more recurrences when compared to children older than age 2 years.

While the great majority of children with nursemaid’s elbow do not need referral to an orthopedist, those with two or more occurrences should be considered for referral to a specialist.

Case 2
A 6-year-old boy was presented to the ED by his father, who had placed the boy’s arm in a home-made sling. The child tearfully told the provider that he fell trying to catch himself after tripping over the house pet.

FOOSH Injury
The above case depicts a very common presentation in the ED—the so-called “FOOSH” (fall onto an outstretched hand) injury. This type of injury occurs with such frequency in both adults and children that it is one of the only injury patterns with a commonly used acronym. The bony injuries seen with FOOSH in children, however, have a different pattern than those in adults.

Pediatric fractures are unique due to the difference in the structure of the bones themselves. A child’s bones are more elastic than an adult’s bones, allowing them to bow and bend before they fracture.⁷ Despite this malleability, pediatric bones have been noted to have a thicker periosteum. For this reason, compression or impact may interrupt the periosteal sleeve, minimally yielding an incomplete interruption of the cortex unilaterally.

One fracture pattern commonly seen in children is the torus fracture. This type of fracture is also referred to as a buckle fracture as the bone cortex on radiographic imaging appears “buckled” as a result of the compressive forces on that side of the bone (Figure 1). Since the bone itself is minimally affected, these fractures are quite stable and not at risk for complications. 

 

In comparison, a greenstick fracture, also unique to the pediatric population, is one in which the cortex shows plastic deformity on the side of the force or impact but is interrupted on the opposite side due to the tension of the impact itself. Greenstick fractures are frequently angulated and may require reduction for anatomic alignment, but long-term complications are typically minimal. These fracture patterns are distinguished from complete fractures (as seen in adults), which are quite unstable and generally require surgical intervention.

Of note, the location of pediatric forearm fractures varies with age as well.  Diaphyseal fractures are more common in prepubescent children, whereas  the highest incidence of physeal injuries occurs during large growth spurts, particularly throughout adolescence.⁷

Management
The remodeling potential of pediatric bones also makes management unique. Pediatric orthopedic literature has well-studied acceptable angles and degrees of appropriate displacement based largely on the age of the patient and proximity to a growth plate. Knowledge of these is imperative for definitive care of such fractures but is beyond the scope of this review.

Traditional treatment of pediatric forearm fractures includes immobilization of various types and duration to minimize pain and deformity while producing the best possible outcome. Several recent studies have aimed to determine best practice for the different fracture types with the goal of producing best alignment and return to function while decreasing cost, discomfort, and number of physician visits. Another concern among healthcare providers is the risk of refracture, which in buckle fractures is estimated at approximately 2% with a median time of 8 to 16 weeks after the initial injury.⁷

A 2010 review by Kennedy et al⁸ sought to determine if the refracture rate was affected by the technique used to immobilize torus fractures. The five studies used in this review had no reports of refracture in the 443 patients included in analysis, though only one of the studies (Plint et al) followed patients for more than 6 weeks.^8,9 In this study, 75 patients were randomized to either a plaster removable splint or full below-elbow cast for 3 weeks; thereafter, they were followed for 6 months, during which time none experienced refracture.⁹

Another outcome from the same study assessed the ability of the patient to use the affected arm in the recovery period. While those in removable splints scored better during and immediately after cast removal, no differences were present after 1 week. Not surprisingly, families preferred the soft bandages or a removable splint for treatment.

Case 3
A 13-year-old boy presented to the ED with right ankle pain and difficulty bearing weight. He stated that he was playing basketball when he “rolled” his right ankle coming down from a rebound.

Ankle Fractures
Ankle fractures are among the most common acute injuries of the lower extremity in children, accounting for approximately 5% of pediatric fractures and 15% of physeal injuries.¹⁰ Ankle fractures also account for up to 40% of all injuries to the skeletally immature athlete.^10,11 More specifically, distal fibular physeal fractures are the most common types of pediatric ankle fracture; however, they are associated with a relatively low risk for long-term complications. In contrast, distal tibial physeal fractures are associated with a higher risk for long-term complications.^12,13

Presentation and Evaluation
Typically, patients presenting with ankle fractures are too sore to bear weight, and swelling and ecchymosis can be identified anterior to the ankle. In addition, there may be diffuse tenderness throughout the ankle and point tenderness may be induced on the anterolateral aspect of the distal tibia.¹⁴ A complete evaluation of the entire lower extremity should be conducted before assuming that the injury is confined to the ankle, especially in children younger than age 5 years and/or who are nonverbal.¹⁰ When evaluating an ankle fracture, in general, orthopedic consultation should be obtained for children with neurovascular compromise, open fractures, and/or Salter-Harris III, IV, and V fractures.

The juvenile Tillaux fracture represents a Salter-Harris III physeal injury that involves the anterolateral portion of the tibia. It usually occurs in children between ages 12 and 14 years as they approach skeletal maturity and who have a partially fused tibial physis. The common mechanism of injury is inversion of the ankle with the foot pointed away from the midline (supination with external rotation). This leads to avulsion of the lateral tibial epiphysis that is attached to the anterior inferior tibiofibular ligament. The uninvolved medial portion of the epiphysis is closed.¹⁰

Radiographic Imaging

Three radiographic views should be obtained in the evaluation of pediatric ankle injuries as Tillaux fractures or other subtle injuries could be easily missed if only two views are obtained. Interpretation of the radiographs must be correlated with the physical examination.¹⁰ The fracture line is usually best seen on a mortise view (Figure 2). Computed tomography (CT) is warranted in cases in which displacement greater than 2 mm is suspected because it better defines fracture displacement and can aid in surgical planning.¹⁴ Because of its sensitivity in detecting fractures displaced more than 2 mm, CT is now the preferred imaging modality in the assessment of juvenile Tillaux fractures.¹⁵

 

Definitive Management
There are two important goals when treating children with ankle fractures—achieving a satisfactory reduction and avoiding physeal arrest so as to minimize the risks of angular deformity, early arthrosis, leg-length inequality, and joint stiffness.¹¹ Juvenile Tillaux fractures with greater than 2 mm of displacement require orthopedic consultation for closed or open reduction. Closed reduction is attempted by internally rotating the foot and applying direct pressure over the anterolateral tibia. If necessary, percutaneous pins can be used for stabilization of the reduction. If closed reduction is unsuccessful, open reduction is required. Care must be taken to assure no displacement occurs after casting; this requires weekly X-ray evaluation for the first 2 weeks.¹²

Patients with nondisplaced Salter-Harris III fractures are treated with long-leg casting for 4 weeks with conversion to a short-leg cast or boot for an additional 4 weeks. Patients should anticipate 8 weeks of nonweight-bearing. The patient is allowed to remove the boot for range-of-motion exercises but must remain nonweight-bearing for the first 2 weeks.¹⁴

Case 4
A 3-year-old previously healthy girl presented to the ED with a limp and difficulty bearing weight. Her mother reported that the child was playing in the yard when she caught her foot on a tree root, stumbled, and fell down. Since the incident, the child has been tearful, limping, and refusing to walk.

