Dr Manoj Das Ortho Resident

Institute Of Medicine TUTH, Nepal

An Approach To Limping Child

INTRODUCTION

• An uneven, jerky, or laborious gait, usually caused by pain, weakness, or deformity.

• It is a common complaint in childhood, accounting for 4 per 1000 visits in pediatric emergency department. [ Uptodate 2016]

• Limp can be caused by both benign and life-threatening conditions; the management varies from reassurance to major surgery depending upon the cause.

INTRODUCTION

Pathophysiology

• Three major factors cause a child to limp: pain, weakness, and structural or mechanical abnormalities of the spine, pelvis, and lower extremities (Clark, 1997; deBoeck & Vorlat, 2003; Lawrence, 1998).

Differential Diagnosis

Age

Tachdjian’s Pediatrics Orthopaedics

History

History…

• AGE..

Apley’ system of orthopaedics and fractures

History…• Sex

• Painful vs Nonpainful limp

• Location of pain

• Duration and course

• Does limp improves or aggravate with activity

• No. of involved joint

• Associated symptoms (e.g., fever, weight loss, anorexia, back pain, arthralgia)

History…• Recent history of viral illness or streptococcal infection (post infectious

arthritis)• • Recent history of dysentry ( Reiters syndome)

• Recent history of new or increased sports activity

• Recent history of intramuscular injection (can cause muscle inflammation or sterile abscess)

• History of endocrine dysfunction (may predispose to slipped capital femoral epiphysis)

• Family history of connective tissue disorder, inflammatory bowel disease, hemoglobinopathy, bleeding disorder, or neuromuscular disorder

• Prenatal and birth history

Red flags • Children < 3 yr ( as septic arthrits more common in this age group)

• Inability to bear wt

• Fever or systemic illness

• Child > 9 yr with hip pain or restricted hip movement (SCFE)

PHYSICAL EXAMINATION

• GAIT

Normal gait variations in children

• The development of mature gait depends upon maturation of C.N.S(postural ,labyrinthine and rightining reflexes )

• Normal variations of gait in children:-

-Toe walking is common up to 3 years

-In-toeing can be due to persisting femoral anteversion (this is most common between ages 3-8 years)

-Internal tibial torsion is also common (knees point forwards but feet point in)

-Metatarsus adductus resolve by the age of 6 years.

Normal gait variations in children…

-Bow legs (genu varus) are common from birth to early toddler-phase, maximum at age 1 year, often with out-toeing. Most resolve by 18 months

-Knock knees (genu valgus) are common and associated with in-toeing. Most resolve by the age of 7 years

-Flat feet are common. Most children have a flexible foot with a normal arch on tiptoeing. Flat feet usually resolve by the age of 6 years

-Crooked toes. Most resolve with weight-bearing.

Normal gait variations in children…

Toddler’s walking

-walks on wide base to avoid falling -Reduced period of single limb support -shorter step length -Increased cadance -more pelvic tilt The adult pattern of gait develops between 3-5 years of age.

PATHOLOGICAL GAIT

1. Muscle weakness:(source of motion )

2. Deformities of bones and joints (Articulated lever

3. Neurological disorders

“disturbed awareness of the need for action and control of motion “

Antalgic Gait• compensatory gait pattern adopted in order to remove or diminish the

discomfort caused by pain in the LL or pelvis

• Characteristic features:

– Decreased in duration of stance phase of the affected limb

– There is a lack of weight shift laterally over the stance limb and also to keep weight off the involved limb

– Decrease in stance phase in affected side will result in a decrease in swing phase of sound limb.

Trendelenburg Gait

1. Weak abductors :poliomyelitis . muscular dystrophies, motor neuron disease

2. Defective fulcrum: Congenital dislocaion of hip(CDH), pathological dislocation of hip

3. Defective lever : Perthes disease, Coxa vara.

Proximal Muscle Weakness Gait

- Increase lordosis- Gower sign positive

Gluteus maximus gait(BACKWARD LURCH)

• During midstance phase ipsilateral hip must maintain in extension to prevent forward collapse of trunk

• Trunk is thrust posteriorly resulting in extension lurch

Quadriceps gait

• Stabilizes knee by

- leaning on affected side

-Pressing over lower thigh by ipsilateral hand and finger

Equinus Gait

• Walks on toes• Weakness of dorsiflexors• Compensation for LLD

Steppage Gait/Foot Drop Gait

- Weakness of foot and ankle dorsiflexion

- Stance phase: Foot slap gait

- Swing Phase : Steppage gait

• Circumduction Gait - In overcoming hip hike

gait or steppage gait -To avoid the foot from

scrapping the ground, the hip and the lower limb rotates outward.

Scissoring gait• one leg crosses directly

over the other with each step due to adductor tightness

• Seen in Cerebral palsy

Genu recurvatum gait• In Paralysis of

hamstring muscles the knee goes in for hyper extension while transmitting the weight in mid stance phase.

• Seen in poliomyelitis

Short limb gait

• Shortening less than 1.5 cm compensated by

pelvic tilt, and shortening upto 5 cm

compensated by equinus.

• Shortening more than 5 cm the patient dips

his body on that side.

Physical ExaminationStanding: - back should be examined for scoliosis ,local tenderness, range of

motion.

-if there is pelvic tilt is present , it can be measured by placing blocks under the shorter leg until the pelvis in level (horizontal)

-trendelenburg test

• Measurement of thigh and calf circumference should reveal atrophy (more than 1 to 2 cm of difference between sides) in a patient with any hip or knee condition that has limited function for more than one to two months.

Supine:

- each joint should be examined separately -look for swelling, feel for tenderness, assess the ROM -for hip flexion contracture --------Thomas test -neurological examination should be performed

-check for leg length discrepancy , the short leg must be differentiated from apparent shortening that is caused by scoliosis or pelvic obliquity or joint contracture.

