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Cristaldi S, Boni A, Ferro V, Musolino A, Della Vecchia N, Boccuzzi E, Bellelli E, Biagiarelli FS, Aulisa AG, Cirillo M, Raucci U, Villani A. Atraumatic Limping Child, a Challenge for Pediatricians: An Observational Age-Related Study in a Pediatric Emergency Department. CHILDREN (BASEL, SWITZERLAND) 2024; 11:185. [PMID: 38397297 PMCID: PMC10887381 DOI: 10.3390/children11020185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/19/2024] [Accepted: 01/30/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Atraumatic limping is a frequent cause of consultation in Pediatric Emergency Departments (PED) and often represents a challenge for pediatricians for its variability in etiology ranging from benign causes to potential crippling conditions. The aims of this research are to illustrate the clinical features of acute limping children (LC) and to identify the possible red flags that could help to make a diagnosis of severe pathologies. METHODS We carried out a retrospective study about non-traumatic limping children referred to the PED of Bambino Gesù Children's Hospital over a 2-year period. We divided the cohort into three groups based on the patient's age: toddlers, children and adolescents. We considered crippling conditions: oncologic etiologies, bone or neurological infections, epiphysiolysis, Perthes disease, Guillain Barrè syndrome and non-accidental injuries. RESULTS We analyzed 485 patients. At clinical evaluation, 19.5% of the patients presented at least one sign and/or symptom of red flags. Crippling conditions (6.2% of the total population) showed red flags in 36.7%. Transient synovitis of the hip was the most frequent diagnosis. We found crippling conditions in 30 patients, mostly represented by toddlers. CONCLUSIONS Our data suggest that toddlers and patients presenting red flags should be evaluated with particular suspicion because they have an increased risk of underlying severe conditions.
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Affiliation(s)
- Sebastian Cristaldi
- General Pediatrics and ED 2nd Level, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.C.); (V.F.); (N.D.V.); (E.B.); (E.B.); (F.S.B.); (A.V.)
| | - Alessandra Boni
- Pneumology and Cystic Fibrosis, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Valentina Ferro
- General Pediatrics and ED 2nd Level, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.C.); (V.F.); (N.D.V.); (E.B.); (E.B.); (F.S.B.); (A.V.)
| | - Antonio Musolino
- Residency School of Pediatrics, University of Rome Tor Vergata, 00133 Rome, Italy;
| | - Nicoletta Della Vecchia
- General Pediatrics and ED 2nd Level, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.C.); (V.F.); (N.D.V.); (E.B.); (E.B.); (F.S.B.); (A.V.)
| | - Elena Boccuzzi
- General Pediatrics and ED 2nd Level, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.C.); (V.F.); (N.D.V.); (E.B.); (E.B.); (F.S.B.); (A.V.)
| | - Elena Bellelli
- General Pediatrics and ED 2nd Level, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.C.); (V.F.); (N.D.V.); (E.B.); (E.B.); (F.S.B.); (A.V.)
| | - Francesco Saverio Biagiarelli
- General Pediatrics and ED 2nd Level, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.C.); (V.F.); (N.D.V.); (E.B.); (E.B.); (F.S.B.); (A.V.)
| | - Angelo Gabriele Aulisa
- Orthopaedics and Traumatology Division, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Marco Cirillo
- Department of Radiology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Umberto Raucci
- General Pediatrics and ED 2nd Level, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.C.); (V.F.); (N.D.V.); (E.B.); (E.B.); (F.S.B.); (A.V.)
| | - Alberto Villani
- General Pediatrics and ED 2nd Level, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.C.); (V.F.); (N.D.V.); (E.B.); (E.B.); (F.S.B.); (A.V.)
- Systems Medicine Department, University of Rome Tor Vergata, 00133 Rome, Italy
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Abstract
BACKGROUND Nondisplaced metaphyseal fractures of the distal tibia, or toddler's fractures, are one of the most common pediatric injuries. Healing typically occurs quickly without sequelae. Treatment ranges from long leg cast immobilization to observation. This study compares short-term clinical and radiographic outcomes of toddler's fractures treated with long leg casting versus observation. METHODS Patients with toddler's fractures were offered enrollment and randomization at diagnosis. Because many families opposed randomization, a preference arm was added after one year. All subjects were analyzed as a prospective cohort. Radiographs were obtained at diagnosis and 4 weeks. A modified Oxford Ankle Foot Questionnaire for Children (OAFQ-C) and family satisfaction survey were collected at diagnosis, 4 and 8 weeks. Scores were analyzed using mixed effect models. Family satisfaction surveys were compared using a Wilcoxon rank sum test. RESULTS Forty-four subjects participated in the study, 34 (77%) in the preference arm and 10 (23%) in the randomized cohort. The median patient age was comparable between the cast and the observation groups, 2.0 versus 1.8 years, respectively. Significant improvement in OAFQ-C scores was observed in both groups over 8 weeks (P<0.01). Patients in the observation group had a higher initial play score than the cast group (P=0.03). The observation group trended toward higher physical scores at all time points (P=0.11). There was no significant difference in emotional scores between groups (P=0.77). No displacement was observed in any patient. Casted patients had significantly more minor complications with 4 patients requiring cast change or removal compared with 0 in the observed group (P=0.01). At 8 weeks, 80% of parents in the cast group were likely or very likely to choose the same treatment compared with 95.6% in the observation group. Family satisfaction scores did not differ between groups (P=0.18). They demonstrated differences in perceived normal walking at 4 weeks, with 50% of casted patients walking normally compared with 92% of observed patients. Over 90% of patients in both groups were reportedly walking normally at week 8. CONCLUSION Observation of toddler's fractures results in equivalent clinical and radiographic outcomes, high family satisfaction and fewer complications compared with treatment with a long leg cast. LEVEL OF EVIDENCE Level II.
