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The Limping ChildThe Limping ChildThe Limping ChildThe Limping Child
Chrissie AshdownChrissie Ashdown
Aims and Objectives• How to assess the limping child
who presents to the GP• Investigations• Common diagnoses• Basic management
The Limping Child• A common reason for a child to present• Long list of potential diagnoses, some
of which demand urgent treatment• How do they present?• What are the potential diagnoses?• How should they be diagnosed and
managed?
Gait Differences• The gait of a child is different from that of an
adult for the first 3 yrs• Children typically take more steps/minute at
a slower speed than adults to compensate for immature balance.
• Toddlers tend to flex hips, knees, + ankles more than adults in order to lower their centre of gravity + improve their balance.
Developmental stages of gait
• Age (months) Developmental stage• 10-12 Cruises while holding on to objects • 12-14 Walks short distances, stands unaided• 17-21 Walks on 1 foot long enough to walk
up steps• 30-36 Balances on 1 foot for >1s • 36 Develops sufficient balance to attain a
normal gait pattern
Common Causes• 0-3 years old
– #/soft tissue injury (toddler’s #/NAI)– Osteomyelitis or septic arthritis – Developmental dysplasia of the hip
Common Causes• 3-10 years old
– Trauma – Transient synovitis/irritable hip– Osteomyelitis or septic arthritis – Perthes disease
Common causes• 10-15 years old
– Trauma – Osteomyelitis or septic arthritis – Slipped upper femoral epiphysis – Chondromalacia – Perthes’
Other Dx• Haematological eg Sickle cell• Infective eg pyomyositis/discitis• Metabolic eg rickets• Neoplastic eg acute lymphoblastic
leukaemia• Neuromuscular eg cerebral palsy• 1ary anatomical eg limb length
inequality• Rheumatological eg juvenile idiopathic
arthritis
What questions What questions should you ask?should you ask?What questions What questions should you ask?should you ask?
Child presents with a limpChild presents with a limp
History – Q’s to ask• Duration and progression of limp? • Recent trauma and mechanism? Beware
limitations of paediatric history, possibility of unintentional trauma
• Associated pain and its characteristics? • Accompanying weakness? • Time of day when limp is worse? • Can the child walk or bear weight?
History – Q’s to ask• Has the limp interfered with normal
activities? • Presence of systemic symptoms - fever,
weight loss? • Do not forget PMHx, BIND—birth history,
imms, nutritional history, developmental history
• Also include the other essentials— DHx and allergies and FHx
ExaminationExaminationExaminationExamination
pGALS• Pain or stiffness in joints/mm/back?• Gait/general: Temp, observe gait
including on tiptoes and heels• Arms – N/A• Legs: Knee effusion, ‘bend +
straighten you knee’ – crepitus?, apply passive flexion (90deg) with internal rotation of hip
pGALS• Spine: observe from behind,• ‘can you bend and touch your
toes?’• Observe curve of spine from side
and behind
Look, feel, moveLook, feel, moveLook, feel, moveLook, feel, move
Examination• Look
– Feverish?– Can they stand? Spine straight? Pelvis level?– Deformity, erythema, swelling, effusion, – limitation of motion, asymmetry. – shoes - unusual wear on soles, asymmetry,
point of initial foot strike, assess fit. – Older children - scoliosis, midline dimples,
hairy patches, (?spinal pathology)
Examination• Feel
– Can they localise the pain?– Measure true leg length - anterior
superior iliac spines to medial malleoli. – Assess thigh or calf circumference if
asymmetry suggests atrophy. – Feel for warmth, fluctuance, palpable
masses, stiffness, focal tenderness
Examination• Move
– Assess ROM, laxity, stiffness with guarding, pain, discomfort, and fluidity
– Assess gait with the child barefoot. – Any discomfort as the child bends
down – Hips: move normally? Internally rotate
symmetrically, no pain?
Don’t forget!• Both intra-abdominal
pathology and testicular torsion may present simply as a limp – examine abdomen and testicles in boys!!
DiagnosesDiagnosesDiagnosesDiagnoses
Trauma• Diagnosis is by plain x ray as a
primary investigation. • Anteroposterior and lateral views
are indicated. • A+E usually indicated
Toddler’s #Toddler’s #Toddler’s #Toddler’s #
Toddler’s #• Subtle undisplaced spiral # of the
tibia• Usually pre-school• Sudden twist after an unwirnessed
fall
Toddler’s #• Local tenderness over tibial shaft
may be present or on gentle strain on the tibia
• In 1 series 5/37 # not present on initial x-ray
• Immobolise, expectant Mx
Transient synovitisTransient synovitisTransient synovitisTransient synovitis
Transient Synovitis• Acute onset, after a respiratory
illness (weak evidence)• Affects young children (boys more
than girls) most often• Most common cause of acute hip
pain in young children age 3-10 • Usually unilateral• May refuse to walk/limp
Transient Synovitis• Usually no pain at rest + passive
movements only painful at extreme ranges
• FBC + ESR normal or slightly elevated • XR may be normal • USS may show effusion • Main treatment rest + physio • NSAIDs useful, can shorten the duration
of symptoms in children, usually resolves within 2 weeks
Septic Septic arthritis/osteomyelitisarthritis/osteomyelitis
Septic Septic arthritis/osteomyelitisarthritis/osteomyelitis
Septic Arthritis• Most often hip, knee, ankle, shoulder, elbow. • Most often children <2yrs. • Early features often non-specific. • Child often very unwell. • Pain often present at rest, resistance to
attempted movement of the hip. • Older children usually reluctant to weight
bear, may be more aware of referred pain in the knee.