Prone:

-hip rotation *-femoral anteversion

Asymmetric Abduction

Prone internal rotation of the hip

Galeazzi’s test - useful in diagnosing developmental

hip dysplasia or leg length discrepancy.

- performed by putting the child in a supine position and then flexing the hips and knees by bringing the ankles to the buttocks .

- positive when the knees are of different heights.

-Abnormal shortening of the leg can be caused by DDH, Perth's disease.

Klisic test

FABER TEST

Don,t forget!!!Both intraabdominal pathology and testicular

torsion may present as limpSo always examine abdomen and testes in boys!

InvestigationsHematological• CBC • ESR, CRP Kocher’s criteria for differentiating septic arthritis from transient synovitis

-Fever > 38.5 c-Cannot bear wt-ESR> 40 mm-WBC > 12000/mm cu

Probability of septic arthritis0= < 0.2%1=3%2= 40%3= 93.1%4= 99.6%

• Blood culture – Septic arthritis, OM

• Peripheral blood smear- leukemia

• Montoux test –TB

• PCR- TB

• Coagulation profile - Hemarhrosis • Immunological : RF, ANA - JIA , SLE

• RFT- SCFE

Endocrinal screening -SCFE- TFT

Synovial fluid analysis

X-RayToddlers Fracture

Sign of effusion : - Widening of the joint space.-Discrepancies greater than 1

mm indicate the presence of fluid

Septic arthritisNarrowing of joint space and irregularity of subchondral bone

Joint space loss subchondral erosions and sclerosis of the femoral

osteonecrosis and complete collapse of the femoral head

X-ray related to overuse syndrome

SCFE

Perthes Disease

Congenital coxa vara

Hilgenreiner’s epiphyseal angle

Hemophilic arthritis

Discitis

• Decrease disc space

Ultrasonography• Effusion -Widening of space between capsule and bone of > 2mm indicates

effusion. -Echo-free transient synovitis -Positively echogenic septic arthritis

• useful in the detection of early slips by demonstrating joint effusion and a “step” between the femoral neck and the epiphysis created by slipping-SCFE

• Acute osteomyelitis- periosteal thickening , subpriosteal thickening

CT scan• deep soft tissue infections of the Para

spinal and retroperitoneal regions

• Three dimensional images of shape of femoral head and acetabulum in perthes disease

• SCFE- confirm closure of the proximal femoral physis. Provide three-dimensional reconstructed CT images used to assess the severity of residual deformity of the upper femur,[ especially when reconstructive osteotomy is being considered.

MRI• evaluation of the spine (for discitis or

spinal tumors), soft tissue tumors and abscesses in the Para spinal and retroperitoneal regions, osteomyelitis of the pelvis and long bones.

• Legg-Calvé-Perthes disease • Highly specific for detection of AVN

• MRI with gadolinium-contrast arthrography- the evaluation of the adolescent patient with hip dysplasia and pain for assessing of the condition of the labrum and the articular cartilage of the hip joint

Radionuclide scans : - sensitive means of detecting alterations

in the metabolic rate of bone and thus a sensitive means of localizing pathology

-lacks specificity because such alterations in bone metabolism can occur in Legg-Calvé-Perthes disease, osteomyelitis, osteoid osteoma, and malignant bone tumors.

- Decrease uptake in AVN

- increased uptake in the capital femoral physis of an involved hip, decreased uptake in the presence of AVN, and increased uptake in the joint space in the presence of chondrolysis

Antalgic Gait

History of trauma / oveuse YESNO

Acute traumatic eventOveuse

Fracture, soft tissue injury, FB Osgood Schlatter Dz,

Sever Dz, Stress #, Osteochondritis dessicans

Radiography

Radiography

Are there Systemic Symptoms

NO

Knee pain or thigh pain

Hip painNormal hip

Accessory navicular/Discoid lateral meniscus

Radiography

SCFE/Perthe s dz

Radiography

YES

Radiography, CBC , ESR,

Back pain /tenderness

Discitis / vertebral OM

Hip pain, elevated ESR CRP, WBC

Joint Aspiration Pelvic Abscess

Bone pain / Tenderness

Elevated TLC ESR, CRP

Night pain , Palpable mass

Pancytopenia, night pain

Osteomyelitis

MRI

Osteosarcoma/ Ewing sarcoma

Leukemia

Septic Arthritis/ Transient Synovitis

Positive psoas sign FABER TEST,

Tender SI Jt

Sacroilitis

Non Antalgic Gait

Steppage gait

Any neurologic condition in which child loses ability to dorsiflex foot and ankle

Trendelenberg gait

Circumduction gait

Equinus gait

DDH, Abnormality in hip abductor mechanism

CTEV,Cerebral palsy, Idiopathic tight achillis, Limb length discrepancyNeurogenic or

mechanical condition causing stifness of hip

Positive Galleazzi Sign

Limb length discrepancy

TAKE HOME MESSAGE• Acute limp in a child should be taken seriously as it can indicate serious

underlying pathology

• Age of child is important when considering the most likely aetiology

• If trauma has occurred there is lower threshold for performing x-rays in children as fractures and dislocations are more common

• For atraumatic limp, red flags are age < 3 yr , inability to bear wt, systemic illness, pain or restricted movement of hip

TAKE HOME MESSAGE…

• In children 3-9 who are well , have no fever , are able to bear wt, and < 48 hr history of atraumatic limp transient synovitis is usually the cause

• Suspect SCFE in children > 10 yr if there is reduced internal rotation of hip and pain on extreme of movement

• Kocher’s criteria may be useful in distinguising transient synovitis

from septic arthritis

THANK YOU