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Boutin A, Misir A, Boutis K. Management of Toddler's Fracture: A Systematic Review With Meta-Analysis. Pediatr Emerg Care 2022; 38:49-57. [PMID: 34393216 DOI: 10.1097/pec.0000000000002488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES In studies that included children diagnosed with toddler's fractures (TFs), we determined the fracture-related adverse outcomes in those treated with immobilization versus no immobilization. Furthermore, we compared health services utilization between these 2 immobilization strategies. METHODS A search was done on Ovid MEDLINE(R), Embase Classic + Embase, and Cochrane Central Register of Controlled Trials along with reference lists as conference proceedings and abstracts. No language or publication status or location restrictions were used. All study steps, including the methodological quality assessment, were conducted independently and in duplicate by 2 authors. RESULTS Of the 490 references identified, 4 retrospective studies of low quality met inclusion criteria and collectively included 355 study participants. With respect to fracture-related adverse outcomes, there was no risk difference [0; 95% confidence interval (CI), -0.09 to 0.09] between the immobilization and no immobilization treatment strategies. Furthermore, in the immobilization versus no immobilization groups, there was a higher mean difference in the number of radiographs (0.69; 95% CI, 0.15-1.23) and scheduled outpatient orthopedic visits (0.96; 95% CI, 0.24-1.68), but a decreased relative risk (0.41; 95% CI, 0.05-3.19) of repeat emergency department visits. No data were reported on patient pain or caregiver satisfaction. CONCLUSIONS In children with TF, this study suggests that no immobilization may be a safe alternative to immobilization for this minor fracture; however, high-quality evidence is needed to optimally inform clinical decision making. Future work should include validated measures of patient recovery, pain, and caregiver perspectives when comparing treatment strategies for this injury.
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Affiliation(s)
- Ariane Boutin
- From the Department of Pediatric Emergency Medicine, CHU Sainte-Justine and University of Montreal, Montreal
| | - Amita Misir
- Division of Emergency Medicine, Department of Pediatrics, London Health Sciences Center, London
| | - Kathy Boutis
- Division of Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Canada
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Abstract
OBJECTIVE The tibial toddler's fracture is an important diagnosis in both emergency and urgent care, presenting as acute onset lower extremity pain or limping in a young child. Diagnosis and management may be challenging because of an extensive differential diagnosis. The objectives of this study were to provide an overview of the toddler's fracture and to guide clinicians by summarizing up to date literature for both diagnosis and management this common condition. METHODS This study analyzed literature from the PubMed database from the years of 1964 to 2018. The main focus was on the diagnosis and management of the toddler's fracture. RESULTS This review demonstrates that diagnosis is primarily made through history and physical examination, as radiographs are often negative at initial presentation. Treatment involves a short period of immobilization, which can be facilitated through the use of a cast, a splint, or no external support. Successful healing and a full return to normal activities and development are near universal. CONCLUSIONS Although a stable fracture with an excellent prognosis, opportunities exist to improve toddler's fractures diagnosis and treatment protocols, to optimize clinical management.
