THE CHILD WITH A LIMP

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THE CHILD WITH A LIMP

• Madesa Espana, MD, FAAP
• Pediatric Emergency Medicine
• St. Josephs Regional Medical Center
• Paterson, New Jersey

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LIMP

• An uneven, jerky or laborious gait, usually
  caused by pain, weakness or deformity.
• 4/1000 visits in a pediatric ED

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A CHILD WITH A LIMP

• Epidemiology
• Median age 4 years old
• Malefemale ratio 21
• Most common diagnosis Transient synovitis
• Pain is present in 80 of cases
• Localization hip and knee
• Benign cause 77

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THE CHILD WITH A LIMP

• HISTORY
• Duration
• Trauma
• Fever

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THE CHILD WITH A LIMP

• HISTORY
• Location of the pain
• Pain characteristics
• Constant severe pain
• Intermittent mild to moderate pain
• Bilateral pain
• Modifying factors

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THE CHILD WITH A LIMP

• HISTORY
• Other symptoms
• Morning stiffness
• Incontinence, weakness or sciatica
• Recent viral or bacterial illness
• Recent medications
• Endocrine and other systemic diseases

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THE CHILD WITH A LIMP

• PHYSICAL EXAMINATION
• General appearance
• Ill or toxic appearing
• Fever
• Obvious discomfort/pain at rest

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THE CHILD WITH A LIMP

• PHYSICAL EXAMINATION
• Gait evaluation
• Phases of a gait
• Stance time when the foot is in contact with the
  surface
• Heel-strike to toe flat (contact)
• Foot-flat to heel-off (mid-stance)
• Heel-lift to toe off (propulsion)
• Swing time from toe-off to heel strike

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THE CHILD WITH A LIMP

• PHYSICAL EXAMINATION
• Young child (lt4 years) vs. adult gait
• Increased flexion of the hips, knees and ankles
• Rotation of the feet externally, wider base of
  support
• Faster cadence, slower velocity, shorter stride
  length
• Smaller percentage of the gait cycle is spent in
  single limb stance

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THE CHILD WITH A LIMP

• PYSICAL EXAMINATION
• Gait examination
• Expose the legs
• Bare feet or wearing only a pair of socks
• Listening to the gait
• Cadence
• Foot slap
• Scraping

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THE CHILD WITH A LIMP

• PHYSICAL EXAMINATION
• Gait examination
• Observe several gait cycles
• Includes jumping/hopping

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Gait evaluation
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THE CHILD WITH A LIMP

• PHYSICAL EXAMINATION
• Musculoskeletal
• Muscle strength
• Muscular atrophy
• Bony tenderness
• Bony deformity

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THE CHILD WITH A LIMP

• PHYSCIAL EXAMINATON
• Musculoskeletal
• Active and passive ROM
• Joint swelling/tenderness
• Muscle tenderness
• Tenderness on the tendons, insertions sites

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THE CHILD WITH A LIMP

• PHYSICAL EXAMINATION
• Musculoskeletal
• Back and spine
• Hip
• Thigh
• Knee
• Leg
• Ankle
• Foot

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THE CHILD WITH A LIMP

• PHYSICAL EXAMINATION
• Musculoskeletal
• Limb length discrepancy
• Hip rotation
• Galeazzi test
• Trendelenburg test
• FABERE test

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THE CHILD WITH A LIMP

• PHYSICAL EXAMINATION
• Skin
• Bruises
• Rashes and other lesions
• Swelling
• Redness
• Tenderness

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THE CHILD WITH A LIMP

• PHYSICAL EXAMINATION
• Lymphatic
• Lymphadenopathy
• Localized vs. systemic
• Lymphadenitis
• Lymphangitis

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THE CHILD WITH A LIMP

• PHYSICAL EXAMINATION
• Neurologic
• Muscle strength
• Muscle tone
• DTRs

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THE CHILD WITH A LIMP

• PHYSICAL EXAMINATION
• Gastroentestinal
• Abdominal tenderness
• Abdominal swelling
• Genitourinary
• Testicular or scrotal pain/swelling
• Inguinal swelling

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THE CHILD WITH A LIMP

• DIFFERENTIAL DIAGNOSES
• Age of the child
• Location of abnormal findings
• Duration of symptoms
• Type of gait abnormality

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THE CHILD WITH A LIMP

• DIFFERENTIAL DIAGNOSES
• OSSEOUS
• Fractures
• Salter-Harris or growth plate injuries
• Toddlers tibia, calcaneous and cuboid
• Stress
• Incomplete buckle, greenstick
• Complete
• Plastic or bowing deformity
• Avulsion
• Child abuse bucket-handle fractures

