Age, atraumatic etiology, fever predict admission for limp

ORLANDO – Most children presenting to the emergency department with a limp have a traumatic etiology, and in most cases, a thorough history and physical examination coupled with radiographs are sufficient for diagnosis, a retrospective study of cases at a tertiary care pediatric emergency department showed.

Of 16,056 children aged 10 months to 18 years (mean, 2.2 years) who presented to the ED between Jan. 1, 2010, and April 1, 2010, 1,776 (11%) presented with a musculoskeletal complaint, and 779 had a lower-extremity injury, a limp, and/or an inability to bear weight. Among those 779 patients, the most common diagnoses were sprain or strain (26%), contusion (19%), fracture (14%), cellulitis/abscess (9%), and abrasion/laceration/puncture (8%), Dr. Johnathan J. Whitaker reported at the annual meeting of the American Academy of Pediatrics.

Of the 779 patients, 527 (68%) had a traumatic injury and 252 (32%) had an atraumatic etiology.

Transient synovitis was discovered in 15 patients (1.9%), and septic arthritis was discovered in 2 patients (0.3%). Other causes of a limp, from among more than 50 diagnoses, were animal bites, an ingrown or avulsed toenail, back spasm, sickle cell crisis, apophysitis, a burn injury, frostbite, slipped capital femoral epiphysis (SCFE), psoas abscess, deep venous thrombosis, rhabdomyolysis, and testicular torsion, said Dr. Whitaker of the Philadelphia College of Osteopathic Medicine.

Overall, 59 patients (7.6%) were admitted, with most of those having a fracture (36%) or an infection (27%). Others who were admitted had transient synovitis (8.5%), sickle cell crisis (6.8%), or SCFE (1.7%).

Several differences were seen between patients who were admitted and patients who were not admitted, including average age, mechanism of injury, presence of a fever, inability to bear weight, past medical history, serum white blood cell count level, and the use of advanced imaging or a laboratory work-up for diagnosis.

For example, among those with a traumatic etiology, the average age was 14 years; among those with an atraumatic etiology, the average age was 10 years. Only 1% of those with a traumatic etiology had a fever, compared with 5% of those with an atraumatic etiology, Dr. Whitaker said.

The inability to bear weight, the presence of a fever greater than 101.5  F, younger age, and an atraumatic mechanism of injury were significant predictors of admission; increased age and a traumatic mechanism of injury were significantly associated with a decreased likelihood of admission, Dr. Whitaker said.

"Limping primarily results from orthopedic diagnoses. However, limping is a chief complaint for a wide variety of other diagnoses," he said.

Though limited by a relatively small number of limp-related presenting complaints and the fact that the study was conducted during winter months – which may have an impact on the types of injuries seen, the findings suggest that laboratory studies and advanced imaging to assist in establishing a diagnosis that may require admission or urgent treatment are best utilized for younger children with an atraumatic mechanism of injury, the inability to bear weight, or a fever upon presentation, he said.

Dr. Whitaker reported having no relevant financial disclosures.

ORLANDO – Most children presenting to the emergency department with a limp have a traumatic etiology, and in most cases, a thorough history and physical examination coupled with radiographs are sufficient for diagnosis, a retrospective study of cases at a tertiary care pediatric emergency department showed.

Of 16,056 children aged 10 months to 18 years (mean, 2.2 years) who presented to the ED between Jan. 1, 2010, and April 1, 2010, 1,776 (11%) presented with a musculoskeletal complaint, and 779 had a lower-extremity injury, a limp, and/or an inability to bear weight. Among those 779 patients, the most common diagnoses were sprain or strain (26%), contusion (19%), fracture (14%), cellulitis/abscess (9%), and abrasion/laceration/puncture (8%), Dr. Johnathan J. Whitaker reported at the annual meeting of the American Academy of Pediatrics.

Of the 779 patients, 527 (68%) had a traumatic injury and 252 (32%) had an atraumatic etiology.

Transient synovitis was discovered in 15 patients (1.9%), and septic arthritis was discovered in 2 patients (0.3%). Other causes of a limp, from among more than 50 diagnoses, were animal bites, an ingrown or avulsed toenail, back spasm, sickle cell crisis, apophysitis, a burn injury, frostbite, slipped capital femoral epiphysis (SCFE), psoas abscess, deep venous thrombosis, rhabdomyolysis, and testicular torsion, said Dr. Whitaker of the Philadelphia College of Osteopathic Medicine.

