Transcript Evaluation of the Child with a Limp

Evaluation of the Child
with a Limp
DD Aronsson
University of Vermont
Hx – 2-year-old boy limps
because of pain in the right
thigh (antalgic)
PE – pain and swelling
just above the knee
Differential Diagnosis
• Bone infection (osteomyelitis)
• Joint infection (septic
arthritis)
• Fracture
• Toxic synovitis
Bone & Joint Infections
• Hematogenous origin
–Strep throat
• Implantation
–Stepping on a nail
Osteomyelitis
• Metaphyseal
•
origin
Vessels don’t
cross the growth
plate
Septic Arthritis
• Infection can
•
decompress into
a joint
Septic dislocation
Clinical Findings
• Systemically ill
• Irritable
• Refusal to bear weight
• Pseudoparalysis
• Pain & swelling @ the site
Laboratory Studies
• Elevated WBC,ESR, & CRP
• 50% Positive blood culture
• Infant
–May be normal
Imaging
• Radiographs
–Soft tissue
swelling
• Bone scan
–Increased uptake
Treatment
• Aspiration is
•
the “key” to
the diagnosis
Don’t wait for
imaging
Subperiosteal aspiration
Treatment
• IV antibiotics
–S aureus, gram-negative
enteric, & Group B
Streptococcus
• Surgical decompression
–Hip & shoulder
Hx – 18 month-old girl limps
on the left leg (no pain)
PE – short left lower
extremity is causing the
limp
Differential Diagnosis
• Developmental dysplasia of
the hip
• Limb-length discrepancy
DDH
• Instability
• Subluxation
• Dislocatable
• Reducible dislocation
• Irreducible dislocation
Etiology Unknown
Multifactorial
• Genetic
• Physiologic
• Mechanical
• Environmental
whites
girls
breech
swaddling
Barlow Provocative Test
• Dislocates hip
(exit)
Clunk
Ortolani Maneuver
• Reduces
Abduction
dislocated hip
(entry)
Clunk
PE > 3 Months
57º
43º
Limited abduction is key
PE > 3 Months
• Asymmetric
thigh folds
–Limb-length
discrepancy
Radiographs
Ultrasound
• Alpha > 60º
–Slope of osseus
acetabulum
Pavlik Harness Success
• Dysplasia 95%
• Dislocated 80%
Hx – 6-year-old boy limps
on the right leg
PE – limp with painful
range-of-motion of the hip
Differential Diagnosis
• Infection
• Toxic synovitis
• Slipped capital femoral
epiphysis (endocrine)
• Legg-Calv-Perthes disease
Legg-Calv-Perthes
• Loss of blood
supply of the
epiphysis
Legg-Calv-Perthes
• History
–Pain in the groin or knee
–Limp
–Aggravated by exercise
Legg-Calv-Perthes
• Physical examination
–Decreased internal rotation
–Decreased abduction
–Irritable hip
Necrotic stage
Fragmentation stage
Reossification stage
Remodeling stage
Treatment
• Containment
–Physical therapy
• ROM exercises
–Orthosis
• Abduction & internal rotation
–Osteotomy
Toxic synovitis
• History – sudden onset
–Pain in groin or thigh
–Painful limp
–URI 2 weeks ago
Physical Examination
• Limp
• Irritable hip with guarding
• Mimic septic hip
Treatment
• Activity modification
• Expect improvement
• Question diagnosis if not
responding
Hx – 14-year-old obese boy
has pain in the right knee
and limps
PE – no swelling and full ROM
of the knee but decreased
internal rotation of the hip
Differential Diagnosis
• Infection
• Osgood-Schlatter disease
• Anterior knee pain
• Slipped capital femoral
epiphysis
Slipped Capital Femoral
Epiphysis (SCFE)
• Most common hip disorder in
adolescents
• Age
–Boys 14 y/o
–Girls 12 y/o
Etiology
• Endocrine
–Hypothyroid
–Growth hormone treatment
• Mechanical
–63% > 95th percentile weight
Hip Flexion Causes Abduction
& External Rotation
FABER
AP Pelvis Radiograph
• Wide & irregular
•
physis
Epiphysis at or
below Klein’s
line
Klein’s line
Frog Pelvis Radiograph
• Posterior slip
• Wide, irregular
physis
Preop AP pelvis
Preop frog pelvis
Postop AP pelvis
Postop frog pelvis
Limp
Think hips