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THE CHILD WITH A LIMP

• DIFFERENTIAL DIAGNOSES
• OSSEOUS
• Apophysitis
• Sinding-Larsen-Johnson disease
• Kohler disease
• Sever disease
• Freiberg disease
• Osgood-schlater disease

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THE CHILD WITH A LIMP

• DIFFERENTIAL DIAGNOSES
• OSSEOUS
• Vasoocclussive crisis of SCD
• Slipped capital femoral epiphysis
• Legg-Calve-Perthes disease

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THE CHILD WITH A LIMP

• DIFFERENTIAL DIAGNOSES
• TUMORS
• Leukemia
• Lymphoma
• Spinal cord tumor
• Osteogenic sarcoma
• Ewings sarcoma
• Osteoid sarcoma
• Metastatic neuroblastoma

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THE CHILD WITH A LIMP

• DIFFERENTIAL DIAGNOSES
• ARTICULAR
• Transient synovitis of the hip
• Septic arthritis
• Osteochondritis dessicans
• Acute rheumatic fever
• Juvenile rheumatoid arthritis

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THE CHILD WITH A LIMP

• DIFFERENTIAL DIAGNOSES
• ARTICULAR
• Serum sickness
• Discitis
• Developmental dysplasia of the hip
• Chondromalacia of the patella
• Hemarthrosis traumatic, hemophilia

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THE CHILD WITH A LIMP

• DIFFERENTIAL DIAGNOSES
• ARTICULAR
• Henoch-Schonlein purpura
• Lyme disease
• SLE
• Patellar dislocation

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THE CHILD WITH A LIMP

• DIFFERENTIAL DIAGNOSES
• SOFT TISSUE
• Contusion
• Muscle strain
• Sprain
• Tendonitis
• Viral myositis
• Foreign body

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THE CHILD WITH A LIMP

• DIFFERENTIAL DIAGNOSES
• SOFT TISSUE
• Cellulitis
• Abscess
• Pyomyositis
• IM vaccination
• Insect envenomation
• Plantar warts

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THE CHILD WITH A LIMP

• DIFFERENTIAL DIAGNOSES
• SOFT TISSUE
• Bunion
• Ingrown toenail
• Bakers cyst rupture
• Myositis ossificans
• Bursitis
• Benign hypermobility syndrome

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THE CHILD WITH A LIMP

• DIFFERENTIAL DIAGNOSES
• NEUROLOGICAL
• Meningitis/Intracranial abscess
• Cerebral palsy
• Peripheral neuropathy
• Epidural abscess
• Spinal cord tumor
• Complex regional pain syndrome (reflex
  sympathetic dystrophy)

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THE CHILD WITH A LIMP

• DIFFERENTIAL DIAGNOSES
• INTRA-ABDOMINAL
• Appendicitis
• PID
• Pelvic abscess
• Psoas abscess
• Perirectal abscess
• Iliac adenitis

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THE CHILD WITH A LIMP

• DIFFERENTIAL DIAGNOSES
• GENITO-URINARY
• Incarcerated inguinal hernia
• Testicular torsion
• STDs

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THE CHILD WITH A LIMP

• DIFFERENTIAL DIAGNOSES
• PSYCHIATRIC
• Conversion disorder
• Malingering

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THE CHILD WITH A LIMP

• DIFFERENTIAL DIAGNOSES
• DERMATOLOGIC
• Erythema multiforme
• VASCULAR
• Henoch-schonlein purpura

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THE CHILD WITH A LIMP

• DIFFERENTIAL DIAGNOSES
• LIFE OR LIMB-THREATENING CAUSES OF
• LIMP IN CHILDREN
• Septic arthritis SCFE
• Osteomyelitis Fracture
• Tumors Appendicitis
• Testicular torsion Discitis
• Meningitis Epidural abscess
• Developmental dysplasia of the hip

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CAUSES OF LIMP IN CHILDREN OF ALL AGES

• ACUTE
• Contusion
• Foreign body
• Fracture
• Osteomyelitis
• Reactive arthritis
• Septic arthritis
• Transient synovitis
• Lyme arthritis
• Poor shoe fit

• CHRONIC
• Rheumatic disease
• JRA
• Acute rheumatic fever
• SLE
• Inflammatory bowel disease