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Affiliation(s)
- Yiqiao Wang
- From the University of Toronto Faculty of Medicine, Toronto
| | - Meagan Doyle
- Department of Pediatric Emergency Medicine, McMaster Children's Hospital, Hamilton
| | - Kevin Smit
- Division of Pediatric Orthopedics, Department of Surgery
| | - Terry Varshney
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Sasha Carsen
- Division of Pediatric Orthopedics, Department of Surgery
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Toddler's Fractures: Time to Weight-bear With Regard to Immobilization Type and Radiographic Monitoring. J Pediatr Orthop 2019; 39:314-317. [PMID: 31169752 DOI: 10.1097/bpo.0000000000000948] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The toddler's fracture is a common pediatric nondisplaced spiral tibia fracture that is considered stable with a course of immobilization. However, there is no widely accepted type of immobilization, expected time to weight-bear, nor guidelines for radiographic monitoring. We aimed to compare immobilization type with respect to displacement and time to weight-bear, as well as determine the usefulness of follow-up radiographs. METHODS A 3-year retrospective chart review of all children aged 9 months to 4 years who had a lower leg radiograph was performed. Those who fulfilled the criteria of a nondisplaced spiral tibia fracture, without fibula or physeal injury, were included in data collection, as were subjects with a negative initial radiograph that were treated presumptively as a toddler's fracture. Subjects were compared with regard to clinical and radiographic presentation; initial and subsequent immobilization; and clinical and radiographic follow-up. RESULTS There were 606 subjects with lower leg radiographs, with 192 meeting study criteria: 117 (61%) with an initially visible fracture and 75 (39%) without. Of the 75 without initially visible fractures, 70 (93%) had robust periosteal reaction on follow-up, and none were diagnosed as anything further. At final follow-up, 184 (96%) were known to be weight-bearing, with 98% of these by 4 weeks. There was an earlier return to weight-bear for those initially treated in a boot compared with short leg cast (2.5 vs. 2.8 wk, P=0.04), but there were no other differences between immobilization type. No fractures displaced at any time point, including 7 that had received no immobilization. Patients received an average of 2.5 two-radiograph series; no radiographs were noted to affect treatment decisions in follow-up. CONCLUSIONS In our cohort, initial immobilization of a toddler's fracture in a boot may allow faster return to weight-bearing, but fractures were universally stable regardless of immobilization type, and nearly all regained weight-bearing by 4 weeks. This reliable healing suggests that immobilization type can be at the physician and family's discretion, and that radiographic follow-up may be unnecessary for treatment planning. LEVEL OF EVIDENCE Level III-this is a retrospective comparative study.
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Trochanteric Fractures in Young Children. Pediatr Emerg Care 2019; 35:e84-e85. [PMID: 30998653 DOI: 10.1097/pec.0000000000001825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Isolated avulsion fractures of the greater and lesser trochanter are usually seen in adolescents prior to the fusion of the apophysis. Greater trochanter fractures in adults have a high incidence of intertrochanteric extension and lesser trochanter fractures are regarded as a pathognomonic sign of metastatic disease. These fractures are very rare among children. METHODS We report five cases of trochanteric fractures in children of less than two years of age three of which were unrecognized initially in the accident and emergency department. RESULTS Early and complete recovery ensued following immobilization and symptomatic treatment. Surgical intervention was not required. CONCLUSIONS There needs to be a high index of suspicion to diagnose these fractures in children and plain radiographs need to be carefully examined when assessing a limping child. Our experience shows when correctly diagnosed these injuries can be treated successfully with supportive treatment and no need for surgical intervention. LEVEL OF EVIDENCE IV Case series.
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Cook PC. Transient synovitis, septic hip, and Legg-Calvé-Perthes disease: an approach to the correct diagnosis. Pediatr Clin North Am 2014; 61:1109-18. [PMID: 25439014 DOI: 10.1016/j.pcl.2014.08.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Transient synovitis, septic hip, and Legg-Calvé-Perthes disease are common conditions in children. Distinguishing between these disorders can be a diagnostic challenge. Similar presentations, in an age group difficult to examine, coupled with literature that is confusing creates difficulty. It is important to make the correct diagnosis of septic hip in a timely fashion to avoid serious and potentially crippling consequences. As there is no single test for discriminating between these conditions, knowledge of the nuances of clinical presentation, physical examination, laboratory investigations, and imaging is essential. Judicious use of clinical algorithms can complement clinical acumen.
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Affiliation(s)
- P Christopher Cook
- Division of Pediatric Orthopaedics, Department of Orthopaedics, Golisano Childrens Hospital, University of Rochester, 601 Elmwod Avenue, Rochester, NY 14642, USA.
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Abstract
Transient synovitis is a benign, self-limiting condition that is diagnosed after the exclusion of more serious causes of acute hip pain in children. Although its etiology remains unclear, it is largely believed to be viral in nature. Transient synovitis typically presents as an acute onset of thigh pain with a limp or an unwillingness to bear weight. It can be distinguished from similar conditions by the absence of fever, as well as unremarkable bloodwork (WBC, CRP, ESR), radiographs, and hip aspiration. Conservative treatment and observation are the mainstay of management. Resolution of symptoms generally occurs by 1 week and may be accelerated by NSAIDs. Although numerous papers have emerged over the years with an effort to advance our understanding, many questions remain about its pathomechanics, etiology, and how to exclude other more serious conditions that present similarly.
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Murias S, Remesal A, Quiles M, Merino R. Características de los pacientes con cojera en Reumatología. An Pediatr (Barc) 2012; 76:290-3. [DOI: 10.1016/j.anpedi.2011.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 10/05/2011] [Accepted: 10/27/2011] [Indexed: 01/24/2023] Open
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