Transcript The Limping Child Chrissie Ashdown

The Limping Child
Chrissie 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
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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
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Trauma
Transient synovitis/irritable hip
Osteomyelitis or septic arthritis
Perthes disease
Common causes
• 10-15 years old
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Trauma
Osteomyelitis or septic arthritis
Slipped upper femoral epiphysis
Chondromalacia
Perthes’
Other Dx
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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 should
you ask?
Child 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
Examination
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, move
• Look
Examination
– 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!!
Diagnoses
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 #
• 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 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
arthritis/osteomyelitis
Septic Arthritis
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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
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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’ 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:
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low birth weight
short stature
low socio-economic class
passive smoking.
• Unilateral in 85% of cases
Perthes’ disease
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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 Femoral
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 AfroCaribbean, 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
Dysplasia of the Hip
(DDH)
DDH Risk Factors
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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 midchest down to below the knee.
• This cast is usually left in place for 6-8
weeks
Neoplasm
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
Arthritis
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
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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
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Fever >38.5
Cannot weight bear
ESR>40 in 1st hr
WCC>12
That’ll do for now!
Any Questions?