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THE CHILD WITH A LIMP

• SEPTIC ATHRITIS
• Clinical signs/symptoms
• Fever
• Pain
• Decreased ROM
• Minor trauma

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THE CHILD WITH A LIMP

• SEPTIC ARTHRITIS
• Clinical signs/symptoms
• Toxic or ill appearance
• Painful ROM
• Joint effusion
• Warmth/erythema

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THE CHILD WITH A LIMP

• SEPTIC ARTHRITIS
• Laboratory findings
• Elevated WBC count with left shift
• Elevated ESR
• Elevated CRP
• Positive blood culture

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THE CHILD WITH A LIMP

• SEPTIC ARTHRITIS
• Laboratory findings
• Synovial fluid analysis
• Volume gt 3.5 ml
• Clarity opaque
• Color yellow to green
• WBC gt 100,000/mm3, gt75 PMNs
• Gram stain/Culture positive
• Total protein 3 5 g/dl
• Glucose lt25 mg/dl
• LDH variable compared to blood level

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THE CHILD WITH A LIMP

• SEPTIC ARTHRITIS
• Common organisms
• Staphylococcus aureus
• Beta hemolytic streptococcus
• Group A strep
• Hemophilus influenzae
• Neisseria gonorrhea

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THE CHILD WITH A LIMP

• SEPTIC ARTHRITIS
• Radiologic findings
• Plain films
• Soft tissue swelling
• Widened joint space
• Periosteal reaction of the adjacent bone,
  suggestive of osteomyelitis

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THE CHILD WITH A LIMP

• SEPTIC ARTHRITIS
• Radiologic findings
• Ultrasonography
• Increased joint space and amount of joint fluid
• Increased vascularity
• CT scan
• Joint effusion
• Increased vascularity
• Erosion of the cartillage
• Periosteal reaction or osteomyelitis

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THE CHILD WITH A LIMP

• SEPTIC ARTHRITIS
• Radiologic findings
• MRI
• Radionuclide studies

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CAUSES OF LIMP IN PRE-SCHOOL CHILDREN

• ACUTE
• Fractures
• Abusive injuries
• Toddlers fracture
• Salter I fractures
• Hemarthrosis
• HSP
• Septic hip
• IM shots
• Toxic synovitis

• CHRONIC
• Blount disease
• Cerebral palsy
• Developmental dysplasia of the hip
• Discitis
• Kohler disease
• Leg length discrepancy
• Vertical talus

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CAUSES OF LIMP IN SCHOOL-AGE CHILDREN

• ACUTE
• Fractures
• Myositis

• CHRONIC
• Legg-calve-Perthes disease
• Baker cyst
• Kohler disease
• Leukemia
• Spinal dysraphism (tethered cord)
• Tarsal coalition

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THE CHILD WITH A LIMP

• LEGG-CALVE-PERTHES DISEASE
• Idiopathic vascular necrosis of the femoral head
• More common in boys
• Common in 5 9 years old, may affect 2 11
  years old
• Transitional stage of development of the vascular
  anatomy of the femur

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THE CHILD WITH A LIMP

• LEGG-CALVE-PERTHES DISEASE
• Preceding history of minor trauma
• Predisposing factors
• SCD
• Steroid use
• Hip dysplasia

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THE CHILD WITH A LIMP

• LEGG-CALVE-PERTHES DISEASE
• Radiologic studies
• Plain films
• Radioisotope studies
• MRI

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THE CHILD WITH A LIMP

• KOHLER DISEASE
• Affects more boys than girls
• Most common in 5 10 years old, as early as 2
  years old
• Impaired perfusion to the navicular bone of the
  talus
• Inflammatory changes over the navicular bone

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THE CHILD WITH A LIMP

• KOHLER DISEASE
• Treatment
• Weight bearing with below the knee cast followed
  by arch support

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CAUSES OF LIMP IN ADOLESCENTS

• ACUTE
• Sprain
• Strain
• Tendonitis

• CHRONIC
• Arthritis
• Herniated disc
• SCFE
• Scoliosis
• Spinal dysraphism
• Spondylolisthesis
• Chondromalacia
• RSD
• Osgood-Schlatter

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THE CHILD WITH A LIMP

• OSGOOD-SCHLATTER DISEASE
• Over use injury affecting the insertion site of
  the patellar tendon on the anterior tibial
  tubercle
• Inflammatory changes over the tubercle
• Treatment goal decrease the stress on the
  tubercle
• Rest
• Cast
• Excision of an ossicle

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Surface Anatomy of the Knee
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Saggital view of the knee
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Osgood-Schlatter Disease radiographs
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THE CHILD WITH A LIMP

