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Vital Signs: Fever is likely to be associated with an infectious etiology but may be absent in 18% to 28%2,3 of patients with septic arthritis.
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General: Toddlers with painful foot conditions may crawl or ambulate on their knees. A child with a painful limb will be apprehensive and less active. Acute abdominal processes such as appendicitis and painful groin conditions such as testicular torsion and obstructed inguinal hernia may cause limping. Inspect the child's limbs from the waist down, examining the skin for contusions, puncture wounds, deformity, pustules or abscesses, retained foreign bodies, and ecchymosis or bruises as seen in accidental or nonaccidental trauma, hemophilia, or bleeding disorders with hematoma or Henoch–Schonlein purpura. Ingrown toenails, calluses caused by tight-fitting shoes, retained foreign bodies, and puncture wounds may cause a painful limp.
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Musculoskeletal: Compare both lower limbs and evaluate for warmth, point tenderness, soft-tissue or joint swelling, deformity, limb-length discrepancy, and differences in girth. Leg-length discrepancy is seen in developmental conditions (limb hypoplasia, developmental hip dysplasia, and club foot), hemihypertrophy syndromes, or posttraumatic physeal injury. Arthritis causes pain on movement of the joint. The position of comfort for the hip joint is abduction and external rotation. Severe pain and swelling in the setting of a crush injury may suggest compartment syndrome. In the absence of fever, trauma, and systemic symptoms, pain on palpation of the tendon and fascia insertion sites suggest conditions such as Osgood–Schlatter disease (tibial tubercle apophysitis), Sever disease (calcaneal apophysitis), or plantar fasciitis. Compare active and passive ranges of motion of the joints on the affected and nonaffected sides, starting with the sacroiliac joints, hips, and knees to the ankles and toes (Table 108-2; Figs. 108-1 to 108-5).
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A history of trauma and localized pain will point toward the injured area. However, in toddlers with a limp, a history of trauma may be absent, or there may not be localized tenderness. A useful radiographic screening strategy has been described for five types of fractures in the lower extremity.4 Type 1 is a spiral fracture of the tibia, which may be subtle and may be seen only on an oblique radiograph. It is diagnosed when you elicit pain upon twisting the leg while holding the knee and ankle. Hyperextension causes another type of fracture (Type 2) diagnosed when pain is elicited by holding the tibia and hyperextending the knee. Findings on imaging include a hairline fracture of the upper tibia often accompanied by a buckle fracture of the lateral or medial tibial cortex, buckling of the anterior, upper tibial cortex and/or increased concavity of the notch for the tibial tubercle on lateral view, and anterior tilting of the epiphyseal plate. Buckle fractures of the distal tibia and fibula (Type 3) should be suspected when squeezing and wobbling of the ankle while holding the ankle with a thumb and forefinger, causes pain. Type 4 or bunk-bed foot and ankle fractures are impaction-buckle fracture of the base of the first metatarsal and a compression fracture of the cuboid bone. This occurs when a child lands on the forefoot in a hyperflexed position. Point tenderness will be present when you press directly on the base of the first metatarsal and the cuboid bone Finally, fractures of the upper femur are usually nondisplaced Salter–Harris Type I fractures. Pain is elicited by holding the leg at the knee and rotating the hip (see Chapter 31 for fractures of the lower extremity).
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It may be challenging to differentiate between a psoas abscess and septic arthritis of the hip. Patients with a psoas abscess may have a palpable abdominal mass and a positive psoas sign (Table 108-1); scoliosis, sciatica, and femoral nerve neuropathy may be present. Unlike children with septic arthritis, in whom range of motion is markedly limited in all directions due to pain, flexing the hip of a child with a psoas abscess will decrease the pain and internal and external rotation of the hip can be performed easily.
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Examine the muscle groups for tenderness, strength, and tone. Proximal muscle weakness will be seen in muscle dystrophy and myopathies. In peripheral neuropathy or radiculopathy (Guillain–Barré syndrome), the reflexes will be depressed whereas they will be exaggerated in upper motor neuron disease with spasticity. Spinal dysraphism may present with midline abnormalities such as a dimple or tuft of hair.
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Spine: Examine the spine for kyphosis or scoliosis and range of movement. A patient with a painful spinal condition will resist bending the spine. The differentiation between discitis and vertebral osteomyelitis in children can be difficult. In vertebral osteomyelitis, the child is usually ill-appearing, and the fever is usually higher and present for a longer duration. It may involve any part of the spine, as opposed to the lumbar area in discitis. In discitis, children may have fever, fussiness, or refusal to walk or sit, and there may be poor localizing signs. Plain radiographs may not show any changes early in the condition, and the diagnosis may be delayed. Older children with spondylolisthesis will experience lumbosacral pain on extension of the spine.
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Gait: Evaluate the gait after completing the physical examination. As young children may refuse to walk for the examiner, ask the parents to beckon the child after they have moved some distance away. Examine the stance for pelvic tilting, scoliosis, knee flexion, leg asymmetry, or rotation of the foot. Pay attention to the overall motion, the stride length, and stance and swing phases. Also look at the pelvis, hips, thighs, knees, legs, ankles, and feet. Examine the shoes for wear and tear. Conditions, which cause foot drop, will lead to the foot “slapping” the ground during swing phase on the affected side. Test muscle strength by having the patient climb stairs, squatting, and heel and toe walking.
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The most common gait abnormality is an antalgic gait. It is caused by a painful condition on the affected limb or referred pain from the back. Weight-bearing is reduced on account of the pain, and the stance phase gets shortened. The swing on the unaffected limb may lengthen. Gait due to limb-length discrepancy is manifested by a downward tilting of the trunk and pelvis during the stance phase on the shortened limb and circumduction of the longer leg during the swing phase of that side. Some children may walk on the toes of the shortened side. A circumduction gait is seen in a child with spastic hemiparesis or with an ankle or foot problem. The spastic limb is moved outwards in a half circle during the swing phase to allow the toes to clear the ground. A Trendelenburg gait occurs due to weakness in the hip abductors or in DDH. Here, the pelvis tilts towards the unaffected side during the stance phase of the affected side since the hip abductors on the affected side are not strong enough to counter the weight of the opposite side. If the weakness is bilateral, the patient will demonstrate a waddling gait as the pelvis tilts alternately on either side during walking. In a “steppage gait,” due to an inability to dorsiflex the foot, the hip and knee joints are flexed during the swing phase to allow the toes to clear the ground.