limbing child

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BY DR.
ESSAM HOZAYEN SAIF orthopedic specialist
ALDHAID HOSPITAL
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Definition

• Limp is defined as an uneven, jerky gait, usually
  caused by pain, weakness, or deformity .
• Limp can be caused by both benign and
  life-threatening conditions, the management
  varies from reassurance to major surgery
  depending upon the cause .

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DIFFERENTIAL DIAGNOSIS 

• Bones.
• Joints.
• Soft tissue.
• Neurological.

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• Bone
• Fractures.
• Legg-Calvé -Perth's.
• Slipped capital femoral epiphysis.
• Tumors.
• Vasoocclusive crisis of sickle cell disease
• ( the pain is sever, some times equal to
  cancer pain)

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• Joints
• Transient synovitis
• Septic arthritis
• Acute rheumatic fever
• Juvenile rheumatoid arthritis
• Developmental dysplasia of the hip
• Hemarthrosis traumatic, hemophilia
• Systemic lupus erythematosis.

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• Soft tissue
• Viral myositis.( high level of serum
  creatinine kinas )
• Intramuscular vaccination.
• Cellulitis.

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• Neurological
• Cerebral palsy
• Peripheral neuropathy
• Meningitis.
• Epidural abscess of the spine.

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• Infectious
• Septic arthritis
• Osteomylitis
• descitis

• Non-Infectious
• Inflammation
• Trauma
• Tumor
• Bony deformity
• Aseptic necrosis

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Age specified conditions that cause a limp

• 1-3 years
  
• DDH
  
• Child abuse
  
• Neuromuscular disease
  
• Leg length discrepancy
  
• Infections
  
• 4-10 years
  
• Transient synovitis
  
• Perth's disease
  
• Infections
  
• leg length discrepancy
  
  
• gt10 years
  
• SCFE
  
• OVERUSE SYNDROME
  
• all age groups
  
• Trauma
  
• Tumors
  

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The Limping Child
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Physical examination should started with
observation of the gait

• Gait is a repeated cycle of limb motion
  controlled by muscle activity that carries the
  body forward
• The gait cycle is traditionally described as
  starting when one heel strikes the ground and
  ending when it strikes the ground again
• There is two phases of the gait cycle (60
  stance phase and 40 swing phase)
• The progress of gait as following
  
• initial contact---loading response---mid
  stance---terminal stance---preswing initial
  swing---mid swing---terminal swing.

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• Prior to the heel strikerelaxation of the
  hamstrings ms contraction of quadriceps ms
  gtgtgtgtstraightening of knee jointgtgtgtgtcontraction of
  the dorsiflexors of the ankle foot gtgtgtgtheel
  strike. which followed by flat foot ( loading
  response)gtgtgtgtmotion of the body forward over the
  foot ( mid stance )gtgtgtgt contraction of the calf
  ms gtgtgtgtplanter flexion( heel off)gtgtgtgtknee flexion
  gtgtgtgttoe off beginning of the swing phase by
  contraction of the iliopsoas ms gtgtgtgt flexion of
  the hipgtgtgtgt knee flexion contraction of the
  ankle dorsiflexors ( acceleration or preswing
  phase)gtgtgtgtmidswing phase midstance phase of the
  other limb (moving of the body with ipsilateral
  limb forward gtgtgtgtdeceleration occur to start new
  heel strike ( by contraction of Q.ms hamstring
  ms relaxation to make the knee straight gtgtgtgt new
  heel strike

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• Other components of the gait
• 1- pelvic tilt
• during normal gait , the pelvis dropped at the
  side of swing limb by 5 degrees below the
  horizontal plane
• 2- pelvic rotation
• during swing phase the pelvis rotates
  anteriorley by 4 degrees on the stance side the
  pelvis rotates posteriorely by 4 degrees
• 3- lateral shift
• during the stance phase the pelvis trunk
  shifted laterally toward the stance limb by one
  inch
• N.B. Pelvic tilt ,pelvic rotation , lateral
  shift, knee flexion,, knee -ankle foot motion
  gtgtgtgtminimize the shift of the gravity body centre
  in both vertical horizontal axis's
• 4- width of the base
• by the examiner behind the pt. distance
  between both foot during double support 2-4
  inches
• 5- stride length
• the distance between the heel strike of limb
  the next heel strike of the same limb
• 6- step length
• The distance between heel strike of one limb
  heel strike of the other limb

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PATHOLOGICAL GAIT

• Child limp may be caused by pain, structural
  changes, weakness or a combination of these.Most
  of abnormalities occur at the stance phase.
• For example
  1-antalgic gait (anti-pain)
  in which the child limits the time spent on the
  painful leg in stance phase2-leg length
  discrepancy gait the pt. can
  compensate by walking on tip-toe on the short
  side and with slight hip and knee flexion on the
  long side3-trendelenburg gait
  is a painless limp in a pt. with weakened
  hip abductor muscles the pt. leans over the
  affected side. bilateral involvement causes
  waddling gait4-gait in cerebral palsy
  
• there is brain lesion with secondary muscle
  contracture and compensatory movements.

