Morning Report 5/11/05 Corey Mayfield, Robert Marks, Stephen Ratcliff, Joslyn Witherspoon, Cassie Huynh HPI 3 yo Hispanic Male with no significant PMH presents to UTMB ER with c/o of left hip pain x 2d Patient’s mother states that 2 days ago patient experienced pain and unwillingness to bear weight on left leg Patient reported to his mother that he fell down the stairs Day prior to admission the patient had difficulty ambulating but no bruises or swelling noted Patient had URI symptoms approximately 1 wk ago but no fever Decreased PO intake 2 days prior to admission, but on admission normal PO intake with normal UOP Patient has never had these symptoms before, denies bowel or bladder incontinence or other limb weakness Birth History Born a 4175 gm TAGA male to a G5P4 mom delivered via scheduled C-section (low transverse) Normal nursery course Other History PMH: Nurse maid’s elbow secondary to trauma; innocent murmur FH: GM with uterine and breast CA; + FH of seizures SH: lives with both parents and siblings (14 and 16 yo boy, 1 yo girl) in Crystal Beach; mom is BICU nurse; MGM watches kids during day; + cats, dogs, horse; MGM smokes outside house Other History Meds: MVI Immunizations: UTD per mom Allergies: NKDA Diet: Eats from all food groups, good appetite, regular schedule Developmental: walked at approx. 1 year of age, can dress himself, hop in place; speaks full sentences, yet has problems with “s” sounds and is being followed by speech therapist; greater than 500 word vocabulary Physical Exam Vitals: T 37.9 ; HR 127; BP 107/60; RR 24 Measurements: Wt 14 kg (50%) PE (cont) General: NAD, Alert, Lying in bed, Appears non-toxic HEENT: NCAT; PERRL;EOMI; Conjunctiva pink; No eye discharge; TMs clear bilateral; MMM; neck supple; No LAD Lungs: CTAB; no W/R/R CV: RRR; normal S1/S2; II/VI SEM; cap refill <2 sec, brisk Abd: soft, NT/ND; NABS x 4; No HSM PE (cont) GU: Normal male; descended testes Ext: Left hip exquisitely tender to palpation, decreased ROM 2 pain, ↓ abduction > adduction, no swelling or erythema, no crepitus or fluctuance, no superficial skin changes, patient voluntarily keeping left hip flexed at 30 degrees, right hip full ROM, pulses 2+ bilaterally, wiggles toes Neuro: CN II-XII intact, good tone, DTR 2+ and symmetrical, sensation grossly intact Skin: warm, dry, no rashes, 2mm abrasions on right knee What do you think… Problems? Differential Diagnoses? Labs/Imaging? Labs CBC w/Diff – WBC 15.0 G 71.1 L 13.0 M 14.0 E 1.5 B 0.4 ESR 74 (NML 0-10) CRP 32 (NML 0-0.8) – Hb 12.3 – Hct 35.9 – Plt 369 Imaging Left Hip X-Ray – Widened left hip joint superiorly. No evidence of fracture. Left Hip US – Increased fluid present in left hip joint. Consults Orthopedics – Evaluated patient and diagnosed with septic hip vs. transient synovitis Septic Hip vs Transient Synovitis Septic Hip vs Transient Synovitis To minimize tension: - Flexed Abducted Externally rotated *Both may present this way* Why do we care? Prognosis! If left untreated: – Septic Arthritis (Bacterial) Dislocation, subluxation, coxa vara/breva (defects of ossification of the femoral neck), absence of head & neck of femur, degenerative (postinfectious) arthritis, leg length discrepancy (3-4 inch). Complete destruction of the hip joint. Limited course, no treatment required! Full recovery. May develop Legg-Calve-Perthes Disease in ~2 years. – Relationship unclear – Transient Synovitis (Viral, probably) **WE DON’T WANT TO CONFUSE THESE TWO!!! Pathogenesis Septic Arthritis: – Osteomyelitis of the femoral neck Synovial Membrane – Bacteremia – Faulty Femoral Culture – Septic Organisms: >50% of neonates; 20% of infants Why? Staph Aureus > Streptococcus Rarely: Neisseria meningitidis, Kingella kingae, Pseudomonas aeurginosa Transient Arthritis: – Toxic Post traumatic event or URI; Viral etiology suspected MOST common cause of hip pain in children <10 y/o other joints also involved – Rheumatoid The Matchup (Diagnosis) Septic Arthritis – – – – – – – – – – – Rapid Onset (24 hr) Acutely ill Refuses to bear weight Fever Leukocytosis Elevated ESR Xray: widened joint space as a result of swelling Bone Scan: undetected initially Ultrasound: fluid present More common: M < 3yo Joint aspirate: + BACTERIA Transient Synovitis – Child appears well – Painful limp; referred to inner thigh/knee joint. – MILD fever – MILD leukocytosis – MILD ESR elevation – Xray: widened joint space as a result of swelling – Ultrasound: fluid present – More common: age 4-8 – Joint aspirate: increased WBC (especially PMN’s); Gram stain - ; Culture - except hip Septic Hip: Kocher Criteria (For CHILD with painful hip) 4 Criteria – – – – Non-weight bearing on affected side ESR >40 mm/hr Fever WBC >12,000 If 4/4 criteria met: 99% chance of septic arthritis If ¾ criteria met: 93% chance of septic arthritis If 2/4 criteria met: 40% chance of septic arthritis If ¼ criteria met: 3% chance of septic arthritis Now do joint aspiration: Bacteria = Septic Joint! Septic Arthritis Treatment: Emergency – I&D of joint – IV antibiotics Direct sterilization of joint with antibiotics – Weight-bearing as tolerated – Pain relief with anti-inflammatory agent (Ibuprofen) Anti-Staph agent should be used for presumed S. Aureus Culture and susceptibility should be followed to guarantee treatment efficacy Follow ESR: persistently elevated levels indicate continued activity of disease process Total duration of IV Antibiotics up to 3-6 weeks Transient Synovitis Treatment: – Bed Rest and Symptomatic Care Anti-inflammatory (Ibuprofen) Improvement in 24 hours – Motion restored in 2-4 days – Crutches X 2-4 weeks – Observe patient X 2 years watch for Legg-Calve-Perthes Disease Hospital Course Due to patient being admitted on the weekend, there was no conscious sedation team. Patient was taken to OR for aspiration of left hip. Ortho aspirated 8-10cc of pus from the left joint. Cultures sent for identification/sensitivity – 2+ Staph Aureus, Methicillin resistant; Sensitive to Clindamycin IV Clindamycin given 140mg Q8H X 14 days. Patient had PICC line placed so antibiotics could be administered at home. Followup with Orthopedics 1 week after d/c.