Why Won’t Junior Walk?

Method of Participation: To earn AMA PRA Category 1 Credit™

Read the rules and terms of use below
Read the educational objectives and article "Why Won’t Junior Walk?" in print from the February 2013 issue of Emergency Physicians Monthly. You may also read the article online once you have read the rules and terms of use.
Complete the post-test and evaluation (Note: A score of at least 80% must be achieved to earn CME credit)
Participate in the discussion/debate thread about specific articles
Process your online payment of $10 (fees are non-refundable).
A certificate of attendance will be forwarded within 4 to 6 weeks of participation

Step One: Rules and Terms of Use

Release Date: February 12, 2013

Expiration Date: February 12, 2014

Estimated Time of Completion: 1 hour
Fee: This CME activity costs $10, payable by credit card at the completion of the activity. Fees are non-refundable.

CME Accreditation:
The Center for Emergency Medical Education (CEME) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Center for Emergency Medical Education (CEME) designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Target Audience:
This activity is designed for emergency medicine physicians and other health care providers interested in the treatment of patients with cardiopulmonary arrest.

Description:
The Center for Emergency Medical Education (CEME) offers a one-credit content-specific posttest and evaluation based on an article in the Emergency Physicians Monthly magazine as each issue is published.

Disclosure of Faculty Financial Interests or Relationships:
It is the policy of Center for Emergency Medical Education (CEME) to insure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities, and that all contributors present information in an objective, unbiased manner without endorsement or criticism of specific products or services and that the relationships that contributors disclose will not influence their contributions. In accordance with the Standards for Commercial Support issued by the Accreditation Council for Continuing Medical Education (ACCME), the Center for Emergency Medical Education (CEME) requires resolution of all faculty conflicts of interest to ensure CME activities are free of commercial bias. Those involved in the planning and teaching of this activity are required to disclose to the audience any relevant financial interest or other relationship.

All faculty, planners, and staff in a position to control the content of this CME activity have indicated that he/she has no relationship, which, in the context of the article, could be perceived as a potential conflict of interest:

Kevin M. Klauer, DO, FACEP, Director, CEME
Logan Plaster, Editor/Creative Director, Emergency Physicians Monthly
Ginger Brake, CEME Program Coordinator

System Requirements:
Participants must have access to the Internet:
Internet Explorer
Netscape
Safari
Firefox

Contact Information
Ginger Brake
CEME Program Coordinator
Emergency Medicine Physicians
4535 Dressler Road NW
Canton, Ohio 44718
(330) 493-4443 Ext: 1445
This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Privacy Policy
The Center for Emergency Medical Education (CEME) is committed to protecting your privacy while using the CEME website. You can, in general, visit our website without identifying yourself or disclosing any personal information. Any personal information you choose to provide will not be shared with third parties without permission.

When you submit online registration, the information you provide is confidential. At no point do we now, or will we ever sell, rent or lease information we collect to any outside individual or organization.

The CEME website contains links to other sites. CEME is not responsible for the privacy practices or the content of such websites.

Copyright Notice
The materials on this site are protected by copyright laws and may not be reproduced, modified, displayed, transmitted, or otherwise published without the prior written consent of The Center for Emergency Medical Education (CEME). You may access the materials on this website only for your personal, noncommercial use.

Disclaimer
The materials on this site are provided for general medical education purposes only and are not meant to be applied rigidly and followed in all cases. Use of this information in a particular situation remains the professional responsibility of the practitioner. In no event will CEME be liable for any decision made or action taken in reliance upon the information provided.

STEP 2: READ THE ARTICLE

STEP 3: TAKE THE QUIZ

STEP 4: PROCESS PAYMENT

Educational Objectives:
After evaluating this article, participants will be able to:
1. Develop strategies to clinically differentiate septic arthritis from transient synovitis
2. Incorporate into clinical practice ultrasound imaging of the pediatric hip

alt Sometimes you wish you were a pediatrician; other times you don’t. When you walk into the room and your patient immediately starts crying like you are a scary monster, you gain a new appreciation for your adult patients. But when everything you do elicits a smile or a giggle, you wish all your patients were three years old. Fortunately, today you are popular with the kids. When you gently shook the head of a febrile, vomiting 2-year-old to check for the “jolt sign” – all while smiling and making funny noises – she started giggling and laughing. No CNS infection likely there. When you played “poke the belly” with the constipated 3-year-old to make sure there was no appendicitis, he laughed and tried to poke your belly.

