Pediatric Case Challenge: A 7-Year-Old Boy With a Limp and Obesity Who Fell in the Street

Derik L. Davis, MD; Ogechukwu R. Menkiti, MD; Brighita Weinberg, MD


June 15, 2022

Physical Examination and Workup

Upon physical examination, the patient has a temperature of 98.2° F (36.8° C). He has a pulse of 82 beats/min and a blood pressure of 138/74 mm Hg. The patient's respiratory rate is 19 breaths/min, and his oxygen saturation is 99% while he is breathing room air. The patient is obese in appearance. His weight is 181 lb (82 kg), well above the 95th percentile for boys of the same age. He is alert, oriented x 3, and in no acute distress.

The neurovascular examination reveals normal pulses, capillary refill, sensation, and motor function. The right and left upper extremities are unremarkable. The right lower extremity is normal. The left hip has a decreased range of motion, with pain elicited on passive internal rotation while the patient is lying in the supine position, and positive tenderness to palpation at the left groin. The left knee is tender to palpation and has a decreased range of motion, with no swelling, laxity, or effusion. The left ankle and foot examinations are unremarkable. The patient refuses to bear weight on the left lower extremity and demonstrates an antalgic gait. The skin has no abrasions, ecchymosis, or lacerations.

A frontal radiograph of the knees shows abnormal medial metaphyseal beaking of the left proximal tibia and mild flattening of the epiphysis medially. The right knee is normal. When compared with the previous radiographs of the knees obtained 10 months earlier, no significant change is noted for the patient's mild form of unilateral left-sided juvenile Blount disease. A review of the frontal and lateral radiographs of the hips obtained 10 months ago demonstrates that the left hip showed only slight physial widening compared with the right hip but was otherwise unremarkable. Films of the hips at the present visit (Figures 1 and 2) show an interval change.

Figure 1

Figure 2


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