Overall, 59 patients (7.6%) were admitted, with most of those having a fracture (36%) or an infection (27%). Others who were admitted had transient synovitis (8.5%), sickle cell crisis (6.8%), or SCFE (1.7%).

Several differences were seen between patients who were admitted and patients who were not admitted, including average age, mechanism of injury, presence of a fever, inability to bear weight, past medical history, serum white blood cell count level, and the use of advanced imaging or a laboratory work-up for diagnosis.

For example, among those with a traumatic etiology, the average age was 14 years; among those with an atraumatic etiology, the average age was 10 years. Only 1% of those with a traumatic etiology had a fever, compared with 5% of those with an atraumatic etiology, Dr. Whitaker said.

The inability to bear weight, the presence of a fever greater than 101.5  F, younger age, and an atraumatic mechanism of injury were significant predictors of admission; increased age and a traumatic mechanism of injury were significantly associated with a decreased likelihood of admission, Dr. Whitaker said.

"Limping primarily results from orthopedic diagnoses. However, limping is a chief complaint for a wide variety of other diagnoses," he said.

Though limited by a relatively small number of limp-related presenting complaints and the fact that the study was conducted during winter months – which may have an impact on the types of injuries seen, the findings suggest that laboratory studies and advanced imaging to assist in establishing a diagnosis that may require admission or urgent treatment are best utilized for younger children with an atraumatic mechanism of injury, the inability to bear weight, or a fever upon presentation, he said.

Dr. Whitaker reported having no relevant financial disclosures.

ORLANDO – Most children presenting to the emergency department with a limp have a traumatic etiology, and in most cases, a thorough history and physical examination coupled with radiographs are sufficient for diagnosis, a retrospective study of cases at a tertiary care pediatric emergency department showed.

Of 16,056 children aged 10 months to 18 years (mean, 2.2 years) who presented to the ED between Jan. 1, 2010, and April 1, 2010, 1,776 (11%) presented with a musculoskeletal complaint, and 779 had a lower-extremity injury, a limp, and/or an inability to bear weight. Among those 779 patients, the most common diagnoses were sprain or strain (26%), contusion (19%), fracture (14%), cellulitis/abscess (9%), and abrasion/laceration/puncture (8%), Dr. Johnathan J. Whitaker reported at the annual meeting of the American Academy of Pediatrics.

Of the 779 patients, 527 (68%) had a traumatic injury and 252 (32%) had an atraumatic etiology.

Transient synovitis was discovered in 15 patients (1.9%), and septic arthritis was discovered in 2 patients (0.3%). Other causes of a limp, from among more than 50 diagnoses, were animal bites, an ingrown or avulsed toenail, back spasm, sickle cell crisis, apophysitis, a burn injury, frostbite, slipped capital femoral epiphysis (SCFE), psoas abscess, deep venous thrombosis, rhabdomyolysis, and testicular torsion, said Dr. Whitaker of the Philadelphia College of Osteopathic Medicine.

Overall, 59 patients (7.6%) were admitted, with most of those having a fracture (36%) or an infection (27%). Others who were admitted had transient synovitis (8.5%), sickle cell crisis (6.8%), or SCFE (1.7%).

Several differences were seen between patients who were admitted and patients who were not admitted, including average age, mechanism of injury, presence of a fever, inability to bear weight, past medical history, serum white blood cell count level, and the use of advanced imaging or a laboratory work-up for diagnosis.

For example, among those with a traumatic etiology, the average age was 14 years; among those with an atraumatic etiology, the average age was 10 years. Only 1% of those with a traumatic etiology had a fever, compared with 5% of those with an atraumatic etiology, Dr. Whitaker said.

The inability to bear weight, the presence of a fever greater than 101.5  F, younger age, and an atraumatic mechanism of injury were significant predictors of admission; increased age and a traumatic mechanism of injury were significantly associated with a decreased likelihood of admission, Dr. Whitaker said.

"Limping primarily results from orthopedic diagnoses. However, limping is a chief complaint for a wide variety of other diagnoses," he said.

Though limited by a relatively small number of limp-related presenting complaints and the fact that the study was conducted during winter months – which may have an impact on the types of injuries seen, the findings suggest that laboratory studies and advanced imaging to assist in establishing a diagnosis that may require admission or urgent treatment are best utilized for younger children with an atraumatic mechanism of injury, the inability to bear weight, or a fever upon presentation, he said.

Dr. Whitaker reported having no relevant financial disclosures.