The Limping Child

1. The Limping Child Chrissie Ashdown

2. Aims and Objectives • How to assess the limping child who presents to the GP • Investigations • Common diagnoses • Basic management

3. 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?

4. 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.

5. 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 >1s • 36 Develops sufficient balance to attain a normal gait pattern

6. Common Causes • 0-3 years old • #/soft tissue injury (toddler’s #/NAI) • Osteomyelitis or septic arthritis • Developmental dysplasia of the hip

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

8. Common causes • 10-15 years old • Trauma • Osteomyelitis or septic arthritis • Slipped upper femoral epiphysis • Chondromalacia • Perthes’

9. 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

10. What questions should you ask? Child presents with a limp

11. 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?

12. 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

13. Examination

14. 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

15. pGALS • Spine: observe from behind, • ‘can you bend and touch your toes?’ • Observe curve of spine from side and behind

16. Look, feel, move

17. 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)

18. 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

19. 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?

20. Don’t forget! • Both intra-abdominal pathology and testicular torsion may present simply as a limp – examine abdomen and testicles in boys!!

21. Diagnoses

22. Trauma • Diagnosis is by plain x ray as a primary investigation. • Anteroposterior and lateral views are indicated. • A+E usually indicated

23. Toddler’s #

24. Toddler’s # • Subtle undisplaced spiral # of the tibia • Usually pre-school • Sudden twist after an unwirnessed fall

25. 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

26. Transient synovitis

27. 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

28. 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

29. Septic arthritis/osteomyelitis

30. SepticArthritis • 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.

32. 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

33. 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.

34. Perthes’ Disease

36. 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

37. 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.

38. 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

39. 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

40. Slipped Capital Femoral Epipysis

42. 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)

43. 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.

44. 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.

45. Developmental Dysplasia of the Hip (DDH)

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

47. 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

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

49. 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.

50. DDH - Management • > 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