PEDIATRICS
ORTHOPEDICSA 12-year-old obese African-American male begins to limp for 3 days. He has
no fever and there is no associated trauma. What is a likely diagnosis?
SCFE (slipped capital femoral epiphysis).Nursemaid’s Elbow
■ Most common elbow injury in children <5 years of age
■ Proximal end of the radial head is held in place by the overlying annular
ligament. It is fairly straight and does not become flared and nodular until
approximately 5–6 years of age, allowing it to slip out of place.
■ The typical mechanism of injury is when the child’s arm is pulled in an
extended, pronated position.
SYMPTOMS/EXAM
■ The child usually cries immediately after the injury and refuses to use the
arm.
■ Injured arm is held in a characteristic position—slightly flexed at the
elbow and pronated (“thumb rotated in toward the body”).
■ Usually well appearing, other than refusal to use the arm
■ May be diffusely tender along the entire arm, but should not have any visi-
ble deformity or swelling
DIAGNOSIS
Clinical history and exam are usually sufficient. Radiographs are indicated
only if history is unclear or the exam suggests another injury.
TREATMENT
Place your thumb over the radial head, supinate the forearm, then flex the
elbow. A palpable click is usually felt with successful reduction. With successful
reduction, the child will begin to use the affected arm within a few minutes.
Limp
In the ED evaluation of a child with limping, careful history taking and physi-
cal examination are key. X-rays are usually needed, often of the entire affected
extremity; other ancillary studies may include blood cultures, CBC with differ-
ential, ESR, CRP. The differential diagnosis can often be narrowed based on
age, history of trauma, and/or likelihood of infectious causes. Four of the
more common causes are listed below; other causes include nutritional defi-
ciencies (eg, rickets), fractures (eg, toddler’s fractures, avulsion fractures, stress
fractures), sprains/contusions, JRA, osteomyelitis, and neoplasms (Ewing’s sar-
coma, osteogenic sarcoma, leukemia).
LEGG-CALVÉ-PERTHES
■ Also known as avascular necrosis of the femoral head (specifically the capi-
tal femoral epiphysis)
■ Typical age is 2–12 years, primarily in boys
■ Bilateral in 15%
■ Unknown cause, other than association with sickle cell disease