Tibial Fractures
Tibial fractures are among the most frequent types of orthopedic injuries in young children, with only femur and forearm fractures having a higher incidence of occurrence. Tibial fractures account for up to 15% of long bone fractures in children and adolescents.^16,17 The mechanism of injury varies depending on the patient’s age. In young children, the most common cause of injury is from a seemingly minor twisting around a fixed foot or from a minor fall. In older children and adults, high-energy motor vehicle accidents and sports-related injuries are more common causes.

Fractures of the tibial shaft are typically short oblique or transverse fractures of the middle or distal third of the shaft. Thirty percent of tibial shaft fractures are associated with fractures of the fibula.¹⁶

Toddler’s Fracture
The term toddler’s fracture refers to a nondisplaced oblique fracture of the tibial shaft without concomitant fibular fracture. It usually results from an indirect rotational or twisting force applied to the foot and lower leg.^16-18 More specifically, the term describes a specialized case of spiral fracture of the distal tibia in patients aged 9 months to 3 years, when weight-bearing is just beginning.^19,20 Such injuries commonly occur when a toddler stumbles and falls, or attempts to extricate the foot from between the bars of a crib. Often, however, the mechanism is minimal or unknown.¹⁸ Of those injuries that are witnessed, most caregivers report a minor twisting mechanism. Most children with toddler’s fracture are younger than age 6 years. Sixty-three of 76 such fractures reported by Dunbar et al^17,19 occurred in children younger than 2.5 years of age. Toddler’s fractures occur more often in boys than girls, and in the right leg more often than the left. Most children will give a history of tripping or twisting their ankle.¹⁷

Evaluating the Toddler
Toddlers can be challenging patients as they can not relate history and are often uncooperative on examination. A child may present with a limp, diminished movement of the affected limb, or refuse to bear weight without a distinct history of injury. The onset of limping or refusal to bear weight after minor trauma, or without an obvious injury in a young ambulatory child, warrants a detailed examination looking for tenderness over the tibia, along with radiographic evaluation to rule out a toddler’s fracture.

The examination of the patient is rarely impressive as there is little swelling and bruising with most toddlers’ fractures. A complete clinical history is needed, including a detailed description of any observed traumatic event to exclude the existence of other injuries.

When no traumatic event is observed or an inconsistent history is provided, the physician should obtain a detailed social history, including a list of the child’s most recent caregivers and contacts.¹⁶ Because of mild clinical symptoms and frequent lack of a history of injury in this patient population, presentation for evaluation may be delayed. In such cases, by the time the extremity is examined, the fracture has begun to heal. This healing phase may be accompanied by periosteal new bone and, in the absence of a history, may erroneously suggest other, more ominous conditions such as osteomylelitis or tumor.^17,18

Consideration of Abuse
Although tibial shaft fractures are rarely found in abused children, diagnosis of child abuse must be considered in cases where a tibial fracture is discovered in the nonambulatory child; his or her clinical history is inconsistent with the injury; and/or there are other physical findings suggestive of abuse. Investigation for suspected nonaccidental trauma includes a thorough physical examination, skeletal survey, and evaluation by social services personnel.¹⁶

 

Radiographic Imaging

Quality anteroposterior (AP) or lateral radiographs of the affected leg may show a hairline fracture, but these can easily be missed on initial plain films in almost a third of patients.²¹ An internal oblique view can aid in identifying nondisplaced toddler fractures.¹⁷ The AP view is the best view for observing the nondisplaced spiral fracture along the distal tibia (Figure 3).⁶ Occasionally, a fracture line is not identified on initial plain films and the first evidence of fracture becomes apparent on X-ray when new periosteal bone forms 7 to 10 days after the initial injury.

Definitive Treatment
Children with a classic history for a toddler’s fracture and an inability to bear weight should be immobilized with a long-leg splint or cast—even when X-rays are negative—until a definitive diagnosis can be made. Such fractures usually become visible on X-ray 7 to 10 days after injury as a result of new bone growth.²²

When definitive diagnosis of a toddler’s fracture is made on plain radiographs, the child should either be immobilized in a long-leg splint with referral to an orthopedist within 5 to 7 days, or immediately casted.¹⁶

Conclusion
Fractures in both children and adults are among the most common injury-related presentations to the ED. Based on the structure and increased elasticity of bone in the pediatric patient, there are several fracture patterns unique to this population. Appropriate evaluation, diagnosis, and management in the ED helps to maximize and ensure long-term function and healing while minimizing trauma to the patient.

Dr McBride is an associate professor of pediatrics and pediatric emergency medicine, Wake Forest Baptist Health, Brenner Children’s Hospital, Winston-Salem, North Carolina.
Dr Sutton is a pediatric resident, Wake Forest Baptist Health, Brenner Children’s Hospital, Winston-Salem, North Carolina.

Case 1
A 2-year-old girl presented to the ED with arm pain. Her mother stated that her daughter was playing with a 5-year-old sibling when she heard the child cry- out in pain and noticed she was holding her right arm by her side, not wanting to move it. Neither child gave a reliable story of the injury.

Nursemaid’s Elbow
Nursemaid’s elbow, also known as pulled elbow, subluxation of the radial head, and most recently annular ligament displacement, is a common injury in children younger than age 6 years. One study estimates that the condition represented about 1% of injury-related ED visits in 2005.¹

Patients with nursemaid’s elbow typically present holding the injured arm at their side, slightly flexed and pronated. These patients appear relatively comfortable until moved actively or passively. The classic history of nursemaid’s elbow includes a traction mechanism, with the child being pulled up by one arm or being grabbed by the arm suddenly to keep him or her out of harm’s way.² Due to the laxity of connective tissues in children of this age, the head of the radius slips out of the annular ligament causing acute pain and decreased function.

Nursemaid’s elbow is usually diagnosed by history and examination alone, with special consideration to the mechanism of injury. There is rarely swelling or bruising.³ Passive flexion and extension at the elbow may be normal, but rotational maneuvers can be painful or fully resisted.

Reduction Techniques
In 2012, Cochrane updated its earlier review on nursemaid’s elbow and in 2013 followed up with an article in Pediatrics in Review.^3,4 Each covered research on reduction techniques, summarizing studies comparing supination-flexion (SF) versus hyperpronation (HP) as the initial reduction maneuver. Given that these maneuvers are difficult to camouflage, studies tend to be pseudorandomized with assessment by a nonblinded healthcare provider, decreasing the strength of the studies. In the Cochrane review, four different trials that included 379 children under age 7 years were selected for the review. In all four studies, pronation was found to have the least chance of failed first attempt, the chosen outcome for this meta-analysis. The risk ratio of failure of reduction for pronation was 0.45 (95% confidence interval [CI], 0.28-0.73).

There is some data supporting hyperpronation to be less painful as well; however, the Cochrane reviewers felt there may have been reporting bias.⁴ Since the time of each of these reviews, another study comprised of 150 children was conducted and also favored similar practice styles, as the hyperpronation maneuver had 95% success rate on first attempt versus 68% first-time success with supination and flexion.⁵

Complications and Recurrence
In a small study aimed at identifying recurrence rates for nursemaid’s elbow, Teach and Schultzman⁶ studied 93 children for 1 year after probable or definite diagnosis of nursemaid’s elbow. Of these children, 23.7% had recurrent radial head subluxation.  Children younger than age 2 years were found to have a relative risk of 2.6 (95% CI, 1.04-6.30) for one or more recurrences when compared to children older than age 2 years.

