Evaluation of the Child with a Limp

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Evaluation of the Child with a Limp

• DD Aronsson
• University of Vermont

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Hx 2-year-old boy limps because of pain in the
right thigh (antalgic)

• PE pain and swelling just above the knee

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Differential Diagnosis

• Bone infection (osteomyelitis)
• Joint infection (septic arthritis)
• Fracture
• Toxic synovitis

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Bone Joint Infections

• Hematogenous origin
• Strep throat
• Implantation
• Stepping on a nail

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Osteomyelitis

• Metaphyseal origin
• Vessels dont cross the growth plate

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Septic Arthritis

• Infection can decompress into a joint
• Septic dislocation

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Clinical Findings

• Systemically ill
• Irritable
• Refusal to bear weight
• Pseudoparalysis
• Pain swelling _at_ the site

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Laboratory Studies

• Elevated WBC,ESR, CRP
• 50 Positive blood culture
• Infant
• May be normal

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Imaging

• Radiographs
• Soft tissue swelling
• Bone scan
• Increased uptake

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Treatment
Subperiosteal aspiration

• Aspiration is the key to the diagnosis
• Dont wait for imaging

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Treatment

• IV antibiotics
• S aureus, gram-negative enteric, Group B
  Streptococcus
• Surgical decompression
• Hip shoulder

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Hx 18 month-old girl limps on the left leg (no
pain)

• PE short left lower extremity is causing the
  limp

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Differential Diagnosis

• Developmental dysplasia of the hip
• Limb-length discrepancy

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DDH

• Instability
• Subluxation
• Dislocatable
• Reducible dislocation
• Irreducible dislocation

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Etiology Unknown Multifactorial

• Genetic whites
• Physiologic girls
• Mechanical breech
• Environmental swaddling

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Barlow Provocative Test

• Dislocates hip (exit)

Clunk
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Ortolani Maneuver

• Reduces dislocated hip (entry)

Abduction
Clunk
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PE gt 3 Months
43º
57º
Limited abduction is key
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PE gt 3 Months

• Asymmetric thigh folds
• Limb-length discrepancy

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Radiographs
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Ultrasound

• Alpha gt 60º
• Slope of osseus acetabulum

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Pavlik Harness Success

• Dysplasia 95
• Dislocated 80

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Hx 6-year-old boy limps on the right leg

• PE limp with painful range-of-motion of the hip

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Differential Diagnosis

• Infection
• Toxic synovitis
• Slipped capital femoral epiphysis (endocrine)
• Legg-Calv?-Perthes disease

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Legg-Calv?-Perthes

• Loss of blood supply of the epiphysis

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Legg-Calv?-Perthes

• History
• Pain in the groin or knee
• Limp
• Aggravated by exercise

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Legg-Calv?-Perthes

• Physical examination
• Decreased internal rotation
• Decreased abduction
• Irritable hip

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Necrotic stage
Fragmentation stage
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Reossification stage
Remodeling stage
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Treatment

• Containment
• Physical therapy
• ROM exercises
• Orthosis
• Abduction internal rotation
• Osteotomy

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Toxic synovitis

• History sudden onset
• Pain in groin or thigh
• Painful limp
• URI 2 weeks ago

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Physical Examination

• Limp
• Irritable hip with guarding
• Mimic septic hip

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Treatment

• Activity modification
• Expect improvement
• Question diagnosis if not responding

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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

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Differential Diagnosis

• Infection
• Osgood-Schlatter disease
• Anterior knee pain
• Slipped capital femoral epiphysis

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Slipped Capital Femoral Epiphysis (SCFE)

• Most common hip disorder in adolescents
• Age
• Boys 14 y/o
• Girls 12 y/o

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Etiology

• Endocrine
• Hypothyroid
• Growth hormone treatment
• Mechanical
• 63 gt 95th percentile weight

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Hip Flexion Causes Abduction External Rotation
FABER
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AP Pelvis Radiograph
Kleins line

• Wide irregular physis
• Epiphysis at or below Kleins line

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Frog Pelvis Radiograph

• Posterior slip
• Wide, irregular physis

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Preop AP pelvis
Preop frog pelvis
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Postop AP pelvis
Postop frog pelvis
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Limp

• Think hips