Definition

2. Definition • Limp is defined as an uneven, jerky, or laborious 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 .

3. EPIDEMIOLOGY • The incidence was 4 per thousand. • Male:female ratio was 2:1. • Median age was 4 years. • Eighty percent of patients had pain; pain localized to the hip, knee, and other areas of the leg in 34, 19, and 18 percent, respectively. • 12 percent of patients were admitted to the hospital.

4. DIFFERENTIAL DIAGNOSIS  • Bones. • Joints. • Soft tissue. • Neurological.

5. Bone: Fractures. Legg-Calvé-Perthes. Slipped capital femoral epiphysis. Tumors. Vasoocclusive crisis of sickle cell disease

6. Joints: Transient synovitis Septic arthritis Acute rheumatic fever Juvenile rheumatoid arthritis Henoch-Schönlein purpura Developmental dysplasia of the hip Hemarthrosis: traumatic, hemophilia Lyme disease Systemic lupus erythematosis.

7. Soft tissue: Viral myositis. Intramuscular vaccination. Cellulitis. Myositis.

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

9. INFECTION: Sepic arthritis Ostiomylitis descitis NON INFECTION Inflamation Trauma Tumor Bony deformitiy Aseptic necrosis

13. The Limping Child Total no. of admissions: 304 286 patients

14. 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?

15. 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

16. Limps of recent onset are more often due to trauma or acute infection. • Limps of longer duration may be due to more chronic problems (e.g., developmental or neuromuscular problems).

17. Associated symptoms can help to narrow the differential diagnosis. • Fever may be present in infection, rheumatologic conditions, or malignancy, whereas voiding or stooling problems suggest a spinal cord problem or pelvic mass, and back pain may indicate discitis or vertebral osteomyelitis.

18. The severity and constancy of the pain can help to narrow the differential diagnosis. Pain typically is severe, constant, localized, and consistently reproducible in fractures, dislocations, septic bacterial arthritis, osteomyelitis, and sickle cell disease. • In contrast, pain typically is intermittent and less severe in juvenile rheumatoid arthritis, Perthes disease, slipped capital femoral epiphysis, and transient synovitis.

20. PHYSICAL EXAMINATION • General :  Examination of the skin may reveal the characteristic rash of serum sickness, Henoch-Schönlein purpura , acute rheumatic fever, or Lyme disease.

21. Neurologic and spine :  The spine should be examined for abnormalites (kyphosis or scoliosis) or limited range of motion. Limitations or asymmetry on forward bending may indicate spinal cord tumors or discitis. Abnormalities in deep tendon reflexes may indicate peripheral neuropathy , or involvement of the central nervous system with spasticity.

22. Musculoskeletal : Examination of the musculoskeletal system should include evaluation of muscle strength, muscular atrophy, joint tenderness, bony tenderness, bony deformity, joint effusion, range of motion (active and passive).

23. Joint : effusion / heat / erythema / restriction of movement - if all 4 signs are present then sepsis is likely • Large joints more commonly affected than small joints. • The majority of joint sepsis occurs in the hip or knee . • Joints involved : monoarticular/polyarticular - 22% septic arthritis affects >1 joint.

24. 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.

26. Hip rotation • Decreased or absent hip rotation, a "lag of internal rotation," is particularly useful in raising the suspicion for slipped capital femoral epiphysis and Legg-Calvé-Perthes disease; • children with septic arthritis of the hip and even transient synovitis of the hip usually cannot tolerate this maneuver because of pain.

27. 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, ischemia, Perthes disease.

29. Trendelenburg test : • Asking the child to stand on the affected leg, causes a pelvic tilt (the unaffected hip is lower). • In children with slipped capital femoral epiphysis, Legg-Calvé-Perthes disease, or developmental dysplasia of the hip.

31. GAIT EVALUATION

33. 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.

34. 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.

35. 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.

36. 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.

37. Osteomyelitis

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

40. LABORATORY EVALUATION • Complete blood count (CBC), ESR (or CRP),and blood culture are useful in the evaluation of febrilepatients 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.

41. ESR • Nonspecific test of inflammation • Not reliable in neonates • Elevated in 48-72 hrs returns to baseline 2-4 weeks • No change with antibiotic therapy. • Not good for early evaluation of tx

42. CRP • Rises within 6 hrs and peaks 30-50hrs • Half life 47hrs • Makes this marker of greater value for early diagnosis and resolution of inflammation • CRP is elevated in trauma, in otitis media(22%bacterial 65% viral)

43. Cultures • Blood cultures • yield organisms 30-50% of cases • Decreases w/ previous antibiotic therapy • Aspiration of joint fluid • Gram stain, leukocyte cell count, PMNs • Cell counts 80,000 – 100,000/ml likely septic arthritis • Gram stain can give you early diagnosis • 1/3 are positive

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

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

47. 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

48. 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

49. Septic arthritis or osteomyelitis • Blood cultures are commonly positive • Raised white cell count and C reactive protein, which normalises 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.

50. WIDENED JOINT SPACE Septic arthritis