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• 5- foot slap gait
• due to weakness of the ankle foot
  dorsiflexorsdrop foot during the swing phase
• 6- G. maximums gait
• during midstance gtgtgtthe ipsilateral hip must be
  maintained in extension or the trunk falls
  forward .if there is weakness of the G.M gtgtthe
  pt. push his trunk posteriorly resulting in
  extension lurch or G.M. gait.
• 7- calceneal gait
• weakness of calf ms or flat foot( loss of
  planter flexion gtgtgt loss of heel off)
• 8- hip hike gait
• pt. with stiff knee gtgtgt may elevate the
  ipsilateral pelvis to hold the foot up.
  circumduction gait
• 9- wide based gait
• the width of the base is more than 4 inches
  ( cerebellar lesion ) gtgtgt loss of coordination
  gtgtgt execive shift of the gravity centre

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HISTORY

• Duration and course of the limp?
• History of trauma ?
• Associated symptoms (e.g., fever, weight loss,
  anorexia, back pain, arthralgia, voiding or
  stooling problems)
• If pain is present, where is it located, when
  does it occur, and what its severity?
• Does the limp improve or worsen with activity?

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• Recent history of viral illness or streptococcal
  infection (post infectious arthritis).
• Recent history of new or increased sports
  activity
• Recent history of intramuscular injection (can
  cause muscle inflammation or sterile abscess)
• History of endocrine dysfunction (may predispose
  to slipped capital femoral epiphysis)
• Family history of connective tissue disorder,
  inflammatory bowel disease, hemoglobinopathy,
  bleeding disorder, or neuromuscular disorder

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Physical examination

• Standing
• back should be examined for
  scoliosis ,local tenderness, range of motion.
• if there is pelvic tilt is present ,
  it can be measured by placing blocks under the
  shorter leg until the pelvis in level
  (horizontal) .
• trendelenburg test
• skin dimples ,hairy patches over
  lumbar spine
• Supine
• each joint should be examined
  separately
• look for swelling, feel for
  tenderness, assess the ROM
• for hip flexion contracture
  --------Thomas test
• abdomen should always examined
  ------may be appendicitis
• neurological examination should be
  performed
• check for leg length discrepancy ,
  the short leg must be differentiated from
  apparent shortening that is caused by scoliosis
  or pelvic obliquity or joint contracture.
• Prone
• hip rotation
• femoral anteversion

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Hip rotation

• Internal rotation of the hips is performed with
  the child in the prone position with the knees
  flexed the ankles and feet are then rotated away
  from the body to compare the amount of internal
  rotation in the symptomatic versus the
  asymptomatic hip.

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Galeazzi test 

•  The Galeazzi test is useful in diagnosing
  developmental hip dysplasia or leg length
  discrepancy.
• This test is performed by putting the child
  in a supine position and then flexing the hips
  and knees by bringing the ankles to the buttocks
  .
• The test is positive when the knees are of
  different heights. Abnormal shortening of the leg
  can be caused by DDH, Perth's disease.

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Trendelenburg test 

• Asking the child to stand on the affected leg,
  causes a pelvic tilt (the unaffected hip is
  lower).

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RADIOLOGIC EVALUATION

• Plain radiographs  Most children who limp
  require radiographic evaluation.
• Both anteroposterior and lateral views should
  be obtained. The frog-leg view of the pelvis
  provides the lateral view of the femoral heads.

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• Ultrasonography  Ultrasonography is an excellent
  technique for identifying small joint effusions
  of the hip and should be used when plain
  radiographs are normal but the suspicion of
  septic arthritis remains high.
• A difference of more than 2 mm between the
  anterior joint capsule and the femoral neck is
  considered significant.

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• Ultrasonography also may be used to guide
  aspiration of the hip (e.g., isolated unilateral
  hip effusion in a febrile child).
• Bilateral effusions suggest a systemic arthritic
  disorder or transient synovitis because as many
  as one-quarter of patients with symptomatically
  unilateral transient synovitis have bilateral
  effusions.

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• Radionuclide scans 
• Bone scintigraphy is a sensitive means of
  detecting alterations in the metabolic rate of
  bone and thus a sensitive means of localizing
  pathology.
• However, bone scintigraphy lacks specificity
  because such alterations in bone metabolism can
  occur in Legg-Calvé-Perthes disease,
  osteomyelitis, osteoid osteoma, and malignant
  bone tumors.