While the great majority of children with nursemaid’s elbow do not need referral to an orthopedist, those with two or more occurrences should be considered for referral to a specialist.

Case 2
A 6-year-old boy was presented to the ED by his father, who had placed the boy’s arm in a home-made sling. The child tearfully told the provider that he fell trying to catch himself after tripping over the house pet.

FOOSH Injury
The above case depicts a very common presentation in the ED—the so-called “FOOSH” (fall onto an outstretched hand) injury. This type of injury occurs with such frequency in both adults and children that it is one of the only injury patterns with a commonly used acronym. The bony injuries seen with FOOSH in children, however, have a different pattern than those in adults.

Pediatric fractures are unique due to the difference in the structure of the bones themselves. A child’s bones are more elastic than an adult’s bones, allowing them to bow and bend before they fracture.⁷ Despite this malleability, pediatric bones have been noted to have a thicker periosteum. For this reason, compression or impact may interrupt the periosteal sleeve, minimally yielding an incomplete interruption of the cortex unilaterally.

One fracture pattern commonly seen in children is the torus fracture. This type of fracture is also referred to as a buckle fracture as the bone cortex on radiographic imaging appears “buckled” as a result of the compressive forces on that side of the bone (Figure 1). Since the bone itself is minimally affected, these fractures are quite stable and not at risk for complications. 

 

In comparison, a greenstick fracture, also unique to the pediatric population, is one in which the cortex shows plastic deformity on the side of the force or impact but is interrupted on the opposite side due to the tension of the impact itself. Greenstick fractures are frequently angulated and may require reduction for anatomic alignment, but long-term complications are typically minimal. These fracture patterns are distinguished from complete fractures (as seen in adults), which are quite unstable and generally require surgical intervention.

Of note, the location of pediatric forearm fractures varies with age as well.  Diaphyseal fractures are more common in prepubescent children, whereas  the highest incidence of physeal injuries occurs during large growth spurts, particularly throughout adolescence.⁷

Management
The remodeling potential of pediatric bones also makes management unique. Pediatric orthopedic literature has well-studied acceptable angles and degrees of appropriate displacement based largely on the age of the patient and proximity to a growth plate. Knowledge of these is imperative for definitive care of such fractures but is beyond the scope of this review.

Traditional treatment of pediatric forearm fractures includes immobilization of various types and duration to minimize pain and deformity while producing the best possible outcome. Several recent studies have aimed to determine best practice for the different fracture types with the goal of producing best alignment and return to function while decreasing cost, discomfort, and number of physician visits. Another concern among healthcare providers is the risk of refracture, which in buckle fractures is estimated at approximately 2% with a median time of 8 to 16 weeks after the initial injury.⁷

A 2010 review by Kennedy et al⁸ sought to determine if the refracture rate was affected by the technique used to immobilize torus fractures. The five studies used in this review had no reports of refracture in the 443 patients included in analysis, though only one of the studies (Plint et al) followed patients for more than 6 weeks.^8,9 In this study, 75 patients were randomized to either a plaster removable splint or full below-elbow cast for 3 weeks; thereafter, they were followed for 6 months, during which time none experienced refracture.⁹

Another outcome from the same study assessed the ability of the patient to use the affected arm in the recovery period. While those in removable splints scored better during and immediately after cast removal, no differences were present after 1 week. Not surprisingly, families preferred the soft bandages or a removable splint for treatment.

Case 3
A 13-year-old boy presented to the ED with right ankle pain and difficulty bearing weight. He stated that he was playing basketball when he “rolled” his right ankle coming down from a rebound.

Ankle Fractures
Ankle fractures are among the most common acute injuries of the lower extremity in children, accounting for approximately 5% of pediatric fractures and 15% of physeal injuries.¹⁰ Ankle fractures also account for up to 40% of all injuries to the skeletally immature athlete.^10,11 More specifically, distal fibular physeal fractures are the most common types of pediatric ankle fracture; however, they are associated with a relatively low risk for long-term complications. In contrast, distal tibial physeal fractures are associated with a higher risk for long-term complications.^12,13

Presentation and Evaluation
Typically, patients presenting with ankle fractures are too sore to bear weight, and swelling and ecchymosis can be identified anterior to the ankle. In addition, there may be diffuse tenderness throughout the ankle and point tenderness may be induced on the anterolateral aspect of the distal tibia.¹⁴ A complete evaluation of the entire lower extremity should be conducted before assuming that the injury is confined to the ankle, especially in children younger than age 5 years and/or who are nonverbal.¹⁰ When evaluating an ankle fracture, in general, orthopedic consultation should be obtained for children with neurovascular compromise, open fractures, and/or Salter-Harris III, IV, and V fractures.

The juvenile Tillaux fracture represents a Salter-Harris III physeal injury that involves the anterolateral portion of the tibia. It usually occurs in children between ages 12 and 14 years as they approach skeletal maturity and who have a partially fused tibial physis. The common mechanism of injury is inversion of the ankle with the foot pointed away from the midline (supination with external rotation). This leads to avulsion of the lateral tibial epiphysis that is attached to the anterior inferior tibiofibular ligament. The uninvolved medial portion of the epiphysis is closed.¹⁰

Radiographic Imaging

Three radiographic views should be obtained in the evaluation of pediatric ankle injuries as Tillaux fractures or other subtle injuries could be easily missed if only two views are obtained. Interpretation of the radiographs must be correlated with the physical examination.¹⁰ The fracture line is usually best seen on a mortise view (Figure 2). Computed tomography (CT) is warranted in cases in which displacement greater than 2 mm is suspected because it better defines fracture displacement and can aid in surgical planning.¹⁴ Because of its sensitivity in detecting fractures displaced more than 2 mm, CT is now the preferred imaging modality in the assessment of juvenile Tillaux fractures.¹⁵

 

Definitive Management
There are two important goals when treating children with ankle fractures—achieving a satisfactory reduction and avoiding physeal arrest so as to minimize the risks of angular deformity, early arthrosis, leg-length inequality, and joint stiffness.¹¹ Juvenile Tillaux fractures with greater than 2 mm of displacement require orthopedic consultation for closed or open reduction. Closed reduction is attempted by internally rotating the foot and applying direct pressure over the anterolateral tibia. If necessary, percutaneous pins can be used for stabilization of the reduction. If closed reduction is unsuccessful, open reduction is required. Care must be taken to assure no displacement occurs after casting; this requires weekly X-ray evaluation for the first 2 weeks.¹²

Patients with nondisplaced Salter-Harris III fractures are treated with long-leg casting for 4 weeks with conversion to a short-leg cast or boot for an additional 4 weeks. Patients should anticipate 8 weeks of nonweight-bearing. The patient is allowed to remove the boot for range-of-motion exercises but must remain nonweight-bearing for the first 2 weeks.¹⁴

Case 4
A 3-year-old previously healthy girl presented to the ED with a limp and difficulty bearing weight. Her mother reported that the child was playing in the yard when she caught her foot on a tree root, stumbled, and fell down. Since the incident, the child has been tearful, limping, and refusing to walk.

