Evaluation of the Child with a Limp

1. Evaluation of the Child with a Limp DD Aronsson University of Vermont

2. Hx – 2-year-old boy limps because of pain in the right thigh (antalgic) PE – pain and swelling just above the knee

3. Differential Diagnosis • Bone infection (osteomyelitis) • Joint infection (septic arthritis) • Fracture • Toxic synovitis

4. Bone & Joint Infections • Hematogenous origin • Strep throat • Implantation • Stepping on a nail

5. Osteomyelitis • Metaphyseal origin • Vessels don’t cross the growth plate

6. Septic Arthritis • Infection can decompress into a joint • Septic dislocation

7. Clinical Findings • Systemically ill • Irritable • Refusal to bear weight • Pseudoparalysis • Pain & swelling @ the site

8. Laboratory Studies • Elevated WBC,ESR, & CRP • 50% Positive blood culture • Infant • May be normal

9. Imaging • Radiographs • Soft tissue swelling • Bone scan • Increased uptake

10. Treatment Subperiosteal aspiration • Aspiration is the “key” to the diagnosis • Don’t wait for imaging

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

12. Hx – 18 month-old girl limps on the left leg (no pain) PE – short left lower extremity is causing the limp

13. Differential Diagnosis • Developmental dysplasia of the hip • Limb-length discrepancy

14. DDH • Instability • Subluxation • Dislocatable • Reducible dislocation • Irreducible dislocation

15. Etiology Unknown Multifactorial • Genetic whites • Physiologic girls • Mechanical breech • Environmental swaddling

16. Barlow Provocative Test • Dislocates hip (exit) Clunk

17. Ortolani Maneuver • Reduces dislocated hip (entry) Abduction Clunk

18. PE > 3 Months 43º 57º Limited abduction is key

19. PE > 3 Months • Asymmetric thigh folds • Limb-length discrepancy

20. Radiographs

21. Ultrasound • Alpha > 60º • Slope of osseus acetabulum

22. Pavlik Harness Success • Dysplasia 95% • Dislocated 80%

23. Hx – 6-year-old boy limps on the right leg PE – limp with painful range-of-motion of the hip

24. Differential Diagnosis • Infection • Toxic synovitis • Slipped capital femoral epiphysis (endocrine) • Legg-Calv-Perthes disease

25. Legg-Calv-Perthes • Loss of blood supply of the epiphysis

26. Legg-Calv-Perthes • History • Pain in the groin or knee • Limp • Aggravated by exercise

27. Legg-Calv-Perthes • Physical examination • Decreased internal rotation • Decreased abduction • Irritable hip

28. Necrotic stage Fragmentation stage

29. Reossification stage Remodeling stage

30. Treatment • Containment • Physical therapy • ROM exercises • Orthosis • Abduction & internal rotation • Osteotomy

31. Toxic synovitis • History – sudden onset • Pain in groin or thigh • Painful limp • URI 2 weeks ago

32. Physical Examination • Limp • Irritable hip with guarding • Mimic septic hip

33. Treatment • Activity modification • Expect improvement • Question diagnosis if not responding

34. 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

35. Differential Diagnosis • Infection • Osgood-Schlatter disease • Anterior knee pain • Slipped capital femoral epiphysis

36. Slipped Capital Femoral Epiphysis (SCFE) • Most common hip disorder in adolescents • Age • Boys 14 y/o • Girls 12 y/o

37. Etiology • Endocrine • Hypothyroid • Growth hormone treatment • Mechanical • 63% > 95th percentile weight

38. Hip Flexion Causes Abduction & External Rotation FABER

39. AP Pelvis Radiograph • Wide & irregular physis • Epiphysis at or below Klein’s line Klein’s line

40. Frog Pelvis Radiograph • Posterior slip • Wide, irregular physis

41. Preop AP pelvis Preop frog pelvis

42. Postop AP pelvis Postop frog pelvis

43. Limp Think hips