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CT and MRI

• CT scanning is useful in the diagnosis of deep
  soft tissue infections of the Para spinal and
  retroperitoneal regions.
• MRI is useful in the evaluation of the spine
  (for discitis or spinal tumors), soft tissue
  tumors and abscesses in the Para spinal and
  retroperitoneal regions, osteomyelitis of the
  pelvis and long bones, and in Legg-Calvé-Perthes
  disease

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LABORATORY EVALUATION 

• Complete blood count (CBC), ESR or CRP, and blood
  culture are useful in the evaluation of febrile
  patients and those in whom infection is being
  considered
• . CBC and ESR or CRP also should be considered in
  the evaluation of the afebrile child with a
  several day history of limp and no abnormalities
  on plain radiography.

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Cultures

• Blood cultures
• yield organisms 30-50 of cases
• Decreases w/ previous antibiotic therapy
• Aspiration of joint fluid
• Gram stain, leukocyte cell count
• Cell counts 50,000 100,000/ml likely
  septic arthritis
• Gram stain can give you early diagnosis
• 1/3 are positive

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• THE BLOOD SUPPLY OF FEMORAL HEAD
• The main sources of blood supply to the proximal
  femur from
• medial and lateral circumflex vs.each of which
  arise from the profunda femoris artery.
• Additional supply from
• superior gluteal artery
• artery of ligamentum teres

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The Limping ChildAge 1 3

• DDH
• Developmental Dysplasia of the Hip

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• Pathological changes in DDH
• Acetabulum
  shallowthe roof sloops too steeply
  Femoral head dislocated
  superiorly and posteriordelayed ossific centre
  femoral neck
  anteverted capsule
  stretched hourglass
  appearance by iliopsoas tendon
  limbus superiorly the
  acetabular labrum and its capsular edge may be
  pushed into the socket by the dislocated head ,
  this fibrocartilage structure may obstruct closed
  reduction
• ligamentum teres
  elongated and hypertrophied which may obstruct
  the reduction

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Clinical findings
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• Imaging studies
• before age of 6 months diagnosis can be done
  by U/S
• plain x-ray is more helpful after age of 6
  months ( appearance of the ossific nucleus of the
  head
• Hilgenreiners line
• Perkinss line
• Position of the femoral head in relation to this
  two lines
• Acetabular index
• Is the angle between hilgenreiner line the roof
  of the acetabulum, it should be below 30 degree
  by the age of one year below 25 degree by 2
  years age
• Center edge angle
• is the angle between the Perkins line line
  pass through the edge of the acetabulum the
  center of the head . It becomes smaller as the
  hip subluxated.
• normally is 20 degree or greater.

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Imaging findings
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Treatment of DDH

• At age of 0---6 ms
• pavlik harness
• Age of 6---15 ms
• gentle closed reduction under G.A.
  maintenance of a located position for
• 23 ms in a spica cast usually stabilize the
  joint , any residual dysplasia must treated by
  bracing or surgery.
• Age of 15---2yrs
• open reduction
• femoral shortening osteotomy
• may be needed at time of open
  reduction to reduce tension on the soft tissue
  reduce the risk of AVN of the femoral head .
• Capsulorrhaphy
• cast spica
• Age above 2 yrs
• Significant residual dysplasia is present so the
  surgical correction is needed to creates a stable
  mechanical environment that permits remodeling to
  normal joint during growth
• femoral osteotomy
• to correct the ant version and
  valgus deformity
• to be done before age of 4 yrs
  to stimulate normal growth of the acetabulum
• pelvic osteotomy
• to increase the femoral head
  covering needed by the acetabulum
• examples

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The Limping ChildAge 3 6

• Transient synovitis
• Child refuses to walk
• Movement of hip is painful
• May have fever
• Moderately elevated WBC
• Lasts a few days
• Disappears without treatment

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Transient synovitis

• Commonly occurs after a respiratory illness.
• X ray image may be normal
• Ultrasound may show effusion
• Main treatment is bed rest and physiotherapy.
• Non-steroidal anti-inflammatory drugs are useful
  for treatment and can shorten the duration of
  symptoms in children

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• D.D.
• the most difficult and important differential
  diagnosis is septic arthritis of the hip
• The clinical finding are similar but there is
  high temperature in septic arthritis.
• In a recent study , four independent parameters
  were used to distinguish the two entities
• fever (more than 38.5).
• CRP more than 20 mg\L.
• ESR greater than 40 mm/h.
• serum white blood count more than 12000
  cells.
• non wt bearing.

