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When Should a Limping Child Get Help? · Pediatrics in Practice: A CME Podcast

• 0:03
  Michael Smith, MD (Host): Welcome to Pediatrics in Practice, a CME podcast.
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  I'm Dr.
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  Mike.
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  And with me is Heather Barnes, a nurse practitioner in orthopedic surgery,
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  and Angie Vanderpool, a pediatric nurse practitioner in orthopedics and sports
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  medicine, all from Children's Mercy.
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  Today, we're going to be discussing limping and its clinical red flags.
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  Welcome to the show, Heather and Angie.
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  Heather, I'm going to start with you.
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  When should a limping child raise concern beyond a minor injury?
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  And if you could highlight some of those key red flags
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  physicians should be watching for.
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  Heather Barnes, DNP, APRN, CPNP, ONC: Sure.
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  I think some of the things that are concerning when a child is limping is
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  if they're refusing to weight bear.
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  That's usually an indication that there has been an injury.
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  And if there hasn't been an injury, then it's a little more suspicious of
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  why are we not wanting to bear weight.
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  Another concern certainly is any ill symptoms or fever that
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  could indicate that there might be some sort of inflammatory
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  or infectious process going on.
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  If they're complaining of pain without any known injury, if we're noticing
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  that their gait is abnormal or different than it was previously, if they're not
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  behaving the same, if their activity level has changed, they're not doing things that
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  they normally would do because they're in pain or uncomfortable, or sometimes their
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  age, they can't explain what's going on.
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  These are things that are red flags that should indicate maybe kind of look
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  into something a little bit further.
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  Host: Yeah, I like the idea of the, the weight-bearing being a big one.
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  I know that's probably helpful for parents.
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  You know, if your child injures themselves, but they still want to
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  get up and run around and that, you know, that's probably not so bad.
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  But if they don't want to move, if a kid doesn't want to move
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  and play around, that's probably a good red flag, I would assume.
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  Angie, let's move to you.
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  What historical clues or symptoms help differentiate a benign cause of
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  a limp from a more serious condition?
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  Angie Vanderpool, APRN, CPNP, ON: Well, if you don't know of any particular
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  injury, then like a recent illness, if they've had a cold or respiratory
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  infection if they have a persistent pain and no cause that you're aware of.
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  It doesn't count if they started limping after they were running
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  around with some kids and you didn't see them for a while, because they
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  may have hurt themselves then.
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  But if you know, especially on a really small child, that it just kind of came out
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  of the blue, all of those are concerns.
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  Host: When you look at limping in children, you know, obviously,
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  you have the younger kids that are just getting moving.
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  You have some of the older kids, preteens and all that kind of stuff.
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  What are some of the most common causes of limping in, say, the
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  younger kids versus an older child?
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  Heather Barnes, DNP, APRN, CPNP, ONC: Sure.
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  So, more common reasons in a younger child, a toddler or, you know, like a
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  preschool age child is an inflammatory condition, something like transient
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  synovitis or possibly an infectious cause.
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  Commonly in this age group can be like a septic arthritis or a joint infection.
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  So, those are the big things that we worry about in those age groups.
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  A little bit older, maybe your pre-adolescent, they can have
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  a condition that we see in orthopedics called a slipped
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  capital femoral epiphysis or a SCFE.
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  And that's a problem with the hip, that is a common reason—common in
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  orthopedics—that that aged child would be limping or complaining of
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  pain in their hip or their knee.
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  So, just to kind of give a little variation of what I might be thinking
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  of if I see somebody in a certain age group, these are the things that my
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  mind is wanting to look into and make sure that's not what we're dealing with.
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  Host: So Angie, when you're doing a physical exam on a child who's
• 3:58
  limping, are there particular pain patterns you're looking for, location,
• 4:03
  severity, timing, that if you find on physical exam are raising your concern?
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  Angie Vanderpool, APRN, CPNP, ON: Yeah, I think joints are always an issue if
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  they have an irritable joint or a painful swollen joint, pointed redness, warmth,
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  sudden onset, how long has it been going on; refusal, of course, to weight bear;
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  increasing pain, and then how they look.
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  I mean, it's kind of just seeing what they're willing to do and if you
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  can pinpoint where it's coming from.
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  Host: And with that physical exam, how is it different, let's say, with like a
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  non-verbal child, one who can't really express themselves versus an older child?
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  How do you manage that difference?
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  Angie Vanderpool, APRN, CPNP, ON: Very carefully.
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  Getting them to do something, I mean, whatever you can get them
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  to do is hard for the little ones.
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  Heather Barnes, DNP, APRN, CPNP, ONC: I think, in my experience with the little
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  ones, even developmental delay or just age and, you know, they don't communicate
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  with you well yet, is watching them during your physical exam for changes in their
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  facial expressions or, you know, do they pull away, you know, if you're palpating
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  or examining them, trying to find an area maybe of tenderness that you're really
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  watching them to see their reaction.
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  That's very helpful.
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  Host: I kind of want to put this together for the community pediatrician.
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  We've mentioned some red flags here and there, some things
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  that might raise concern.
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  So Heather, I'm going to stick with you.
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  Can you give us a nice summary of those red flags that a community pediatrician
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  should really get some imaging, get that referral going, et cetera?
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  Heather Barnes, DNP, APRN, CPNP, ONC: Something that I see fairly often in
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  my practice is that toddler, preschool age child who not sure if we had an
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  injury, but they're not interested in weight bearing normally, maybe
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  they're limping, maybe the parents think they're not weight bearing.