Tibial Fractures
Tibial fractures are among the most frequent types of orthopedic injuries in young children, with only femur and forearm fractures having a higher incidence of occurrence. Tibial fractures account for up to 15% of long bone fractures in children and adolescents.^16,17 The mechanism of injury varies depending on the patient’s age. In young children, the most common cause of injury is from a seemingly minor twisting around a fixed foot or from a minor fall. In older children and adults, high-energy motor vehicle accidents and sports-related injuries are more common causes.

Fractures of the tibial shaft are typically short oblique or transverse fractures of the middle or distal third of the shaft. Thirty percent of tibial shaft fractures are associated with fractures of the fibula.¹⁶

Toddler’s Fracture
The term toddler’s fracture refers to a nondisplaced oblique fracture of the tibial shaft without concomitant fibular fracture. It usually results from an indirect rotational or twisting force applied to the foot and lower leg.^16-18 More specifically, the term describes a specialized case of spiral fracture of the distal tibia in patients aged 9 months to 3 years, when weight-bearing is just beginning.^19,20 Such injuries commonly occur when a toddler stumbles and falls, or attempts to extricate the foot from between the bars of a crib. Often, however, the mechanism is minimal or unknown.¹⁸ Of those injuries that are witnessed, most caregivers report a minor twisting mechanism. Most children with toddler’s fracture are younger than age 6 years. Sixty-three of 76 such fractures reported by Dunbar et al^17,19 occurred in children younger than 2.5 years of age. Toddler’s fractures occur more often in boys than girls, and in the right leg more often than the left. Most children will give a history of tripping or twisting their ankle.¹⁷

Evaluating the Toddler
Toddlers can be challenging patients as they can not relate history and are often uncooperative on examination. A child may present with a limp, diminished movement of the affected limb, or refuse to bear weight without a distinct history of injury. The onset of limping or refusal to bear weight after minor trauma, or without an obvious injury in a young ambulatory child, warrants a detailed examination looking for tenderness over the tibia, along with radiographic evaluation to rule out a toddler’s fracture.

The examination of the patient is rarely impressive as there is little swelling and bruising with most toddlers’ fractures. A complete clinical history is needed, including a detailed description of any observed traumatic event to exclude the existence of other injuries.

When no traumatic event is observed or an inconsistent history is provided, the physician should obtain a detailed social history, including a list of the child’s most recent caregivers and contacts.¹⁶ Because of mild clinical symptoms and frequent lack of a history of injury in this patient population, presentation for evaluation may be delayed. In such cases, by the time the extremity is examined, the fracture has begun to heal. This healing phase may be accompanied by periosteal new bone and, in the absence of a history, may erroneously suggest other, more ominous conditions such as osteomylelitis or tumor.^17,18

Consideration of Abuse
Although tibial shaft fractures are rarely found in abused children, diagnosis of child abuse must be considered in cases where a tibial fracture is discovered in the nonambulatory child; his or her clinical history is inconsistent with the injury; and/or there are other physical findings suggestive of abuse. Investigation for suspected nonaccidental trauma includes a thorough physical examination, skeletal survey, and evaluation by social services personnel.¹⁶

 

Radiographic Imaging

Quality anteroposterior (AP) or lateral radiographs of the affected leg may show a hairline fracture, but these can easily be missed on initial plain films in almost a third of patients.²¹ An internal oblique view can aid in identifying nondisplaced toddler fractures.¹⁷ The AP view is the best view for observing the nondisplaced spiral fracture along the distal tibia (Figure 3).⁶ Occasionally, a fracture line is not identified on initial plain films and the first evidence of fracture becomes apparent on X-ray when new periosteal bone forms 7 to 10 days after the initial injury.

Definitive Treatment
Children with a classic history for a toddler’s fracture and an inability to bear weight should be immobilized with a long-leg splint or cast—even when X-rays are negative—until a definitive diagnosis can be made. Such fractures usually become visible on X-ray 7 to 10 days after injury as a result of new bone growth.²²

When definitive diagnosis of a toddler’s fracture is made on plain radiographs, the child should either be immobilized in a long-leg splint with referral to an orthopedist within 5 to 7 days, or immediately casted.¹⁶

Conclusion
Fractures in both children and adults are among the most common injury-related presentations to the ED. Based on the structure and increased elasticity of bone in the pediatric patient, there are several fracture patterns unique to this population. Appropriate evaluation, diagnosis, and management in the ED helps to maximize and ensure long-term function and healing while minimizing trauma to the patient.

Dr McBride is an associate professor of pediatrics and pediatric emergency medicine, Wake Forest Baptist Health, Brenner Children’s Hospital, Winston-Salem, North Carolina.
Dr Sutton is a pediatric resident, Wake Forest Baptist Health, Brenner Children’s Hospital, Winston-Salem, North Carolina.

Case 1
A 2-year-old girl presented to the ED with arm pain. Her mother stated that her daughter was playing with a 5-year-old sibling when she heard the child cry- out in pain and noticed she was holding her right arm by her side, not wanting to move it. Neither child gave a reliable story of the injury.

Nursemaid’s Elbow
Nursemaid’s elbow, also known as pulled elbow, subluxation of the radial head, and most recently annular ligament displacement, is a common injury in children younger than age 6 years. One study estimates that the condition represented about 1% of injury-related ED visits in 2005.¹

Patients with nursemaid’s elbow typically present holding the injured arm at their side, slightly flexed and pronated. These patients appear relatively comfortable until moved actively or passively. The classic history of nursemaid’s elbow includes a traction mechanism, with the child being pulled up by one arm or being grabbed by the arm suddenly to keep him or her out of harm’s way.² Due to the laxity of connective tissues in children of this age, the head of the radius slips out of the annular ligament causing acute pain and decreased function.

Nursemaid’s elbow is usually diagnosed by history and examination alone, with special consideration to the mechanism of injury. There is rarely swelling or bruising.³ Passive flexion and extension at the elbow may be normal, but rotational maneuvers can be painful or fully resisted.

Reduction Techniques
In 2012, Cochrane updated its earlier review on nursemaid’s elbow and in 2013 followed up with an article in Pediatrics in Review.^3,4 Each covered research on reduction techniques, summarizing studies comparing supination-flexion (SF) versus hyperpronation (HP) as the initial reduction maneuver. Given that these maneuvers are difficult to camouflage, studies tend to be pseudorandomized with assessment by a nonblinded healthcare provider, decreasing the strength of the studies. In the Cochrane review, four different trials that included 379 children under age 7 years were selected for the review. In all four studies, pronation was found to have the least chance of failed first attempt, the chosen outcome for this meta-analysis. The risk ratio of failure of reduction for pronation was 0.45 (95% confidence interval [CI], 0.28-0.73).

There is some data supporting hyperpronation to be less painful as well; however, the Cochrane reviewers felt there may have been reporting bias.⁴ Since the time of each of these reviews, another study comprised of 150 children was conducted and also favored similar practice styles, as the hyperpronation maneuver had 95% success rate on first attempt versus 68% first-time success with supination and flexion.⁵

Complications and Recurrence
In a small study aimed at identifying recurrence rates for nursemaid’s elbow, Teach and Schultzman⁶ studied 93 children for 1 year after probable or definite diagnosis of nursemaid’s elbow. Of these children, 23.7% had recurrent radial head subluxation.  Children younger than age 2 years were found to have a relative risk of 2.6 (95% CI, 1.04-6.30) for one or more recurrences when compared to children older than age 2 years.

