ULTRASOUND CASE REVIEWS
Bedside Hip Ultrasonography in the Pediatric Emergency Department A Tool to Guide Management in Patients Presenting With Limp Julia Deanehan, MD,* Rachel Gallagher, MD, RDMS,Þ Rebecca Vieira, MD, RDMS,Þ and Jason Levy, MD, RDMSÞ
Abstract: We present a case of a 3-year-old girl brought to the emergency department for evaluation of limp after falling off the monkey bars 1 day prior. X-rays of the entire left lower extremity were normal with no evidence of fracture, dislocation, or effusion. Point-of-care ultrasound of the left hip demonstrated a hip effusion, which prompted further imaging, ultimately revealing an occult fracture of the left proximal femoral metaphysis. This case demonstrates the ability of point-of-care ultrasound to guide the management of patients presenting to the pediatric emergency department with musculoskeletal complaints. Key Words: hip ultrasound, bedside ultrasonography, limp, hip effusion, occult fracture (Pediatr Emer Care 2014;30: 285Y287)
FIGURE 1. Computed tomographic scan of the hips showing a linear lucency (arrows) in the left anterior femoral metaphysis.
CASE A 3-year-old otherwise healthy girl presented to the pediatric emergency department (ED) with left leg pain approximately 20 hours after falling from the monkey bars onto her left side. Her family reported that she cried after the fall and was complaining of left thigh pain. She was able to ambulate but with a slight limp. Overnight, she awoke complaining of left thigh pain and was treated with acetaminophen. On the day of arrival, she was refusing to ambulate secondary to pain. The parents denied any recent fevers or intercurrent illnesses. On examination, the patient was resting with her legs straight out on the stretcher. She had no obvious focal tenderness to palpation of the entire left leg but had apparent pain with internal and external rotation of her left hip. No swelling, deformity, or bruising was noted. She was able to bear weight on her left leg with some discomfort. X-rays (XRs) of the left hip, femur, and tibia/fibula showed no osseous abnormalities or effusions. Point-of-care ultrasound (POCUS) performed by a pediatric emergency medicine physician showed a moderate-sized left hip effusion. A radiology ultrasound was obtained, which confirmed a moderate-sized left hip effusion and also noted an occult fracture of the proximal femoral metaphysis. Orthopedics was consulted and requested a computed tomography for further evaluation, which confirmed a Salter II fracture of the left proximal femur (Fig. 1). The child was admitted to the
From the *Division of Pediatric Emergency Medicine, Johns Hopkins Children’s Center, Johns Hopkins Medical School, Baltimore, MD; †Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA. Disclosure: The authors declare no conflict of interest. Reprints: Julia Deanehan, MD, Division of Pediatric Emergency Medicine, Johns Hopkins Children’s Center, 1800 Orleans Street, Rm 1511, Baltimore, MD 21287 (e
Bedside Hip Ultrasonography in the Pediatric Emergency Department A Tool to Guide Management in Patients Presenting With Limp Julia Deanehan, MD,* Rachel Gallagher, MD, RDMS,Þ Rebecca Vieira, MD, RDMS,Þ and Jason Levy, MD, RDMSÞ
Abstract: We present a case of a 3-year-old girl brought to the emergency department for evaluation of limp after falling off the monkey bars 1 day prior. X-rays of the entire left lower extremity were normal with no evidence of fracture, dislocation, or effusion. Point-of-care ultrasound of the left hip demonstrated a hip effusion, which prompted further imaging, ultimately revealing an occult fracture of the left proximal femoral metaphysis. This case demonstrates the ability of point-of-care ultrasound to guide the management of patients presenting to the pediatric emergency department with musculoskeletal complaints. Key Words: hip ultrasound, bedside ultrasonography, limp, hip effusion, occult fracture (Pediatr Emer Care 2014;30: 285Y287)
FIGURE 1. Computed tomographic scan of the hips showing a linear lucency (arrows) in the left anterior femoral metaphysis.
CASE A 3-year-old otherwise healthy girl presented to the pediatric emergency department (ED) with left leg pain approximately 20 hours after falling from the monkey bars onto her left side. Her family reported that she cried after the fall and was complaining of left thigh pain. She was able to ambulate but with a slight limp. Overnight, she awoke complaining of left thigh pain and was treated with acetaminophen. On the day of arrival, she was refusing to ambulate secondary to pain. The parents denied any recent fevers or intercurrent illnesses. On examination, the patient was resting with her legs straight out on the stretcher. She had no obvious focal tenderness to palpation of the entire left leg but had apparent pain with internal and external rotation of her left hip. No swelling, deformity, or bruising was noted. She was able to bear weight on her left leg with some discomfort. X-rays (XRs) of the left hip, femur, and tibia/fibula showed no osseous abnormalities or effusions. Point-of-care ultrasound (POCUS) performed by a pediatric emergency medicine physician showed a moderate-sized left hip effusion. A radiology ultrasound was obtained, which confirmed a moderate-sized left hip effusion and also noted an occult fracture of the proximal femoral metaphysis. Orthopedics was consulted and requested a computed tomography for further evaluation, which confirmed a Salter II fracture of the left proximal femur (Fig. 1). The child was admitted to the
From the *Division of Pediatric Emergency Medicine, Johns Hopkins Children’s Center, Johns Hopkins Medical School, Baltimore, MD; †Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA. Disclosure: The authors declare no conflict of interest. Reprints: Julia Deanehan, MD, Division of Pediatric Emergency Medicine, Johns Hopkins Children’s Center, 1800 Orleans Street, Rm 1511, Baltimore, MD 21287 (e
