Definitive Diagnosis of Children Presenting to A Pediatric Emergency Department With Fever and Extremity Pain

Background: Children who present to the emergency department (ED) with complaint of fever and new-onset joint or extremity pain can be a diagnostic dilemma for many emergency and consulting physicians.

Objectives: The purpose of our study was to identify the etiologies of pediatric fever and extremity pain presenting to a tertiary care pediatric ED and to define factors that were associated with advanced imaging, admission, and surgical intervention.

Methods: The electronic medical records of children presenting to our institution's pediatric ED with fever and extremity pain were retrospectively reviewed. Data collected included demographic characteristics, laboratory studies, diagnostic imaging, need for admission, and surgical procedures.

Results: The initial ED diagnosis was consistent with the definitive diagnosis 42% of the time. Children with the inability to bear weight on the affected limb were more likely to have a bacterial infection, such as osteomyelitis, septic arthritis, or intramuscular abscess (p = 0.016). An erythrocyte sedimentation rate >36 mm/hour and C-reactive protein levels >60 mg/L were found in children with osteomyelitis or septic arthritis (p = 0.043 and <0.001, respectively). Magnetic resonance imaging was ordered in 63% of children with multiple visits compared to 34% of children with a single visit (p = 0.05).

Conclusions: In addition to a thorough history and physical examination, a complete set of laboratory studies and diagnostic imaging is necessary to reach an accurate diagnosis. The inability to bear weight, elevated C-reactive protein levels, and an elevated erythrocyte sedimentation rate are associated with bacterial infection. Magnetic resonance imaging is a useful imaging modality in determining an accurate diagnosis.