How to Evaluate Bone Pain in a 5-Year Old

In Episode 39 of Med School Question of the Week for USMLE, Faustine Ramirez, MedSchoolCoach expert tutor, answers this medical school question: A 5-year-old boy is brought to the emergency department because of progressive right leg pain, decreased activity, and fevers for the past 5 days. His mother has noticed he has also had difficulty walking and bearing weight on the right side. He recently had a cold about two weeks ago with congestion, rhinorrhea, and malaise. He has had no recent falls, injuries, or trauma. Medical history includes atopic dermatitis and sickle cell disease. Temperature is 38.5, heart rate is 140/min, respiratory rate is 25/min, and blood pressure is 100/58. On examination he appears uncomfortable and irritable. His pulses are strong and symmetric, and his capillary refill time is < 2 seconds. Cardiopulmonary and abdominal examinations are unremarkable. He cries with passive range of motion of the lower extremity. The distal aspect of his right lower leg is very tender to palpation and slightly warm, but there is no skin or joint erythema or swelling. He is reluctant to bear weight but is able to take a few steps. His gait is antalgic. Blood work demonstrates ESR 50, leukocytes 15,000, platelets 500,000, and normal electrolytes. Blood cultures and lower extremity plain films are pending. What is the next best step?

• Ibuprofen
• Morphine
• Vancomycin
• Vancomycin with Ceftriaxone
• Immediate surgical screw fixation
• Incision and drainage
• Hip replacement