While the great majority of children with nursemaid’s elbow do not need referral to an orthopedist, those with two or more occurrences should be considered for referral to a specialist.

Case 2
A 6-year-old boy was presented to the ED by his father, who had placed the boy’s arm in a home-made sling. The child tearfully told the provider that he fell trying to catch himself after tripping over the house pet.

FOOSH Injury
The above case depicts a very common presentation in the ED—the so-called “FOOSH” (fall onto an outstretched hand) injury. This type of injury occurs with such frequency in both adults and children that it is one of the only injury patterns with a commonly used acronym. The bony injuries seen with FOOSH in children, however, have a different pattern than those in adults.

Pediatric fractures are unique due to the difference in the structure of the bones themselves. A child’s bones are more elastic than an adult’s bones, allowing them to bow and bend before they fracture.⁷ Despite this malleability, pediatric bones have been noted to have a thicker periosteum. For this reason, compression or impact may interrupt the periosteal sleeve, minimally yielding an incomplete interruption of the cortex unilaterally.

One fracture pattern commonly seen in children is the torus fracture. This type of fracture is also referred to as a buckle fracture as the bone cortex on radiographic imaging appears “buckled” as a result of the compressive forces on that side of the bone (Figure 1). Since the bone itself is minimally affected, these fractures are quite stable and not at risk for complications. 

 

In comparison, a greenstick fracture, also unique to the pediatric population, is one in which the cortex shows plastic deformity on the side of the force or impact but is interrupted on the opposite side due to the tension of the impact itself. Greenstick fractures are frequently angulated and may require reduction for anatomic alignment, but long-term complications are typically minimal. These fracture patterns are distinguished from complete fractures (as seen in adults), which are quite unstable and generally require surgical intervention.

Of note, the location of pediatric forearm fractures varies with age as well.  Diaphyseal fractures are more common in prepubescent children, whereas  the highest incidence of physeal injuries occurs during large growth spurts, particularly throughout adolescence.⁷

Management
The remodeling potential of pediatric bones also makes management unique. Pediatric orthopedic literature has well-studied acceptable angles and degrees of appropriate displacement based largely on the age of the patient and proximity to a growth plate. Knowledge of these is imperative for definitive care of such fractures but is beyond the scope of this review.

Traditional treatment of pediatric forearm fractures includes immobilization of various types and duration to minimize pain and deformity while producing the best possible outcome. Several recent studies have aimed to determine best practice for the different fracture types with the goal of producing best alignment and return to function while decreasing cost, discomfort, and number of physician visits. Another concern among healthcare providers is the risk of refracture, which in buckle fractures is estimated at approximately 2% with a median time of 8 to 16 weeks after the initial injury.⁷

A 2010 review by Kennedy et al⁸ sought to determine if the refracture rate was affected by the technique used to immobilize torus fractures. The five studies used in this review had no reports of refracture in the 443 patients included in analysis, though only one of the studies (Plint et al) followed patients for more than 6 weeks.^8,9 In this study, 75 patients were randomized to either a plaster removable splint or full below-elbow cast for 3 weeks; thereafter, they were followed for 6 months, during which time none experienced refracture.⁹

Another outcome from the same study assessed the ability of the patient to use the affected arm in the recovery period. While those in removable splints scored better during and immediately after cast removal, no differences were present after 1 week. Not surprisingly, families preferred the soft bandages or a removable splint for treatment.

Case 3
A 13-year-old boy presented to the ED with right ankle pain and difficulty bearing weight. He stated that he was playing basketball when he “rolled” his right ankle coming down from a rebound.

Ankle Fractures
Ankle fractures are among the most common acute injuries of the lower extremity in children, accounting for approximately 5% of pediatric fractures and 15% of physeal injuries.¹⁰ Ankle fractures also account for up to 40% of all injuries to the skeletally immature athlete.^10,11 More specifically, distal fibular physeal fractures are the most common types of pediatric ankle fracture; however, they are associated with a relatively low risk for long-term complications. In contrast, distal tibial physeal fractures are associated with a higher risk for long-term complications.^12,13

Presentation and Evaluation
Typically, patients presenting with ankle fractures are too sore to bear weight, and swelling and ecchymosis can be identified anterior to the ankle. In addition, there may be diffuse tenderness throughout the ankle and point tenderness may be induced on the anterolateral aspect of the distal tibia.¹⁴ A complete evaluation of the entire lower extremity should be conducted before assuming that the injury is confined to the ankle, especially in children younger than age 5 years and/or who are nonverbal.¹⁰ When evaluating an ankle fracture, in general, orthopedic consultation should be obtained for children with neurovascular compromise, open fractures, and/or Salter-Harris III, IV, and V fractures.

The juvenile Tillaux fracture represents a Salter-Harris III physeal injury that involves the anterolateral portion of the tibia. It usually occurs in children between ages 12 and 14 years as they approach skeletal maturity and who have a partially fused tibial physis. The common mechanism of injury is inversion of the ankle with the foot pointed away from the midline (supination with external rotation). This leads to avulsion of the lateral tibial epiphysis that is attached to the anterior inferior tibiofibular ligament. The uninvolved medial portion of the epiphysis is closed.¹⁰

Radiographic Imaging

Three radiographic views should be obtained in the evaluation of pediatric ankle injuries as Tillaux fractures or other subtle injuries could be easily missed if only two views are obtained. Interpretation of the radiographs must be correlated with the physical examination.¹⁰ The fracture line is usually best seen on a mortise view (Figure 2). Computed tomography (CT) is warranted in cases in which displacement greater than 2 mm is suspected because it better defines fracture displacement and can aid in surgical planning.¹⁴ Because of its sensitivity in detecting fractures displaced more than 2 mm, CT is now the preferred imaging modality in the assessment of juvenile Tillaux fractures.¹⁵

 

Definitive Management
There are two important goals when treating children with ankle fractures—achieving a satisfactory reduction and avoiding physeal arrest so as to minimize the risks of angular deformity, early arthrosis, leg-length inequality, and joint stiffness.¹¹ Juvenile Tillaux fractures with greater than 2 mm of displacement require orthopedic consultation for closed or open reduction. Closed reduction is attempted by internally rotating the foot and applying direct pressure over the anterolateral tibia. If necessary, percutaneous pins can be used for stabilization of the reduction. If closed reduction is unsuccessful, open reduction is required. Care must be taken to assure no displacement occurs after casting; this requires weekly X-ray evaluation for the first 2 weeks.¹²

Patients with nondisplaced Salter-Harris III fractures are treated with long-leg casting for 4 weeks with conversion to a short-leg cast or boot for an additional 4 weeks. Patients should anticipate 8 weeks of nonweight-bearing. The patient is allowed to remove the boot for range-of-motion exercises but must remain nonweight-bearing for the first 2 weeks.¹⁴

Case 4
A 3-year-old previously healthy girl presented to the ED with a limp and difficulty bearing weight. Her mother reported that the child was playing in the yard when she caught her foot on a tree root, stumbled, and fell down. Since the incident, the child has been tearful, limping, and refusing to walk.