• Hip is kept flexed, abducted and externally rotated.
Septic arthritis• BCs +ve, raised WCC + CRP• XR show delayed changes• Bony changes not evident for 14-21
days• By 28 days, 90% show some
abnormality. • About 40-50% focal bone loss is
necessary to cause detectable lucency on plain films
Septic arthritis - Mx• Joint aspiration is the definitive diagnostic
procedure and the most common pathogen isolated is Staph aureus
• Emergency orthopaedic consultation with subsequent aspiration, arthroscopy, drainage + debridement required.
• Antibiotics are required as adjunctive treatment.
Perthes’ DiseasePerthes’ DiseasePerthes’ DiseasePerthes’ Disease
Perthes’ disease• Self-limiting hip disorder caused by
varying degrees of ischaemia and subsequent necrosis of the femoral head.
• Most often affects boys (80%) and those aged 5-10 yrs.
• Increased risk with:– low birth weight– short stature– low socio-economic class– passive smoking.
• Unilateral in 85% of cases
Perthes’ disease• Presents with pain in hip or knee, causes limp. • Pain (often in knee), + effusion (from
synovitis). • On examination all movements at hip limited• No history of trauma. • Roll test; with patient lying supine, roll the hip
of the affected extremity into external + internal rotation.
• Should invoke guarding or spasm, especially with internal rotation.
Perthes’ disease• Classic x-ray features:
– Sclerosis, fragmentation and eventual flattening of the proximal femoral epiphysis
– Absent in early disease
• May be initially misdiagnosed as irritable hip
Perthes’ disease• Radionuclide bone scan/MRI helps
evaluate for avascular necrosis • If AVN is shown, bracing, physio +
protection of the hip may be indicated. • Surgery to contain the femoral head
within the acetabular cup sometimes necessary – femoral varus osteotomy
• Done with or without rotation to redirect the ball of the femoral head into the socket of the acetabulum
Slipped Capital Slipped Capital Femoral EpipysisFemoral EpipysisSlipped Capital Slipped Capital
Femoral EpipysisFemoral Epipysis
Slipped capital femoral epiphysis
• Usually occurs at the onset of puberty and most often in children who are either very tall and thin, or short and obese.
• Other risk factors include Afro-Caribbean, boys, family history.
• One quarter of cases are bilateral.• Prepubescent male children (12-15 yrs)
Slipped capital femoral epiphysis
• Hip, thigh and knee pain. • Often initially a several week history of
vague groin or thigh discomfort. • May be able to weight bear, but is
painful. • Flexion of hip often also causes external
rotation. • May be leg shortening.
Slipped capital femoral epiphysis
• XR shows widening and irregularity of the plate of the femoral epiphysis.
• The displacement of the epiphyseal plate is medial and superior
• Surgical pinning of the hip is usually required and should be done quickly.
Developmental Developmental Dysplasia of the Hip Dysplasia of the Hip
(DDH)(DDH)
Developmental Developmental Dysplasia of the Hip Dysplasia of the Hip
(DDH)(DDH)
DDH Risk Factors• Female • Breech position • Caesarean section • 1st child • Prematurity • Oligohydramnios • Family history • Club feet, spina bifida and infantile
scoliosis
DDH • Must be detected early • Delayed identification leads to more prolonged
morbidity • Classic screening tests are Barlow and Ortolani
– Ortolani assesses if the hip is dislocated– Barlow assesses whether the hip is dislocatable.
• Asymmetrical skin creases in the thigh or buttock • Unequal leg length
DDH• Up to 60% of abnormal hips
become normal without Tx after 1mth
• USS usually done • Mx depends on age
DDH - Management• 0-6 months- Pavlik harness• Attempts to place hips in the human position
by flexing them more than 90 degrees (preferably 100-110 degrees) and maintaining relatively full, but gentle abduction (50-70 degrees).
• Redirects the femoral head towards the acetabulum and spontaneous relocation of the femoral head occurs typically in 3-4 weeks.
DDH - Management• > 6m requires closed reduction and use
of a Spica cast - used to immobilize the hip joints and it usually extends from the mid-chest down to below the knee.
• This cast is usually left in place for 6-8 weeks
NeoplasmNeoplasmNeoplasmNeoplasm
Neoplasm • Osteogenic sarcoma causes acute
unremitting limp/limb pain, often involves the distal femur + proximal tibia
• Leukaemia causes ill defined migratory bone or joint pain + generalised weakness
• Neuroblastoma can produce nerve impingement
• Appropriate treatment is multidisciplinary and involves referral to paediatric oncology and orthopaedics.
Juvenile Rheumatoid Juvenile Rheumatoid ArthritisArthritis
Juvenile Rheumatoid Juvenile Rheumatoid ArthritisArthritis
Juvenile rheumatoid arthritis
• Autoimmune disease may present affecting a single ankle or knee (pauciarticular)
• Presence of assoc. systemic findings eg high fever, salmon coloured pink rash, eye inflammation are also useful in Dx
• Treatment is multidisciplinary, involves paediatric rheum, ophthal, ortho, rehabilitation specialists + OTs
Red flags!!Red flags!!Red flags!!Red flags!!
Red flags• Child <3y• Unable to weight bear• Fever• Systemic illness• >9y with pain or restricted hip
movements
Irritable hip v septic arthritis
• Factors for predicting septic arthritis– Fever >38.5– Cannot weight bear– ESR>40 in 1st hr– WCC>12
That’ll do for now!That’ll do for now!That’ll do for now!That’ll do for now!
Any Questions?Any Questions?