4-year-old daughter

"Well, she was doing fine until this morning. We went to the playground yesterday and at one point,
she fell off of the teeter-totter, but she hopped right back up and kept playing. She seemed totally
fine yesterday. This morning, she was fussy when she woke up. She ate some breakfast but she was
walking funny, like her right leg hurt. She didn't have a fever but after a while, she refused to
walk altogether and was making me carry her around. I looked at her leg and didn't see anything wrong
with it."

"She had a cold and has felt a little warm a couple of days ago, but nothing out of the ordinary.
Just sniffles and a little cough, and her temperature was less than 100 the couple times I checked
it."

"Well, when I tried to set her on her feet at home, she would stand on her left leg but will only
touch her right toe on the ground. If I try to let go, she just sinks to the floor and cries. If I
walk away, she asks to be picked up again, but she won't get up on her own."

PMx:
Otitis media (11 months old)
Viral gastroenteritis (15 months old)
Otitis media (2 years old)
Allergy: Nope
Medication: acetaminophen a few days ago when she had the URI and felt warm to the touch
Ill contact: Nope
FHx: The family history is negative for childhood cancers, bleeding disorders, and juvenile
idiopathic arthritis. One of Emily's cousins has developmental dysplasia of the hip.
Social Hx: Emily lives with her mother, her mother's partner, Jennifer Grooms, and Emily's 7-
year-old sister. She still attends daycare in the morning and spends the afternoons at home.
Emily went camping with her family last month and Ms. Daniels tells you she read about Lyme
disease and does not think that Emily has it.
Birth Hx: Nth special
Immunization: Up to date
Growth and development:
She can cut with scissors, copies squares and crosses, hops on one foot, tells short stories and
plays well in groups. She intermittently has temper tantrums.
Diet and appetite
She eats well with adequate protein and fruits/veggies.
Education:
Activity:
Look: looks well and is alert. she is holding her right leg in a turned-out (externally rotated)
position
Sleep:

PE:
General appearance: Well. VS: HR: 120 bpm; RR: 20 bpm; BP: 90/58 mm Hg; Temp: 36.9 C (98.4 F) ax
Ht: 101 cm (39.7 inches) Wt: 16.3 kg (36 lbs)
HEENT: Normocephalic, extraocular movements intact, pupils equal and reactive, tympanic membranes
gray without effusions, oropharynx without erythema, or exudates
Neck: Supple, shotty lymphadenopathy
Pulm: Clear to auscultation bilaterally
Cardiac: Normal S1 and S2, no murmurs
Abd: Soft, nontender, normal active bowel sounds, no masses, no hepatosplenomegaly
Skin: No rashes, few bruises of various ages on shins
MS: Good active range of motion, normal gait
Neuro: Normal power, tone, and reflexes

Vital Signs
P: 128 bpm, RR: 20 bpm, BP: 95/55 mm Hg, T: 37.6 C (99.7 F) axillary, Ht: 102 cm (50th), Wt: 17 kg
(55th)
Physical Exam
HEENT: Tympanic membranes clear without effusion, nose with mild clear rhinorrhea, oropharynx without
erythema or lesions.
Nodes: No cervical, axillary or inguinal lymphadenopathy.
Pulm: Clear to auscultation bilaterally.
Cardiac: Normal S1 and S2, no murmurs.
Abdomen: Normal bowel sounds. Soft, nontender, nondistended, no hepatosplenomegaly or masses
Skin: few bruises of various ages on shins. No wound would affect her willingness to walk

Complete examination of Emily's right hip:

Observation: No bruising, erythema, or swelling.
Palpation: No tenderness, warmth or obvious deformity.
Passive range of motion: Hip flexion seems normal, but there is limitation of internal rotation
secondary to pain. This is reproducible.
Active range of motion: Emily continues to refuse to walk.

1. Why she is holding her right leg in a turned-out (externally rotated) position
Hip pain secondary to an effusion (associated with septic arthritis of the hip and transient
synovitis) is relieved when the patient "opens" her hip capsule by holding her hip in flexion and
external rotation. On the other hand, leg pain associated with osteomyelitis is not position-dependent,
but will increase with weight-bearing so the child will avoid standing alone.
2. Accidental vs. Non-accidental Bruising
a) Bruises over bony prominences (e.g., shins and forearms) are common in toddlers and young
active children.
b) Bruises seen over well-cushioned areas are less common (e.g., buttocks, back, and genitalia)
and potentially raise the suspicion of NON-accidental trauma.
c) Also, bruises cannot be reliably aged based on color.
3. DDx
4. Test to order
CBC, CRP, ESR, Blood culture, Xray
5. Tap
You should wait to see the lab results before deciding whether or not to tap.. As the journal
articles mentioned earlier, a septic hip should be associated with an elevated white count, CRP
and ESR. If these values are within normal limits for Emily, and her clinical condition has not
changed, a septic hip is unlikely and you can avoid traumatizing Emily with the procedure.
6. Characteristics of synovial fluid of septic arthritis
Turbid appearance
Increased white cell count, predominantly polymorphs
Low glucose
Gram stain of the fluid should show bacteria on gram stain and a sample needs to be sent for
culture.