Tibial Fractures
Tibial fractures are among the most frequent types of orthopedic injuries in young children, with only femur and forearm fractures having a higher incidence of occurrence. Tibial fractures account for up to 15% of long bone fractures in children and adolescents.^16,17 The mechanism of injury varies depending on the patient’s age. In young children, the most common cause of injury is from a seemingly minor twisting around a fixed foot or from a minor fall. In older children and adults, high-energy motor vehicle accidents and sports-related injuries are more common causes.

Fractures of the tibial shaft are typically short oblique or transverse fractures of the middle or distal third of the shaft. Thirty percent of tibial shaft fractures are associated with fractures of the fibula.¹⁶

Toddler’s Fracture
The term toddler’s fracture refers to a nondisplaced oblique fracture of the tibial shaft without concomitant fibular fracture. It usually results from an indirect rotational or twisting force applied to the foot and lower leg.^16-18 More specifically, the term describes a specialized case of spiral fracture of the distal tibia in patients aged 9 months to 3 years, when weight-bearing is just beginning.^19,20 Such injuries commonly occur when a toddler stumbles and falls, or attempts to extricate the foot from between the bars of a crib. Often, however, the mechanism is minimal or unknown.¹⁸ Of those injuries that are witnessed, most caregivers report a minor twisting mechanism. Most children with toddler’s fracture are younger than age 6 years. Sixty-three of 76 such fractures reported by Dunbar et al^17,19 occurred in children younger than 2.5 years of age. Toddler’s fractures occur more often in boys than girls, and in the right leg more often than the left. Most children will give a history of tripping or twisting their ankle.¹⁷

Evaluating the Toddler
Toddlers can be challenging patients as they can not relate history and are often uncooperative on examination. A child may present with a limp, diminished movement of the affected limb, or refuse to bear weight without a distinct history of injury. The onset of limping or refusal to bear weight after minor trauma, or without an obvious injury in a young ambulatory child, warrants a detailed examination looking for tenderness over the tibia, along with radiographic evaluation to rule out a toddler’s fracture.

The examination of the patient is rarely impressive as there is little swelling and bruising with most toddlers’ fractures. A complete clinical history is needed, including a detailed description of any observed traumatic event to exclude the existence of other injuries.

When no traumatic event is observed or an inconsistent history is provided, the physician should obtain a detailed social history, including a list of the child’s most recent caregivers and contacts.¹⁶ Because of mild clinical symptoms and frequent lack of a history of injury in this patient population, presentation for evaluation may be delayed. In such cases, by the time the extremity is examined, the fracture has begun to heal. This healing phase may be accompanied by periosteal new bone and, in the absence of a history, may erroneously suggest other, more ominous conditions such as osteomylelitis or tumor.^17,18

Consideration of Abuse
Although tibial shaft fractures are rarely found in abused children, diagnosis of child abuse must be considered in cases where a tibial fracture is discovered in the nonambulatory child; his or her clinical history is inconsistent with the injury; and/or there are other physical findings suggestive of abuse. Investigation for suspected nonaccidental trauma includes a thorough physical examination, skeletal survey, and evaluation by social services personnel.¹⁶

 

Radiographic Imaging

Quality anteroposterior (AP) or lateral radiographs of the affected leg may show a hairline fracture, but these can easily be missed on initial plain films in almost a third of patients.²¹ An internal oblique view can aid in identifying nondisplaced toddler fractures.¹⁷ The AP view is the best view for observing the nondisplaced spiral fracture along the distal tibia (Figure 3).⁶ Occasionally, a fracture line is not identified on initial plain films and the first evidence of fracture becomes apparent on X-ray when new periosteal bone forms 7 to 10 days after the initial injury.

Definitive Treatment
Children with a classic history for a toddler’s fracture and an inability to bear weight should be immobilized with a long-leg splint or cast—even when X-rays are negative—until a definitive diagnosis can be made. Such fractures usually become visible on X-ray 7 to 10 days after injury as a result of new bone growth.²²

When definitive diagnosis of a toddler’s fracture is made on plain radiographs, the child should either be immobilized in a long-leg splint with referral to an orthopedist within 5 to 7 days, or immediately casted.¹⁶

Conclusion
Fractures in both children and adults are among the most common injury-related presentations to the ED. Based on the structure and increased elasticity of bone in the pediatric patient, there are several fracture patterns unique to this population. Appropriate evaluation, diagnosis, and management in the ED helps to maximize and ensure long-term function and healing while minimizing trauma to the patient.

Dr McBride is an associate professor of pediatrics and pediatric emergency medicine, Wake Forest Baptist Health, Brenner Children’s Hospital, Winston-Salem, North Carolina.
Dr Sutton is a pediatric resident, Wake Forest Baptist Health, Brenner Children’s Hospital, Winston-Salem, North Carolina.

Abdominal Ultrasound

An abdominal ultrasound to assess for small bowel obstruction (SBO) is performed with the curvilinear low-frequency probe, scanning the most dependent portions of the abdomen as fluid-filled loops will be most easily identified in these areas. The exact pattern is not important as long as one ensures that the entire dependant portions of the abdomen are examined.

Clinical Signs

There are several signs to look for on ultrasound to make the diagnosis of SBO, the first of which is dilated loops of bowel >25 mm (Figure 1). Another sign is the “to and fro” peristalsis of bowel contents, also called dysfunctional peristalsis. In addition, clinicians should look for fingerlike projections from the inner wall of the intestine also referred to as the “keyboard” sign (Figure 2). These projections, the plicae circulares, become apparent in cases of SBO.

Figure 1

Figure 2

Clinical Importance

Ultrasound, readily available in many EDs, can help emergency physicians (EPs) to rapidly diagnosis SBO, as well as herniated bowel and fascial defects (Figure 3). This imaging modality should be used in a similar diagnostic manner as abdominal X-ray.

A recent study by Jang et al1 evaluating a sample of symptomatic ED patients showed 81% to 97% specificity of ultrasound in detecting obstruction (depending upon the ultrasound finding employed) compared to abdominal X-ray at 66%.1 This study further reported that dilated loops of bowel on ultrasound had a sensitivity of 91% and a specificity of 84%. In addition, a meta-analysis by Taylor and Lalani2 looking at bedside ultrasound in the ED showed a positive likelihood ratio of 9.55.

Conclusion

Even though computed tomography remains the gold standard for the diagnosis for SBO, the studies summarized above demonstrate the benefits of using bedside ultrasound in the ED setting. In addition to improving diagnostic capabilities, this modality assists the EP in quickly diagnosing this condition.

Dr Taylor is an assistant professor and director of postgraduate medical education, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia. Dr Meer is an assistant professor and director of emergency ultrasound, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia. Dr Beck is an assistant professor, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia.

Abdominal Ultrasound

An abdominal ultrasound to assess for small bowel obstruction (SBO) is performed with the curvilinear low-frequency probe, scanning the most dependent portions of the abdomen as fluid-filled loops will be most easily identified in these areas. The exact pattern is not important as long as one ensures that the entire dependant portions of the abdomen are examined.

