The Limping Child

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The Limping Child

• Chrissie Ashdown

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Aims and Objectives

• How to assess the limping child who presents to
  the GP
• Investigations
• Common diagnoses
• Basic management

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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?

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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.

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Developmental stages of gait

• 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 gt1s
• 36 Develops sufficient balance to attain a normal
  gait pattern

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Common Causes

• 0-3 years old
• /soft tissue injury (toddlers /NAI)
• Osteomyelitis or septic arthritis
• Developmental dysplasia of the hip

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Common Causes

• 3-10 years old
• Trauma
• Transient synovitis/irritable hip
• Osteomyelitis or septic arthritis
• Perthes disease

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Common causes

• 10-15 years old
• Trauma
• Osteomyelitis or septic arthritis
• Slipped upper femoral epiphysis
• Chondromalacia
• Perthes

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Other Dx

• 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

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What questions should you ask?

• Child presents with a limp

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History Qs 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?

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History Qs to ask

• Has the limp interfered with normal activities?
• Presence of systemic symptoms - fever, weight
  loss?
• Do not forget PMHx, BINDbirth history, imms,
  nutritional history, developmental history
• Also include the other essentials DHx and
  allergies and FHx

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Examination
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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

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pGALS

• Spine observe from behind,
• can you bend and touch your toes?
• Observe curve of spine from side and behind

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Look, feel, move
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Examination

• Look
• 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)

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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

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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?

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Dont forget!

• Both intra-abdominal pathology and testicular
  torsion may present simply as a limp examine
  abdomen and testicles in boys!!

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Diagnoses
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Trauma

• Diagnosis is by plain x ray as a primary
  investigation.
• Anteroposterior and lateral views are indicated.
• AE usually indicated

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Toddlers
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Toddlers

• Subtle undisplaced spiral of the tibia
• Usually pre-school
• Sudden twist after an unwirnessed fall

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Toddlers

• 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

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Transient synovitis
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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

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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

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Septic arthritis/osteomyelitis
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Septic Arthritis

• Most often hip, knee, ankle, shoulder, elbow.
• Most often children lt2yrs.
• 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.

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Septic arthritis

• 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

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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.
  

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Perthes Disease
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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
• low birth weight
• short stature
• low socio-economic class
• passive smoking.
• Unilateral in 85 of cases

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Perthes disease

• 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.

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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

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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

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Slipped Capital Femoral Epipysis
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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 Afro-Caribbean, boys,
  family history.
• One quarter of cases are bilateral.
• Prepubescent male children (12-15 yrs)

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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.

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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.

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Developmental Dysplasia of the Hip (DDH)
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DDH Risk Factors

• Female
• Breech position
• Caesarean section
• 1st child
• Prematurity
• Oligohydramnios
• Family history
• Club feet, spina bifida and infantile scoliosis

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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

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DDH

• Up to 60 of abnormal hips become normal without
  Tx after 1mth
• USS usually done
• Mx depends on age

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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.

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DDH - Management

• gt 6m requires closed reduction and use of a Spica
  cast - used to immobilize the hip joints and it
  usually extends from the mid-chest down to below
  the knee.
• This cast is usually left in place for 6-8 weeks

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Neoplasm
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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.

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Juvenile Rheumatoid Arthritis
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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

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Red flags!!
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Red flags

• Child lt3y
• Unable to weight bear
• Fever
• Systemic illness
• gt9y with pain or restricted hip movements

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Irritable hip v septic arthritis

• Factors for predicting septic arthritis
• Fever gt38.5
• Cannot weight bear
• ESRgt40 in 1st hr
• WCCgt12

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Thatll do for now!

• Any Questions?