• SINDING-JOHANSSON-LARSEN DISEASE
• Traction tendinitis of the proximal attachment of
  the patellar tendon (inferior pole of the
  patella)
• Boys more than girls
• Age of presentation 10 16 years old
• Overuse injury, athletes

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THE CHILD WITH A LIMP

• SINDING-JOHANSSON-LARSEN DISEASE
• Radiologic findings
• Irregular calcification of the inferior pole of
  the patella
• Treatment
• Rest
• Cast

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THE CHILD WITH A LIMP

• SLIPPED CAPITAL FEMORAL EPIPYSIS (SCFE)
• Epiphyseal dislocation in superolateral
  displacement and external rotation of the femoral
  metaphysis, Salter I injury
• Causes kinking of the epiphyseal vessels that
  leads to compromised blood to the epiphysis

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THE CHILD WITH A LIMP

• SCFE
• Incidence
• 10/100000
• Boys 13.5, Girls 8.5/100000
• Regional and seasonal variation
• Initial presentation 20 bilateral hip
• 20 40 eventually develop bilateral involvement
  within 18 months of initial presentation

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THE CHILD WITH A LIMP

• SCFE
• Radiologic classification
• I lt 33
• II 33 50
• III gt 50
• Displacement in relation to the femoral neck

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THE CHILD WITH A LIMP

• Treatment
• Depends on the onset of symptoms and grade
• Internal fixation with single cannulated screw
• Prophylactic fixation of the unaffected hip
• Osteomy of the proximal femur

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SCFE radiographs
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THE CHILD WITH A LIMP

• LABORATORY STUDIES
• Blood tests
• CBC, differential
• ESR
• CRProtein
• Blood culture
• Lyme studies
• ANA
• ASO

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THE CHILD WITH A LIMP

• LABORATORY STUDIES
• Normal synovial fluid characteristics
• Highly viscous
• Clear
• Essentially acellular
• Protein concentration is 1/3 of plasma protein
• Glucose concentration is similar to plasma

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THE CHILD WITH A LIMP

• LABORATORY STUDIES
• Components of synovial fluid analysis
• Clarity
• Color
• Viscosity
• Glucose content
• Protein content

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THE CHILD WITH A LIMP

• LABORATORY STUDIES
• Components of synovial fluid analysis
• Microscopic examination
• WBC count
• Crystal search
• Gram satin
• Culture
• Routine bacterial culture
• GC culture
• Unusual organisms

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THE CHILD WITH A LIMP

• RADIOLOGIC TESTS
• Plain radiographs
• Affected site
• Comparison views
• Skeletal survey

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THE CHILD WITH A LIMP

• RADIOLOGIC TESTS
• MRI
• Radionuclide studies
• Ultrasonography
• CT scan

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THE CHILD WITH A LIMP

• DISPOSITION
• In-patient
• IV antibiotics
• Diagnostic work-up
• Surgical intervention
• Out-patient
• Observation with close follow up
• NSAIDs
• Sub-specialty referrals

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THE CHILD WITH A LIMP

• DISPOSITION
• Consultation
• Orthopedic
• Joint aspiration
• Surgical intervention
• Hematology-Oncology
• Bone marrow aspiration
• Chemotherapy

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THE CHILD WITH A LIMP

• DISPOSITION
• Consultation
• Gynecologic
• Pelvic examination
• Surgical intervention
• Urology
• Surgical intervention

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THE CHILD WITH A LIMP

• DISPOSITION
• Consultation
• Neurosurgery
• Pediatric or general surgery
• Surgical intervention
• Infectious disease
• Choice of antibiotics
• Length of treatment

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THE CHILD WITH A LIMP

• DISPOSITION
• Consultation
• Rheumatology
• Pain specialist
• Psychiatry
• Physiatry
• Physical/occupational therapy
• Orthotics

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THE CHILD WITH A LIMP

• DISPOSITION
• Diagnoses that require immediate intervention
• Septic arthritis
• Osteomyelitis
• Meningitis
• Epidural abscess

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THE CHILD WITH A LIMP

• DISPOSITION
• Diagnoses that require immediate intervention
• Fractures
• Dislocated patella
• SCFE
• Developmental dysplasia of the hip

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THE CHILD WITH A LIMP

• DISPOSITION
• Diagnoses that require immediate intervention
• Neoplasms/tumors
• Testicular torsion
• Appendicitis
• PID with tuboovarian abscess
• Discitis