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  But on exam, you know, maybe you can get them to weight bear, they just
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  don't want to or they don't like it.
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  And then, you kind of get into the history a little bit more.
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  Was there a recent illness of any kind, an ear infection, strep throat, history
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  of fever, any of those kind of things?
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  Then that's something that might warrant a little bit more investigation
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  and an X-ray or possibly a lab workup to look for any sort of
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  inflammatory or infectious markers.
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  Host: Speaking of you mentioned X-rays, you know, imaging strategies
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  I'm sure play a pretty big role.
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  So Angie, how often do you jump right to imaging as a tool to help you diagnose?
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  Or in some cases, is it okay to maybe delay that based
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  on your physical findings?
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  Angie Vanderpool, APRN, CPNP, ON: I have a tendency to go quickly to X-ray.
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  It's a lot less invasive than getting lab work and a lot easier than
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  doing that on a small child if I don't know for sure what's going on.
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  And a X-ray really can clear the air on what happened.
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  Sometimes you'll have a child that's refuses to walk , you
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  get an X-ray and you find, well, there's a needle in their foot.
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  So, there's a reason for it, but nobody saw it happen.
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  So, an X-ray has its own ability.
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  It tells you if there's a small buckle fracture that may be contributing to it.
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  Host: So, X-ray is great for the bone fractures, dislocations.
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  What about if you're more worried about a tissue, musculoskeletal?
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  How often do you move to, say, maybe MRI?
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  Angie Vanderpool, APRN, CPNP, ON: As a general rule, you have to get
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  an X-ray first because you're going to have to justify getting an MRI.
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  Host: But they're still part of your tool bag in case you needed
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  to do that, the MRIs, I'm sure.
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  Angie Vanderpool, APRN, CPNP, ON: For sure.
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  Host: So, Angie, sticking with you, what conditions are commonly missed or
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  diagnosed late in children presenting with limp or say some unexplained pain?
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  Angie Vanderpool, APRN, CPNP, ON: I think in adolescence, the one we're
• 8:00
  all really worried about the most is a slipped capital femoral epiphysis.
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  And if that is found on a teenager or a preadolescent is usually when you'll
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  see it, because they're not skeletally mature, and that can be a big deal
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  and cause a lot of long-term problems.
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  OCD lesions, sometimes those kids will be limping for quite a while before
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  anybody gets an X-ray or notices what's going on, and part of it's because
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  they don't complain all the time.
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  They complain off and on.
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  In a younger child, Perthes, Legg-Calve-Perthes.
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  So, six to kind of school age, 10 years old, school-aged child.
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  And again, hip pain comes and goes, but it seems to really limit them.
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  Septic arthritis, that's something that as a general rule, they're sicker
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  and gets caught a little quicker.
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  Tumors, leukemia, and rheumatologic causes.
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  Host: Heather, when should pediatricians consider a septic cause?
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  Whether it be infection, inflammatory disease, malignancy in a child with limp.
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  What are some of those red flags that would make you think to go down
• 9:03
  that cancer pathway, for instance?
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  Heather Barnes, DNP, APRN, CPNP, ONC: Well, I think, you know, if we're talking
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  about a neoplastic concern, so, you know, you're kind of checking off your box of
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  differential diagnoses and kind of not getting anywhere of finding a reason.
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  You know, I think that one's always got to be on that differential
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  when there wasn't an injury.
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  And before you've done any labs or radiographs, you have to
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  consider that as a potential.
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  Obviously, that's not that common, but I don't think it's
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  something to just dismiss.
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  So for example, somebody who's had pain, maybe they show up
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  at the pediatrician's office.
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  They've had pain for a month.
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  It's starting to interfere with their activity.
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  They haven't been sick.
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  They didn't have an injury that we're aware of.
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  Maybe they start to complain of asking more questions like,
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  are they having pain at night?
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  If we're thinking about a rheumatologic cause, are we having pain in the morning,
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  like stiffness when we wake up, and then it gets in better as the day goes on?
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  So, just some different thought processes when you're kind of
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  looking at a differential diagnosis list of why somebody might be
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  limping and did not have an injury.
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  Host: This has been fantastic.
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  I really feel like I've learned a lot from both of you, and I
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  want to thank you for coming on.
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  I'm going to start with you, Heather.
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  Do you have any last words for the listening audience?
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  Heather Barnes, DNP, APRN, CPNP, ONC: For pediatricians, I think it's okay
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  to continue to monitor your patient.
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  But if your patient's not getting better, if they're not improving,
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  because I think it's always okay to have time if it's appropriate.
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  But if we're still not seeing an improvement, then that's when, I
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  think, maybe referral is appropriate or, you know, getting labs or
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  X-rays or those kind of things just to look a little bit further into
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  why symptoms aren't resolving.
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  Host: Angie, any last words?
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  Angie Vanderpool, APRN, CPNP, ON: Make sure you use the resources that are
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  available and feel free to reach out to people that have more experience
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  in certain areas if you need help.
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  Host: Fantastic.
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  Again, thank you guys for coming on.
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  Very helpful information I know to the community pediatrician.
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  So, thanks for all of your time that you spent with me today.
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  That was nurse practitioners Heather Barnes and Angie Vanderpool.
• 11:16
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• 11:20
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• 11:29
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• 11:32
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• 11:40
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• 11:44
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