Your next pint-sized patient is a 5-year-old who “won’t walk”. His parents state that he was fine yesterday and last night, but wouldn’t get out of bed this morning because his right leg hurt. They tell you the pain seems to be in the hip. He is otherwise doing well with no trauma, fever, rash or other complaints. They say that he is normally very active and he has never demonstrated this kind of behavior in the past. He is otherwise a healthy 5-year-old with no prior surgeries or medical problems.

The child’s vital signs are all normal and his physical exam is as well, except for pain with any motion of the right hip. He will not stand or even do a straight leg-raise. The knee and ankle seem non-tender and show no warmth or swelling. Interestingly, your colleague mentioned she just admitted a similar patient for similar symptoms this past week.

You order a pelvic x-ray, and a knee x-ray in case this is referred pain; both are negative. A CBC shows a white count of 9.2 with 63% PMN’s and the sed rate is normal at 9 mm/hr. You think he probably has transient synovitis, but you definitely don’t want to miss a septic hip, so you decide to do a bedside pediatric hip ultrasound and a trial of non-opiate analgesia. His hip ultrasound is shown here. What does it show? Do you need to call someone to tap this hip or not? What should be the next step in your care?

What do you see on the ultrasound image?
Conclusion here

Dx: Small Effusion in the Hip

The ultrasound does show a small effusion, but this is not necessarily abnormal. Before you call anyone, you should measure the width of the effusion and compare it to the other side (Images 2 & 3). It turns out that though you didn’t exactly take your measurement at the recommended site, the effusion is symmetric to the one on the asymptomatic hip, and is small enough to be considered normal.

alt After 10mg/kg of ibuprofen and 15mg/kg of acetaminophen both PO and two hours of waiting, he is still not really “walking” but can do a straight leg raise and limp around a bit. Rather than admit this patient like your colleague did, you call the patient’s pediatrician and together formulate a reasonable plan for outpatient care involving ibuprofen, careful aftercare instructions and a recheck the next morning if he is not improving.

The next day you call the family at home and find out that the young lad is playing outside and is almost back to normal self. There is no one there to pat you on the back, so you do it yourself.

Tips & Tricks for Imaging the Pediatric Hip

01 Benefits of Ultrasound: Using ultrasound to rule out a significant hip effusion avoids radiation and can be done at the bedside. EP-performed bedside ultrasound for this indication has been shown to have a sensitivity of 85% and a specificity of 93%. This is better than plain films, but you should be aware of its limitations.

02 Look before You Leap: Ultrasound can be used to help you delineate whether a patient has a joint effusion or not. It is more sensitive than X-ray, can tell you if there is a joint effusion, and help you localize the best area to tap during an arthrocentesis.

03 Go Linear: For most joints use a 5-7.5 MHz linear array transducer. Apply a large amount of ultrasound gel to improve your acoustic interface. If the patient is thin and devoid of much subcutaneous fat, you may need to utilize an acoustic standoff pad or water submersion to improve your sonographic window. If the patient is larger and has more subcutaneous tissue, use a lower frequency probe (e.g. 2-5MHz curvilinear transducer).

04 Take Multiple Views: Always obtain images in multiple planes (longitudinal, transverse, oblique) to help define the borders of the structure you are looking at and avoid mistaking vascular structures for a joint effusion. Use color or spectral Doppler if there is any question as to whether the hypoechoic structure is a vessel or not.

05 Compare Sides: Utilize contra-lateral limbs for comparison views, especially when you are unsure of what you see. If you see a similar structure on the asymptomatic limb, it may be normal. To take a measurement of the hip effusion width, align your probe parallel to the femoral neck and measure at the concavity of the femoral neck. A positive result is an effusion >0.50 cm width or >0.20 cm more than asymptomatic side.

06 Don’t Move: Avoid changing the position of the joint between performing the bedside ultrasound and performing an arthrocentesis. Fluid may move with joint repositioning.

07 Practice Makes Perfect: With bedside ultrasound there is no substitute for experience. The more ultrasounds you do, the better you will be able to differentiate abnormal from normal, even when you may not be sure exactly what the abnormality is.

Brady Pregerson (@TheSafetyDoc) manages a free online EM Ultrasound Image Library and is the editor of the Emergency Medicine Pocketbook series. For more info visit EMresource.org.

Teresa S. Wu (@TeresaWuMD) is the Associate Residency Director, and Director of Ultrasound and Simulation Programs and Fellowships, for the Maricopa EM Program in Phoenix.

STEP 3: TAKE THE QUIZ

STEP 4: PROCESS PAYMENT