The Limping Child

1. The Limping Child AAPA

2. Definition Limp = Asymmetry • Joint - Range of motion • Bone - Deformity • Pain • Control

3. The Limping Child • Diagnosis • Mechanism

4. ADULT TEENAGER PRE-TEEN AGE 5 CHILD TODDLER INFANT NEWBORN The Limping Child • Pitfalls • Being misled by the parents’ analysis • Always a leg length discrepancy • Being misled by the patient’s complaint • Hip problems can cause knee pain • Complaints of pain COMPLAINS LIMPS

5. The Limping Child Causes of limp • Joint - Range of motion • Bone - Deformity • Pain • Hip • Control -Physical exam -X-ray -‘Antalgic’ gait -Abductor lurch -Upper limb

6. The Limping Child Too much to cover Hip Best Bets Age

7. The Limping Child • Age 1 – 3 years • Age 3 – 6 years • Age 6 – 10 years • Age 10 – 14 years

8. The Limping Child:Age 1 – 3 1 Best Bet • DDH • Developmental Dysplasia of the Hip • CDH • Congenital Dislocation of the Hip

9. The Limping Child: Age 1 – 3DDH Physical findings • Girl • Asymmetrical skin folds • Limited abduction • Short leg • Pistoning • Ortolani’s sign • Barlow’s sign

10. The Limping Child: Age 1 – 3DDH X-ray findings • Delayed appearance of ossific nucleus • Small ossific nucleus • Dysplastic acetabulum • Proximal displacement of femur

11. The Limping Child: Age 1 – 3DDH • Pavlik Harness • Check at 3 weeks to confirm reduction • Adjust position every 6 – 12 weeks • Continue until the hips are clincally and radiologically normal Treatment • 0 – ½: Pavlik harness • ½ – 1½: Closed reduction, cast • 1 ½ - 5 or 8: Open reduction, pelvic osteotomy • Older: Leave dislocated

12. The Limping Child:Age 3 – 6 2 s Best Bet • Transient synovitis • Septic arthritis • Flu • Tonsillitis

13. The Limping Child:Age 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

14. WIDENED JOINT SPACE The Limping Child:Age 3 – 6 Septic arthritis • Child refuses to walk • Movement of hip is painful • May have fever • Elevated WBC • Progressively sicker • Progressive joint destruction

15. The Limping Child: Age 3 – 6Septic Arthritis Bacteria White cells Enzymes Enzymes Destroy cartilage Irreversable joint damage

16. The Limping Child: Age 3 – 6Septic Arthritis The Worst Scenario • Destruction of articular cartilage • Destruction of femoral head • Destruction of femoral neck

17. The Limping Child: Age 3 – 6Septic Arthritis Treatment • Kill the bacteria • Antibiotics • Eliminate the white cells • Incision and drainage • Don’t delay • 48 hour window

18. The Limping Child: Age 3 – 6Transient Synovitis vs. Septic Arthritis • How to tell the difference? • Four predictors • History of fever • Refusal to weight-bear • ESR > 40 mm/hr • WBC > 12,000 • If in doubt • Review in 12 hours • Do incision and drainage! Kocher, Kasser, et al.JBJS 86-A: 1629, 2004

19. The Limping Child:Age 6 - 10 3 Best Bet Legg-Calvé-Perthes Disease

20. The Limping Child: Age 6 – 10Perthes Disease Physical findings • Boy • Limp • Antalgic gait • Pain with passive motion • Limited abduction • Positive Trendelenburg sign

21. The Limping Child: Age 6 – 10Perthes Disease • X-ray findings • Perhaps nothing • MRI • Irregular consistency • Flattening • Lateral bump/ridge • Lateral hinging

22. The Limping Child: Age 6 – 10Perthes Disease

23. The Limping Child: Age 6 – 10Perthes Disease Treatment • Maintain range of motion • Physical therapy • Anti-inflammatory medication • “Containment” • Bracing in abduction • Femoral osteotomy • Pelvic osteotomy

24. The Limping Child: Age 6 – 10Perthes Disease 50% need a Total Hip by age 50

25. The Limping Child:Age 10 – 14 4 Best Bet Slipped Capital Femoral Epiphysis(SCFE – skiffey)

26. The Limping Child: Age 10 – 14SCFE Always get a frog lateral view Always check the other side

27. The Limping Child: Age 10 – 14SCFE • Pediatric orthopaedic surgeons • See 6 per year • General orthopaedic surgeons • See 1 every 6 years • Same as fixing a fracture

28. The Limping Child: Age 10 – 14SCFE • Classification • Acute or chronic • Stable or unstable • Severity of displacement • Slip angle • Bilaterality • 10 – 15% at presentation

29. No reductionOne screw Closed reductionTwo screws Useful Classification • Stable • Walks in • Unstable • Wheels in • Bone in one piece • Slow plastic deformation of the growth plate • Bone in two pieces • Physeal fracture

30. Unstable SCFE

31. Xray Findings • Displacement of neck on head • Mainly anterior • Somewhat superior • Decreased projected femoral head height • Chronicity • Inferior new bone • Superior rounding off of metaphysis • Curved neck

32. CastroAP

33. Degree of slip?? Silva Chronic Slip

34. Castro Right Lateral Slip angle

35. The femoral neck “curves” posteriorly Concept Displacement of head on neck Gradual change in shape

36. Starting Point – Severe Slips

37. Correct Path

38. BLIND SPOT Controlling Depth • Approach Withdraw • Rotate hip through full range • Observe projected distance of pin tip from subchondral bone • Watch for change in direction • That moment presents the critical view

39. 3–D Geometry The Critical View

40. Approach-Withdraw 1 1

41. Approach-Withdraw 2 2

42. Approach-Withdraw 3 3

43. Approach-Withdraw 4 4

44. Approach-Withdraw 5 5

45. Approach-Withdraw 6 6

46. Approach-Withdraw 8 7

47. Approach-Withdraw 7 8

48. Approach-Withdraw 5 The Critical View 5

49. The Contralateral Hip • Out of 100 patients: • 10 are bilateral at presentation • 10 will slip on the other side later • 5 will have painless slips on the other side

50. Follow-up for Bilaterality • Follow radiologically • Every three months • For 18 months