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Septic arthritis or osteomyelitis

• Blood cultures are commonly positive
• Raised white cell count and C reactive protein,
  which normalizes more rapidly than erythrocyte
  sedimentation rate once infection is brought
  under control
• X ray images show delayed changes. Radiographic
  evidence of acute osteomyelitis first is
  suggested by overlying soft tissue oedema at 3-5
  days after infection. Bony changes are not
  evident for 14-21 days and initially manifest as
  periosteal elevation followed by cortical or
  medullary lucencies.
• By 28 days, 90 of patients show some
  abnormality.

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Septic arthritis
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• Joint aspiration is the definitive diagnostic
  procedure and the most common pathogen isolated
  is Staphylococcus aureus

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• Perth's disease
• Is a serious but limited pediatric hip disorder
  , more common in boys,
• It affects age 410 years old.
• Is generally unilateral.
• Pathological changes
• initially , the AVN episodes are silent
  and asymptomatic ,as the bone of the proximal
  femoral epiphysis dies, it is revascularized---ost
  eoclast remove dead bone while osteoblast
  simultaneously lay down new bone on a dead
  trabeculas ( during this phase the femoral head
  is mechanically weak) which lead to fragmentation
  and collapse of the bony structure causing
  flattening and deformity of the ossific nucleus
  and femoral head . The newly formed bone has the
  shape of the collapsed head.
• The symptomatic collapse phase rarely
  exceeds 1-1 ½ years but full revascularization
  and remodeling may continue silently for several
  years.
• C/P
• painless limp ,if pain is presents , it may
  be mild and referred to the thigh or knee.
• atrophy of the thigh ms
• limited ROM typically pt has a flexion
  contracture of 0-30 degree, loss of abduction and
  loss of internal rotation of the hip.

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• Radiological study
• early by plain x-ray ------NAD
• but can be diagnosed early by MRI
• late by plain x-ray-----deformed head (
  flattened fragmented )
• Treatment
• no treatment for children less than 5 yrs
  old----with less than ½ of the head involvement
  (why ?)
• most of the head is cartilaginous------and there
  is good time for remodeling.
• Non-operative
• most experts agree that children who
  maintain excellent motion ( particularly
  abduction greater than 30 degree in absence of
  flexion contracture ) may not require
  intervention. (abduction bracing )
• Operative
• varus femoral osteotomy
• Salter osteotomy

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The Limping Child Age 10 14SCFE

• Risk factors Obesity, inflammatory (neglected
  septic arthritis), hypothyroidism,
  hypopituitarism.Clinical presentation
  Pain-limping discomfort in the hip ,
  groin, medial thigh, is accentuated by running ,
  jumping . Antalgic gait , out toeing .
  Preslipage slight discomfortAcute slip sever
  paindeformity (external rotation,
  adduction)limited ROM (internal rotation and
  abduction)Acute on chronic pain ,limp over
  several months which is suddenly becomes very
  painful Chronic mild symptoms ,pain , limp,
  external rotation during walking, mild to
  moderate shortening of the affected leg, atrophy
  of the thigh muscles

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The Limping Child Age 10 14SCFE
Always get a frog lateral view
Always check the other side
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• RADIOLOGICAL CLASSIFICATION

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Treatment

• avoid moving or rotating the leg, the
  patient should not allow to walk .
• analgesia
• determine if it is acute (less than 3
  weeks) or chronic ( 3weeks)
• determine whether stable( able to weight
  bearing) or unstable (non-weight bearing)
• determine the radiological type of the
  SCFE
• Surgical intervention
• by immediate internal fixation using a single
  cannulated screw is the treatment of choice .
• Femoral osteotomy is a secondary procedure to
  relocate the head within the acetabulum to
  improve the ROM
• Bone graft epiphysiodesis
• follow up
• non-weight bearing for at least 6-8 weeks
  then start physiotherapy

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• Child abuse
• An important cause of limping or fracture in a
  child,particulary in those younger than 2 years .
  
• It is important to look for skin manifestations
  such as bruises , burns .
• Metaphyseal corner fracture are typical of child
  abuse, as pull and twist that create these
  fracture are rarely accidental.
• Overuse syndrome
• Children who have very recently undergone a
  significant growth spurt have less joint
  flexibility and are more prone to injury
• Spondylolysis (common in female gymnasts)
• Iliac apophysitis ( seen in adolescent runner)
• Osgood- Sclutters disease ( the most common
  condition around the knee)
• Severs disease ( it is characterized by pain at
  the calcaneal apophysis )

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THANKS FOR YOUR
ATTENSION
The Limping Child