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Prof. Mamoun KremliAlMaarefa College
The limping child
Introduction
Limping is a common presentation in childrenSeen by orthopedic surgeons, pediatricians, primary
care physicians
Need to take a properHistoryphysical examinationInvestigations
Some diseases related to specific age groups
History
Duration, when first noticed
Pain
History of trauma
Associated systemic symptomsFever, night sweating, anorexia, weight loss
Limping
PainfulAntalgic gait – short stance phase of gait cycle
Child may not complain of pain
Painless
History of trauma often reported in all casesRelevantIrrelevant
Types of gait
High steppage:Foot drop – neurologic disease
Trendelenburgh:DDH, weak hip abductors, could not abduct
Circumduction:Stiff hip, neurologic disaese
Tip-toeTight achilles tendon, CTEV, Cerebral Palsy, habitual,
compensating length discrepency
Lurching:Short length
Types of gait
Wide-base:To gain balance – neurologic disease
ScissoringTight hip adductors – Cerebral Palsy
Hemiplegic gaitCerebral palsy - neurologic
AtaxicNeurologic disease
Foot inversion / eversionFoot deformity / avoiding pain
Types of gait
Stiff-kneeKnee disease / arthrogryposis
Hand-knee Weak quadriceps femoris muscle
Causes of painful limping
TraumaMajor musculoskeletalSplinter into foot
InfectionAcute OM, Septic arthritis
Malignant bone tumor
Rheumatic disease
Acute slipped capital femoral epiphysis
Perthes disease (Avascula necrosis)
Causes of painless limping
Benign bone tumors
CongenitalDDH, club foot, congenitally short femur, short tibia
Post injury deformity / length discrepancy
AVN – Perthe’s disease
Slipped capital femoral epiphysis (chronic)
Deformity and leg length discrepancy
History
Sudden onset:Trauma
Gradual onset:Disease
Pitfalls
Misled by parents’ historyHistory of traumaAlways a leg length inequality
Misled by patients’ complaintHip problems may present with knee pain
Children below 5 years do not complain of pain
Many causes
Different diseases occur more commonly at specific age groups
Age 1-4 years
CDH – DDH
History: at risk groups
Physical findings:Asymmetrical foldsLimited abductionHamstring stretch signOrtolani / BarlowShorteningTrendelenburgh
Age 3 – 6 years
Transient synovitisLimping, painful to move, ?WBC, ? Fever, ? ESRResolves in daysDisappears without treatment
Septic arthritisLimping-refuses to walkFever >38.5WBC >12,000ESR >40 mm
If in doubt: Aspiration
Age 5 – 10 years
Legg-Calve-Perthes diseaseBoy, antalgic gaitPain and muscle spasm with passive motionLimitation of rotation and abductionPositive Trendelenburgh
Legg-Calve-Perthes
Age usually: 4-8 years, Boys= 4X girls
Idiopathic avascular necrosis of femoral head
Blood supply of femoral head:Neonates: metaphyseal,lateral epiphyseal, and scanty
ligamentum teres vessels4 years: no epiphyseal vessels7 years: ligamentum teres vessels developed well
4 – 7 years: dependent on lateral epiphyseal vesselsIf trauma or synovitis, pressure occludes blood
supply
Legg-Calve-Perthes
Stages:1. Bone death:
may still look normal on x-ray
2. Revascularization and Repair:Increased density and fragmentationon x-ray
3. Distortion and Remodelling
1. Distortion, falttening (coxa plana), and enlargement (coxa magna), with partial uncoverage
Legg-Calve-Perthes
Clinical picture:Limping (painful / painless)May present with knee/thigh painEarly: limitation of all movementsLater: limitation of abduction and internal rotation
Legg-Calve-Perthes
Apley’s System of Orthopedics and Fractures
Legg-Calve-Perthes
Apley’s System of Orthopedics and Fractures
Legg-Calve-Perthes
Different stages of Perthes in a patient
Sclerosis Collapse Fragmentation Remodelling
http://community.tsrhc.org/Perthes-disease-about-perthes-disease
Legg-Calve-Perthes
Treatment:RestPhysiotherapy: abductionContainment by splintSurgery:
Containment, improved coverLater: for aftermath
Age 10 – 15 years
Slipped Capital Femoral Epiphysis (SCFE)Acute Vs. chronicBoys, overweight, ?hypogonadismLimited internal rotationHip externally rotates when flexedX-ray: AP and Frog lateral
Really is an antero-lateral slippage of the metaphysiswww2.massgeneral.org/ortho/SCFE.htm
SCFE
Around puberty
? Hormonal imbalance between gonadal and growth hormones
Tall, or obese, gonads underdevelopment
Presents with limping
May present with thigh/knee pain
Acute slip Vs. chronic slip
Apley’s System of Orthopedics and Fractures
SCFE
Externally rotated hip
Loss of internal rotation
External rotation on flexion
Slippage of other hip in one third of patients
Apley’s System of Orthopedics and Fractures
SCFE
X-rays diagnosis:
Apley’s System of Orthopedics and Fractures
SCFE
http://reference.medscape.com/
SCFE
TreatmentManipulation to try to reduce the slip may cause AVNFixation in situ? Fix the other hip
Complications:Avascular NecrosisCoxa varaSlippage of opposite hipSecondary osteoarthritis
http://bestpractice.bmj.com/
3 – 12 years
Acute osteomyelitis:Constitutional symptomsWBC, CRP, ESRX-ray may initially be normalMRI
5 – 18 years
Trauma – place related to ageHousehold - earlyPlayground - childhoodSchool and Sports 0 older child - teenagerRTA – teenager
A prick or a splinter in sole of foot
Time algorithm
years1 2 43 5 6 7 8 9 10 1211 13 14 15
DDHPerthes
SCFE
Trauma
Infection
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