The limping Child and Childhood Injuries
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Transcript The limping Child and Childhood Injuries
James Pegrum (Peggers)
MB BS BSc MSc (SEM) MRCS (Eng) Diploma in MM (UIAA)
Overview
The limping child
Assessment of limping child
Key conditions and their concepts
Limping children
Causes?
What is the biggest
worry?
How do you
diagnose it?
Limping Child
Age
Potential problem
0-5
Septic arthritis
DDH / CDH
5-10
Perthes
Trauma
10-15
SUFE
Trauma
Who needs admitting?
Limping child assessment
History
Trauma
DDH Female, FH, First Born, breech
Systemically unwell any URTI, viral sx
Pregnancy and birthing
Vaccination and milestones
Examination
Observations
Examination of all joints and Back/hips/knees/feet/sole
Septic screen rest of patient - ask paeds
Investigation
Bloods CRP/ESR/WCC
AP Pelvis and frog-leg lateral
Consider XR other joints
Tib-fib in toddlers – Toddlers #
Case 1
13 year old chubby boy
Painful knee after PE 7 days ago
No trauma
Limping on presentation
Radiology Limping Child
Classification
Clinical
Loder’s
Weight bearing at presentation
Non weight bearing at presentation
Radiological
Degree of slip
Mild <30%
Moderate 30-60%
Severe >60%
Clinically
History
Weight bearing status and time frame
Risk factors
Obesity / osteodystrophy / Hypothyroidism
Examination
A hip that ER and abducts with flexion
Investigations
Rule out endocrinopathies pathologies
radiographs
Operative Management
Case 2
6 year old boy
Left sided limp last 2 weeks
No history of trauma
Inflammatory markers normal
Afebrile
Clinically
Idiopathic AVN of the proximal femoral epiphysis in childhood
Why this age?
Change in blood supply from metaphyseal to epiphyseal
History
Bilateral in 20%
Other causes of AVN
Clinically
Reduced range of movement
Investigations
Causes of AVN
Classification
Multiple and complex
Waldenstrom – pathological stages
Initial vascular event – may have cresent sign on radiographs
Fragmentation
Re-ossification or resolution
Remodelling or healed
Herring classification / Catterall – radiographic fragmentation
A – no collapse of lateral pillar
B - <50% collapse (I-II)
C - > 50% c0ollapse (III-IV)
Management
Symptomatic relief
2. Head containment
3. Restoration of movement
1.
Age < 6 years conservative management
Age 6-9 severe grades osteotomy and cover femoral head
Age 9 operative containment in most
Case 3
3 year old girl
24 hours history of fever malaise
Reluctance to weight bear
Septic Arthritis
Clinically
History
Recent URTI
Vaccination Hx
RF – prematurity and C section
Examination
Fevers no other source
Irritable hip held in FABERs position
Investigations
Bed side
Bloods
Radiology
Likelihood of septic Arthritis?
Kocher 1999 JBJS (Am)
Not weight bearing / fever / WCC > 12 / ESR > 40
Features
% chance of Septic arthritis
0
0.2
1
3
2
40
3
93.1
4
99.6
Septic arthritis Aspiration
Rapid joint destruction
Send for
MC&S
Urgent Gram stain
Crystals
Treatment
• Aspirate
• Antibiotics
• Joint washout
Case 4
A 2 year old with a limp
1st born, breech position
No trauma
Classification
Dislocated
Dislocatable – Barlow positive
Subluxable – Barlow Suggestive
Clinically
History
Pregnancy / Birth / mile stones
RF – 1st born, female, FH, oligohydramnios,
breech
Clinically
Reduced abduction
Barlow – dislocates hip by adduction and
depression in flexed hip
Ortolani – reduces hip by elevation and
abduction
Radiology
US if < 6months
Management
1. Early concentric reduction
2. Head coverage to allow normal development of head and acetabulum
Non operative
<6/12 – pavlik harness if reducible
6-18/12 – hip spica
Operative
Arthrogram and closed reduction
Open reduction
Open reduction +/- pelvis or femoral osteotomy
Summary
Reviewed the Differentials of a limping child
Septic arthritis
DDH
Perthes
SUFE
Broadly assessed by age
Management options