Transcript Slide 1
Devin Peterson, MD, FRCSC, Dip Sport Med
Associate Professor, McMaster University
McMaster University Medical Centre
David Braley Sport Medicine & Rehabilitation Centre
Faculty/Presenter Disclosure
• Faculty: Devin Peterson
• Program: 51st Annual Scientific Assembly
• Relationships with commercial interests:
• None
Disclosure of Commercial
Support
• This program has received no financial support
• This program has received no in-kind support
• Potential for conflict(s) of interest:
– None
Mitigating Potential Bias
• N/A
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2.
To assess and diagnose common causes of
childhood limping
To understand the management principles
of the limping child including timely
referral
Smooth energy-efficient
transfer of the body
through space
Limp: “to walk with a halting or irregular step”
Funk
& Wagnall's
Antalgic
Gait: body’s effort to compensate
for pain or instability in the stance-phase
limb by minimizing the duration and
magnitude of loading
Trendelenburg
Gait: leaning of the head and
trunk toward the lower extremity affected by
the pathology
Pain
Weakness in the hip muscles
19 month old female referred because of limping
Fifth
born
Normal delivery/presentation
Walking
at 14 months
Always limped
No
pain
Healthy
Negative
Family history
Differential
diagnosis
Top three:
Hip dysplasia
Neuromuscular disease
Leg length discrepancy
Dislocated:
the femoral head is not in contact with the acetabulum
Dislocatable
the femoral head is within the acetabulum but can be forced out
Subluxed
the femoral head is within the acetabulum but not in its proper
position
Subluxable
the femoral head can be moved beyond its physiologic limits
within the acetabulum
Dysplastic
although the femoral head is in the proper position the
acetabulum or head are abnormally developed
History
Risk
Factors
Female
Firstborn
Breech
Large baby
Low amniotic fluid
Family history
Physical
Associated Conditions
o Foot deformity,
Torticollis
o Neuromuscular
disorders
o Syndromes
Hip Examination
o Trendelenburg gait
o Skin folds
o Galeazzi sign
o Abduction
o Provocative maneuvers
- Ortolani, Barlow
Imaging
Ultrasound
< 6 months
X-ray
Treatment
URGENT REFERRAL
Pavlik Harness
Closed Reduction
Safe Zone
Open reduction
Extra-articular blocks
Intra-articular blocks
Osteotomies
Pelvic
Femoral + Shortening
Most common cause of hip pain in
childhood
3% childhood risk
Idiopathic
Frequently associated with concurrent or
antecedent illness
Right hip = left hip
NEVER BILATERAL
2:1 male:female
History
Age
varies (9 months to adolescence)
Most between 3 and 8 years old
Unilateral hip pain
Can present with knee or thigh pain
Limp vs non-weight bearing
Physical
May
have a low grade temperature
Antalgic or Trendelenburg gait
Flexed and externally rotated position
Decreased ROM
Especially abduction and internal rotation
Laboratory
tests
Non-specific
Imaging
Radiographs
usually normal
Ultrasound may show effusion
Diagnosis
of exclusion
Treatment
URGENT
REFERRAL
Differential includes a septic joint
Self limiting disorder
May have symptoms for up to 10 days or
longer
Bed rest until full ROM, no pain, limp free
Crutches for older patients
NSAIDS
Gradual return to activity
Self limiting hip disorder
Caused by ischemia and subsequent necrosis
of the femoral head
Usually 4 to 8 years of age
Male to female ratio:
4-5 to 1
Usually unilateral (88%)
Age and lateral head involvement are the key
to prognosis
8 years of age seems to be the watershed
<50% of lateral pillar involvement better
prognosis
Unilateral Perthes:
septic arthritis
sickle cell disease
spondyloepiphyseal dysplasia tarda
Gaucher’s disease
Bilateral Perthes:
Hypothyroidism
Multiple epiphyseal dysplasia
spondyloepiphyseal dysplasia tarda
sickle cell disease
History
May
be painless at first
present with a limp only
symptoms occur with subchondral
collapse/fracture
Can present with knee or thigh pain
