Lizzie Doll, PGY-2 University of Utah

HPI: 4 yo girl who presents for assessment of frequent tripping.

Has some difficulty keeping up with kids her own age Also complains of night pain in her legs 3-4 times per week, but doesnt interfere with activities Denies any redness or swelling around the knees Likes to W sit

BIRTH HISTORY:
Full-term vaginal delivery, 6 lbs. 6 oz.

DEVELOPMENTAL HISTORY:
Crawled at 9 months Walked at 11 months All other milestones normlal

FAMILY HISTORY:
One grandmother was pigeon-toed and one uncle with clubfeet

VS: age-appropriate, Wt: 17 kg (37%), Ht: 100.5 cm (7%) GAIT: Intoeing gait Foot-progression angle: 30 degrees inward Windmills with running MUSCULOSKELETAL: No deformities of spine or upper extremities Genu valgum Internal rotation of hips: 90 degrees bilaterally External rotation of hips: 15-20 degrees bilaterally Tibial torsion: +5 degrees Thigh-foot angle: +5 degrees Feet: mild bilateral metatarsus adductus

Infection/Infection-related
Septic arthritis Osteomyelitis Reactive arthritis Rheumatic fever Lyme disease Toxic synovitis

Hematologic
Hemophilia Sickle cell anemia

Inflammatory
Juvenile idiopathic arthritis Systemic lupus erythematosus Henoch Schnlein purpura

Trauma/Overuse Fracture
Soft-tissue injury Osgood-Schlatter disease Hypermobility

Orthopedic/Mechanical
Slipped capital femoral epiphysis Legg-Calv-Perthes disease Noninflammatory Growing pains Fibromyalgia Reflex sympathetic dystrophy Conversion reaction

Malignancy
Leukemia Neuroblastoma Bone tumors

Basic Screening
Complete blood count Differential count Blood smear Erythrocyte sedimentation rate C-reactive protein Radiographs

Further Investigations
Blood (antinuclear antibody, rheumatoid factor, culture, viral/bacterial serology, creatine kinase, partial thromboplastin time, sickle cell screen, immunoglobulins, complement) Urinalysis Synovial fluid (cell count, Gram stain, culture) Tuberculin skin test Imaging (bone scan, ultrasonography, computed tomography scan, magnetic resonance imaging) Bone marrow aspiration Slitlamp examination of eyes

History
Birth history Developmental history Sleeping posture Sitting posture Pain/Limp/Disability

Physical
Observe gait Hip rotation while prone Tibial torsion (thigh-foot angle) Foot

Natural history
Infant Age 1 year Adolescent 40 ER > IR 30 IR > ER 15 IR = ER

Natural history
Infant
Age 1 year Child Adolescent

0
+5 +10 +15-20

Hips
Femoral anteversion

Leg
Internal tibial torsion

Feet
Metatarsus adductus

Internal Rotation

External Rotation

Essentials of Musculoskeletal Care. John F. Sarwack, ed. 4th edition, 2010. Nelson Textbook of Pediatrics. 19th edition, 2011. Tse SM, Laxer RM. Approach to acute limb pain in childhood. Pediatrics in review / American Academy of Pediatrics. May 2006;27(5):170179. Thanks to Dr. Jacques DAstous, orthopedic surgeon at Shriners for his help with this presentation