Clinical Signs

There are several signs to look for on ultrasound to make the diagnosis of SBO, the first of which is dilated loops of bowel >25 mm (Figure 1). Another sign is the “to and fro” peristalsis of bowel contents, also called dysfunctional peristalsis. In addition, clinicians should look for fingerlike projections from the inner wall of the intestine also referred to as the “keyboard” sign (Figure 2). These projections, the plicae circulares, become apparent in cases of SBO.

Figure 1

Figure 2

Clinical Importance

Ultrasound, readily available in many EDs, can help emergency physicians (EPs) to rapidly diagnosis SBO, as well as herniated bowel and fascial defects (Figure 3). This imaging modality should be used in a similar diagnostic manner as abdominal X-ray.

A recent study by Jang et al1 evaluating a sample of symptomatic ED patients showed 81% to 97% specificity of ultrasound in detecting obstruction (depending upon the ultrasound finding employed) compared to abdominal X-ray at 66%.1 This study further reported that dilated loops of bowel on ultrasound had a sensitivity of 91% and a specificity of 84%. In addition, a meta-analysis by Taylor and Lalani2 looking at bedside ultrasound in the ED showed a positive likelihood ratio of 9.55.

Conclusion

Even though computed tomography remains the gold standard for the diagnosis for SBO, the studies summarized above demonstrate the benefits of using bedside ultrasound in the ED setting. In addition to improving diagnostic capabilities, this modality assists the EP in quickly diagnosing this condition.

Dr Taylor is an assistant professor and director of postgraduate medical education, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia. Dr Meer is an assistant professor and director of emergency ultrasound, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia. Dr Beck is an assistant professor, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia.

Abdominal Ultrasound

An abdominal ultrasound to assess for small bowel obstruction (SBO) is performed with the curvilinear low-frequency probe, scanning the most dependent portions of the abdomen as fluid-filled loops will be most easily identified in these areas. The exact pattern is not important as long as one ensures that the entire dependant portions of the abdomen are examined.

Clinical Signs

There are several signs to look for on ultrasound to make the diagnosis of SBO, the first of which is dilated loops of bowel >25 mm (Figure 1). Another sign is the “to and fro” peristalsis of bowel contents, also called dysfunctional peristalsis. In addition, clinicians should look for fingerlike projections from the inner wall of the intestine also referred to as the “keyboard” sign (Figure 2). These projections, the plicae circulares, become apparent in cases of SBO.

Figure 1

Figure 2

Clinical Importance

Ultrasound, readily available in many EDs, can help emergency physicians (EPs) to rapidly diagnosis SBO, as well as herniated bowel and fascial defects (Figure 3). This imaging modality should be used in a similar diagnostic manner as abdominal X-ray.

A recent study by Jang et al1 evaluating a sample of symptomatic ED patients showed 81% to 97% specificity of ultrasound in detecting obstruction (depending upon the ultrasound finding employed) compared to abdominal X-ray at 66%.1 This study further reported that dilated loops of bowel on ultrasound had a sensitivity of 91% and a specificity of 84%. In addition, a meta-analysis by Taylor and Lalani2 looking at bedside ultrasound in the ED showed a positive likelihood ratio of 9.55.

Conclusion

Even though computed tomography remains the gold standard for the diagnosis for SBO, the studies summarized above demonstrate the benefits of using bedside ultrasound in the ED setting. In addition to improving diagnostic capabilities, this modality assists the EP in quickly diagnosing this condition.

Dr Taylor is an assistant professor and director of postgraduate medical education, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia. Dr Meer is an assistant professor and director of emergency ultrasound, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia. Dr Beck is an assistant professor, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia.

An 11-year-old boy is brought to the ED with a 1-week of history of increasing crampy lower-quadrant abdominal pain. His vital signs were only significant for mild tachycardia. On physical examination, the child’s abdomen was tender to palpation in the bilateral lower abdominal quadrants with guarding. Laboratory evaluations were unremarkable.

An abdominal radiograph did not reveal any abnormality, and targeted ultrasound did not reveal a dilated appendix. Computed tomography (CT) of the abdomen and pelvis with oral and intravenous contrast were ordered and representative images are provided (Figures 1a and 1b). Note that additional images from the CT demonstrate the abnormality depicted in these figures was not a loop of small bowel (although it appeared to originate from a loop of distal small bowel) and that the appendix was normal.

Figure 1A

Figure 1B

What is the diagnosis?

 

Answer

Computed tomography revealed a blind-ending tubular structure (white arrows, Figure 1c) deep to the umbilicus arising inferiorly from a loop of distal ileum with surrounding fat stranding (Figure 1d). The fluid-containing tubular structure demonstrates marked enhancement of the mucosa. These findings are most consistent with Meckel’s diverticulitis.

Meckel’s diverticulum is the most common anomaly of the gastrointestinal (GI) tract and results from incomplete obliteration of the vitelline duct. As per the rule of “twos,” Meckel’s diverticulum usually occurs 2 feet (40-60 cm) proximal to the ileocecal valve; is 2 cm wide (and 3 cm long); is found in 2% of the population; typically presents before age 2 years; is twice as likely to be symptomatic in boys; and contains ectopic gastric mucosa in approximately half of the cases.¹

Figure 1C

Figure 1D

As many patients are asymptomatic, Meckel’s diverticulum is diagnosed as an incidental finding after a barium study or abdominal surgery is performed for other GI conditions. Symptoms occur as a result of ectopic gastric tissue, obstruction, and/or inflammation. Painless lower GI bleeding, the most common presentation, is reported in up to 50% of patients with symptomatic Meckel’s diverticulosis.² Hemorrhage results from ulceration caused by secreted acid and enzymes from ectopic digestive mucosa. Intestinal obstruction is another common complication usually seen in children, which can be caused by volvulus of the small bowel around a diverticulum, intussusception, incarceration within a hernia, and internal herniation. Inflammation of the Meckel’s diverticulum, or Meckel’s diverticulitis, is more common in older patients and presents similarly to acute appendicitis.²

After removal of a complicated Meckel’s diverticulitis, postoperative morbidity and mortality rates have been reported to be 12% and 2%, respectively. In contrast, postoperative complications after resection of incidental diverticula are fewer, and morbidity and mortality rates are as low as 2% and 1%, respectively.^3-5 Meckel’s diverticulitis should be included as a differential diagnosis when appendicitis or medically managed abdominopelvic inflammatory processes are suspected, as delayed diagnosis can lead to perforation, abscess formation, peritonitis, sepsis, bowel obstruction, and death.

The patient presented in this case was taken to the operating room, and the Meckel’s diverticula confirmed and removed. He experienced an uneventful postoperative course and was discharged a few days later.

Dr Rotman is a radiology resident at Weill Cornell Medical College in New York City. Dr Belfi is an assistant professor of radiology at Weill Cornell Medical College in New York City and an assistant attending radiologist at New York-Presbyterian Hospital/Weill Cornell Medical Center. Dr Hentel is an associate professor of clinical radiology, Weill Cornell Medical College, New York. He is also chief of emergency/musculoskeletal imaging and executive vice-chairman for the department of radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center. He is associate editor, imaging, of the EMERGENCY MEDICINE editorial board.