Positive family history 1.6% – 20%
1% - 3% of patients with transient synovitis
will develop Perthes
Physical
gait: Trendelenburg
decreased abduction/
internal hip rotation
thigh, calf, and
buttock atrophy
LLD
Imaging
X-ray, bone scan,
MRI
Treatment
TIMELY REFERRAL
Principles of treatment
are maintenance of
ROM & containment (good coverage of
the head by the acetabulum) of the femoral
head through the evolution of healing
May be obtained by non-operative means
o relative rest
o pain control
o physiotherapy
o traction
o abduction splinting at night
Containable Hip
adductor release
Femoral varus/pelvic
osteotomies
Non-Containable Hip
Hip/Late-presenting
patient with deformity
Hinge abduction
Chiari/lateral shelf
Cheilectomy
Femoral
abduction/extension
osteotomy
OCD, non-operative,
revascularization,
removal, ORIF
First
description: Young 1889
3-5% in general population have a larger
than normal meniscus
Almost all in lateral, but reported in medial
20% bilateral and 10% associated with OCD
of lateral femoral condyle
THREE SEGMENTS
• Anterior horn
• Body
• Posterior horn
Attached to tibial
plateau, primarily
through Coronary
Ligament
Attached to the
capsule except
at popliteal
hiatus
Clinical
Presentation
History:
Asymptomatic
“Snapping knee syndrome”
Meniscal tear symptoms
Physical:
Snapping knee with gait
Meniscal signs
X-ray
Widened
lateral joint space,
squaring of lateral femoral
condyle, cupping of lateral
tibial plateau
MRI
Verify
diagnosis and assess
damage
Asymptomatic:
observe
Symptomatic:
TIMELY
REFERRAL UNLESS LOCKED KNEE
THEN URGENT
Non-operative: restricted activity, bracing,
physiotherapy
Operative:
Partial meniscal “saucerization”
Repair of tear
Apophysitis
of the Hip and Pelvis
Sinding-Larsen-Johansson: inferior pole of
patella
Osgood-Schlatter Disease: tibial tuberosity
disturbance
Sever Disease: calcaneal apophysitis
Iselin Disease: apophysitis of the fifth
metatarsal
Tibial
tuberosity disturbance
Partial avulsion (microscopic fractures) of
the ossification center and overlying
hyaline cartilage
Epidemiology
10
– 15 years old
Boys > girls
> 10% of teenagers
History
Pain
localized to tubercle
Worse with direct blows to the are and
activity
Physical
Antalgic
gait may be present
Prominent tubercle + local swelling
Tenderness localized to tubercle
Lovell and Winter’s Pediatric Orthopaedics 5th edition
Treatment
Spontaneous
resolution at maturity
20% may have pain with kneeling
surgery for loose ossicles
Reassurance
Symptomatic treatment/activity modification
NSAIDS, stretching, knee pads/braces, foot
orthosis, casts
TIMELY REFERRAL
Acquired
potentially reversible lesion of
subchondral bone resulting in delamination
and sequestration with or without articular
cartilage involvement and instability
Juvenile and Adult forms
Adult form is typically progressive and
unremitting
May occur in almost any joint in upper or
lower extremity
Very common in the knee
15-29
per 100,000
May be bilateral in 25% of cases
Male: female ratio
5:3
>70% are in the classical area
Posterolateral aspect of the medial
femoral condyle
Idiopathic
Theories
include:
Genetics
Inflammation
Ischemia
Ossification
Repetitive trauma (stress reaction causing
a stress fracture in the underlying
subchondral bone)
History
Juvenile
Poorly localized pain
Exacerbated by exercise
May present with
symptoms of instability
(swelling, stiffness,
catching, locking)
Limp
Physical
Antalgic gait
Effusion
Crepitus
Painful ROM
Quads atrophy
Maximum tenderness
usually anteromedial knee
Wilson sign
Pain with internal tibial
rotation
X-rays
AP
Lateral
Notch
MRI + gadolinium
Lesion size
Status of the cartilage and subchondral bone
Bone edema and high signal zone beneath
fragment
Loose bodies
Technetium bone scan
Nonoperative
Open physis = good prognosis?
Activity modification
Immobilization?
Rehabilitation
Local and systemic pain management
Review every 3-6 months or sooner if
symptoms worsening
Repeat MRI every 6 months?
