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Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!
You are seeing a 4 year old with 1 day of limp and now, refusal to bear weight. He is afebrile. On exam, his hip is irritable to passive external and internal rotation. He holds his hip slightly externally rotated. His CBC WBC is 8,400 with 50% neutrophils, and his ESR is 20. His plain films are normal. He has reliable parents and an assigned pediatrician who can see him the next day.
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May 25, 2018 at 1:33 pm
Does NSAID in the ED make him better?
Most likely I’d go with NSAID and next day follow-up.
He meets one Kocher criteria which per that study, would put him at 3% risk septic joint. As an US afficionado, I’d like to see what the joint looks like. If no effusions, I’d feel even more comfortable going the NSAID and see PMD in the morning route. If affected side has notable effusion (important to look at both sides), probably would talk to orthopedics about the kid. Of course an effusion can exist in toxic synovitis as well.