An 11-year-old boy is brought to the ED with a 1-week of history of increasing crampy lower-quadrant abdominal pain. His vital signs were only significant for mild tachycardia. On physical examination, the child’s abdomen was tender to palpation in the bilateral lower abdominal quadrants with guarding. Laboratory evaluations were unremarkable.

An abdominal radiograph did not reveal any abnormality, and targeted ultrasound did not reveal a dilated appendix. Computed tomography (CT) of the abdomen and pelvis with oral and intravenous contrast were ordered and representative images are provided (Figures 1a and 1b). Note that additional images from the CT demonstrate the abnormality depicted in these figures was not a loop of small bowel (although it appeared to originate from a loop of distal small bowel) and that the appendix was normal.

Figure 1A

Figure 1B

What is the diagnosis?

 

Answer

Computed tomography revealed a blind-ending tubular structure (white arrows, Figure 1c) deep to the umbilicus arising inferiorly from a loop of distal ileum with surrounding fat stranding (Figure 1d). The fluid-containing tubular structure demonstrates marked enhancement of the mucosa. These findings are most consistent with Meckel’s diverticulitis.

Meckel’s diverticulum is the most common anomaly of the gastrointestinal (GI) tract and results from incomplete obliteration of the vitelline duct. As per the rule of “twos,” Meckel’s diverticulum usually occurs 2 feet (40-60 cm) proximal to the ileocecal valve; is 2 cm wide (and 3 cm long); is found in 2% of the population; typically presents before age 2 years; is twice as likely to be symptomatic in boys; and contains ectopic gastric mucosa in approximately half of the cases.¹

Figure 1C

Figure 1D

As many patients are asymptomatic, Meckel’s diverticulum is diagnosed as an incidental finding after a barium study or abdominal surgery is performed for other GI conditions. Symptoms occur as a result of ectopic gastric tissue, obstruction, and/or inflammation. Painless lower GI bleeding, the most common presentation, is reported in up to 50% of patients with symptomatic Meckel’s diverticulosis.² Hemorrhage results from ulceration caused by secreted acid and enzymes from ectopic digestive mucosa. Intestinal obstruction is another common complication usually seen in children, which can be caused by volvulus of the small bowel around a diverticulum, intussusception, incarceration within a hernia, and internal herniation. Inflammation of the Meckel’s diverticulum, or Meckel’s diverticulitis, is more common in older patients and presents similarly to acute appendicitis.²

After removal of a complicated Meckel’s diverticulitis, postoperative morbidity and mortality rates have been reported to be 12% and 2%, respectively. In contrast, postoperative complications after resection of incidental diverticula are fewer, and morbidity and mortality rates are as low as 2% and 1%, respectively.^3-5 Meckel’s diverticulitis should be included as a differential diagnosis when appendicitis or medically managed abdominopelvic inflammatory processes are suspected, as delayed diagnosis can lead to perforation, abscess formation, peritonitis, sepsis, bowel obstruction, and death.

The patient presented in this case was taken to the operating room, and the Meckel’s diverticula confirmed and removed. He experienced an uneventful postoperative course and was discharged a few days later.

Dr Rotman is a radiology resident at Weill Cornell Medical College in New York City. Dr Belfi is an assistant professor of radiology at Weill Cornell Medical College in New York City and an assistant attending radiologist at New York-Presbyterian Hospital/Weill Cornell Medical Center. Dr Hentel is an associate professor of clinical radiology, Weill Cornell Medical College, New York. He is also chief of emergency/musculoskeletal imaging and executive vice-chairman for the department of radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center. He is associate editor, imaging, of the EMERGENCY MEDICINE editorial board.

An 11-year-old boy is brought to the ED with a 1-week of history of increasing crampy lower-quadrant abdominal pain. His vital signs were only significant for mild tachycardia. On physical examination, the child’s abdomen was tender to palpation in the bilateral lower abdominal quadrants with guarding. Laboratory evaluations were unremarkable.

An abdominal radiograph did not reveal any abnormality, and targeted ultrasound did not reveal a dilated appendix. Computed tomography (CT) of the abdomen and pelvis with oral and intravenous contrast were ordered and representative images are provided (Figures 1a and 1b). Note that additional images from the CT demonstrate the abnormality depicted in these figures was not a loop of small bowel (although it appeared to originate from a loop of distal small bowel) and that the appendix was normal.

Figure 1A

Figure 1B

What is the diagnosis?

 

Answer

Computed tomography revealed a blind-ending tubular structure (white arrows, Figure 1c) deep to the umbilicus arising inferiorly from a loop of distal ileum with surrounding fat stranding (Figure 1d). The fluid-containing tubular structure demonstrates marked enhancement of the mucosa. These findings are most consistent with Meckel’s diverticulitis.

Meckel’s diverticulum is the most common anomaly of the gastrointestinal (GI) tract and results from incomplete obliteration of the vitelline duct. As per the rule of “twos,” Meckel’s diverticulum usually occurs 2 feet (40-60 cm) proximal to the ileocecal valve; is 2 cm wide (and 3 cm long); is found in 2% of the population; typically presents before age 2 years; is twice as likely to be symptomatic in boys; and contains ectopic gastric mucosa in approximately half of the cases.¹

Figure 1C

Figure 1D

As many patients are asymptomatic, Meckel’s diverticulum is diagnosed as an incidental finding after a barium study or abdominal surgery is performed for other GI conditions. Symptoms occur as a result of ectopic gastric tissue, obstruction, and/or inflammation. Painless lower GI bleeding, the most common presentation, is reported in up to 50% of patients with symptomatic Meckel’s diverticulosis.² Hemorrhage results from ulceration caused by secreted acid and enzymes from ectopic digestive mucosa. Intestinal obstruction is another common complication usually seen in children, which can be caused by volvulus of the small bowel around a diverticulum, intussusception, incarceration within a hernia, and internal herniation. Inflammation of the Meckel’s diverticulum, or Meckel’s diverticulitis, is more common in older patients and presents similarly to acute appendicitis.²

After removal of a complicated Meckel’s diverticulitis, postoperative morbidity and mortality rates have been reported to be 12% and 2%, respectively. In contrast, postoperative complications after resection of incidental diverticula are fewer, and morbidity and mortality rates are as low as 2% and 1%, respectively.^3-5 Meckel’s diverticulitis should be included as a differential diagnosis when appendicitis or medically managed abdominopelvic inflammatory processes are suspected, as delayed diagnosis can lead to perforation, abscess formation, peritonitis, sepsis, bowel obstruction, and death.

The patient presented in this case was taken to the operating room, and the Meckel’s diverticula confirmed and removed. He experienced an uneventful postoperative course and was discharged a few days later.

Dr Rotman is a radiology resident at Weill Cornell Medical College in New York City. Dr Belfi is an assistant professor of radiology at Weill Cornell Medical College in New York City and an assistant attending radiologist at New York-Presbyterian Hospital/Weill Cornell Medical Center. Dr Hentel is an associate professor of clinical radiology, Weill Cornell Medical College, New York. He is also chief of emergency/musculoskeletal imaging and executive vice-chairman for the department of radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center. He is associate editor, imaging, of the EMERGENCY MEDICINE editorial board.