TIMELY REFERRAL if no improvement or
worsening, URGENT IF LOCKED KNEE
Operative
Indications
Lesions not responding to nonoperative
management
Unstable lesions?
Detached lesions
Tarsal coalition is an abnormal connection
between some of the tarsal bones
May be painful
Can be associated with increased ankle sprains
Gait
Antalgic
Flexibility
Toe
standing
Sitting/supine
Subtalar ROM
Flexible Flatfoot
Arch returns with
sitting or tiptoe
standing
Normal subtalar and
midtarsal motion
Tarsal Coalition
Arch may not return
with sitting or tiptoe
standing
May be painful to
move or palpate
subtalar joint or other
tarsal bones
Subtalar motion often
decreased
Normal
in flexible
flatfoot
Oblique views and
Harris view may help
view a coalition
May need an MRI or
CT to make diagnosis
Tarsal
Coalition
TIMELY REFERRAL
Rest/activity modification
Antiinflammatories
Physiotherapy?
Orthotics
Casts
Surgery: resection or fusion
The
slip normally
occurs during
adolescent growth
phase
Mechanical
or
systemic factors may
be present
Commonly obese
Endocrinopathies (eg.
1o & 2o
hypothyroidism,
panhypopituitarism,
GH, hypogonadal
conditions, & renal
osteodystrophy
Male
Left
> female
> right
Bilateral
involvement may occur
Second slip presents within 18 months in 88%
History
Chronic and/or acute
Limp
May present with knee or thigh pain instead of
hip/groin pain
Physical
Gait:
Trendelenburg
Shortened/external rotation
Decreased abduction/internal hip rotation
Passive flexion leads to thigh abduction and
external rotation
Imaging
X-ray,
CT, MRI
X-rays
Physeal plate widening &
irregularity
Decrease in epiphyseal
height
Blanch sign of Steel
Crescent-shaped area of
increased density in the
proximal femoral neck
Femoral metaphysis
appears laterally displaced
Klein’s line
Southwick angles
Imaging
Frog-leg lateral
avoid in acute
situation
Cross-table lateral
Treatment - Acute
EMERGENT REFERRAL
Immediate bed rest
Insertion of one or more
screws
in situ fixation
Designed to fuse the
epiphysis on the metaphysis
to prevent further slipping
Prophylactic Pinning
Known
metabolic/endocrine
disorders?
Inability to follow-up
Stress
Fractures in Skeletally Immature
Patients
Walker et. al.: JPO 1996
34
stress fractures
Tibia (47%), fibula, femur, radius, humerus,
MT
History
Pain
often associated with an increase in
activity
Be wary of female triad
Physical
Antalgic
gait may be present
Tenderness localized
Radiographs
Rapid
bony response may be
present
Bone Scan
Helpful in questionable
situations
Treatment (depends on
causative factors)
URGENT REFERRAL
Modification of activities
Immobilization
History
Pain
Night pain
History of trauma may delay diagnosis
Osteoid Osteoma pain relieved by NSAIDs
Constitutional Symptoms
Fever, night sweats, anorexia, weight loss
eg. Ewing sarcoma
Soft tissue mass may not be symptomatic
Physical
Exam
Gait disturbance
Muscle atrophy
Neurovascular exam
Range of motion
Mass
Size, tenderness, pulsation, mobility,
bruits, tenderness, erythema, consistency
Lymph nodes
Investigations
Bloodwork
CBC, ESR, CRP,
serum alkaline
phosphatase,
serum and urine
calcium &
phosphorus, LDH
Imaging
X-ray
Bone Scan
CT/MRI
Management
Referral
Urgency dependent on tumor type
History
Pain
Refusal to bear weight
Limping
Recent illness
Decreased immunity
eg. chickenpox
Trauma
Physical
Exam
Temperature
Antalgic gait
Disuse of a part
Erythema/swelling
Tenderness
Decreased ROM
Laboratory tests
CBC
WBC
CRP
ESR
Blood cultures
Aspirates (Gram stain,
Culture)
Imaging
X-rays
Ultrasound
Bone Scan
CT
MRI
Treatment
EMERGENT
REFERRAL
Stop tissue destruction ASAP
Decrease bacterial load and irrigation of
the joint
Identify the Organism
Select appropriate antibiotic