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INTRODUCTION

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General note: If you have a choice between acetaminophen and an NSAID for an acute injury, acetaminophen will always be the right choice. Most acute injuries are not inflammatory and acetaminophen is a lot safer without gastropathy or platelet inhibition. If you do use an NSAID, naproxen is the safest from a cardiovascular standpoint but carries the same gastrointestinal risks as other NSAIDs.

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CASE 12.1

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A 5-year-old boy presents with acute onset of left anterior thigh and hip pain that began 2 days ago with no known prior trauma. He reports that it initially "loosened-up" after he had been out of bed for a few hours but has become worse again by afternoon. His pain is exacerbated by weight bearing and active or passive range of motion (ROM). His mother notes that he had a cold 7 to 10 days ago, but has been asymptomatic until he complained of thigh pain two nights ago. She also notes that he has had a low-grade fever. He has no other significant constitutional symptoms and appears to be in some pain, but otherwise he appears well.

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Question 12.1.1 Based on the information obtained thus far, which of the following is the most likely diagnosis?

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A) Osteomyelitis.

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B) Rheumatic fever.

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C) Slipped capital femoral epiphysis (SCFE).

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D) Legg–Calve–Perthes disease (LCPD).

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E) Transient (toxic) synovitis.

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Answer 12.1.1 The correct answer is "E." This presentation is classic for transient (toxic) synovitis. This is the most common cause of hip pain in children aged 3 to 10 years, with peak occurrence in ages 5 to 6 years. It is more commonly seen in boys (male:female ratio of 2–3:1) and is often preceded by a viral respiratory infection, although numerous studies have failed to demonstrate a specific viral or bacterial agent. Physical examination reveals a limp or refusal to walk and complaint of pain over the groin and/or proximal thigh. There is pain with ROM testing, especially during abduction. Most children will be afebrile with a temperature of ≤38°C.

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Question 12.1.2 Appropriate diagnostic work-up might include which of the following?

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A) Joint aspiration.

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B) Plain film radiographs.

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C) Inflammatory markers including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).

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D) CBC with differential.

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E) All of the above.

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Answer 12.1.2 The correct answer is "E." All of the above may be appropriate as transient synovitis is a diagnosis of ...

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