The limping child

1. The limping child Prof. Mamoun Kremli AlMaarefa College

2. Introduction • Limping is a common presentation in children • Seen by orthopedic surgeons, pediatricians, primary care physicians • Need to take a proper • History • physical examination • Investigations • Some diseases related to specific age groups

3. History • Duration, when first noticed • Pain • History of trauma • Associated systemic symptoms • Fever, night sweating, anorexia, weight loss

4. Limping • Painful • Antalgic gait – short stance phase of gait cycle • Child may not complain of pain • Painless • History of trauma often reported in all cases • Relevant • Irrelevant

5. Types of gait • High steppage: • Foot drop – neurologic disease • Trendelenburgh: • DDH, weak hip abductors, could not abduct • Circumduction: • Stiff hip, neurologic disaese • Tip-toe • Tight achilles tendon, CTEV, Cerebral Palsy, habitual, compensating length discrepency • Lurching: • Short length

6. Types of gait • Wide-base: • To gain balance – neurologic disease • Scissoring • Tight hip adductors – Cerebral Palsy • Hemiplegic gait • Cerebral palsy - neurologic • Ataxic • Neurologic disease • Foot inversion / eversion • Foot deformity / avoiding pain

7. Types of gait • Stiff-knee • Knee disease / arthrogryposis • Hand-knee • Weak quadriceps femoris muscle

8. Causes of painful limping • Trauma • Major musculoskeletal • Splinter into foot • Infection • Acute OM, Septic arthritis • Malignant bone tumor • Rheumatic disease • Acute slipped capital femoral epiphysis • Perthes disease (Avascula necrosis)

9. Causes of painless limping • Benign bone tumors • Congenital • DDH, club foot, congenitally short femur, short tibia • Post injury deformity / length discrepancy • AVN – Perthe’s disease • Slipped capital femoral epiphysis (chronic) • Deformity and leg length discrepancy

10. History • Sudden onset: • Trauma • Gradual onset: • Disease

11. Pitfalls • Misled by parents’ history • History of trauma • Always a leg length inequality • Misled by patients’ complaint • Hip problems may present with knee pain • Children below 5 years do not complain of pain

12. Many causes • Different diseases occur more commonly at specific age groups

13. Age 1-4 years • CDH – DDH • History: at risk groups • Physical findings: • Asymmetrical folds • Limited abduction • Hamstring stretch sign • Ortolani / Barlow • Shortening • Trendelenburgh

14. Age 3 – 6 years • Transient synovitis • Limping, painful to move, ?WBC, ? Fever, ? ESR • Resolves in days • Disappears without treatment • Septic arthritis • Limping-refuses to walk • Fever >38.5 • WBC >12,000 • ESR >40 mm • If in doubt: Aspiration

15. Age 5 – 10 years • Legg-Calve-Perthes disease • Boy, antalgic gait • Pain and muscle spasm with passive motion • Limitation of rotation and abduction • Positive Trendelenburgh

16. Legg-Calve-Perthes • Age usually: 4-8 years, Boys= 4X girls • Idiopathic avascular necrosis of femoral head • Blood supply of femoral head: • Neonates: metaphyseal,lateral epiphyseal, and scanty ligamentumteres vessels • 4 years: no epiphyseal vessels • 7 years: ligamentumteres vessels developed well • 4 – 7 years: dependent on lateral epiphyseal vessels • If trauma or synovitis, pressure occludes blood supply

17. Legg-Calve-Perthes • Stages: • Bone death: • may still look normal on x-ray • Revascularization and Repair: • Increased density and fragmentationon x-ray • Distortion and Remodelling • Distortion, falttening (coxaplana), and enlargement (coxa magna), with partial uncoverage

18. Legg-Calve-Perthes • Clinical picture: • Limping (painful / painless) • May present with knee/thigh pain • Early: limitation of all movements • Later: limitation of abduction and internal rotation

19. Legg-Calve-Perthes Apley’s System of Orthopedics and Fractures

20. Legg-Calve-Perthes Apley’s System of Orthopedics and Fractures

21. Legg-Calve-Perthes • Different stages of Perthes in a patient Sclerosis Collapse Fragmentation Remodelling http://community.tsrhc.org/Perthes-disease-about-perthes-disease

22. Legg-Calve-Perthes • Treatment: • Rest • Physiotherapy: abduction • Containment by splint • Surgery: • Containment, improved cover • Later: for aftermath

23. Age 10 – 15 years • Slipped Capital Femoral Epiphysis (SCFE) • Acute Vs. chronic • Boys, overweight, ?hypogonadism • Limited internal rotation • Hip externally rotates when flexed • X-ray: AP and Frog lateral • Really is an antero-lateral slippage of the metaphysis www2.massgeneral.org/ortho/SCFE.htm

24. SCFE • Around puberty • ? Hormonal imbalance between gonadal and growth hormones • Tall, or obese, gonads underdevelopment • Presents with limping • May present with thigh/knee pain • Acute slip Vs. chronic slip Apley’s System of Orthopedics and Fractures

25. SCFE • Externally rotated hip • Loss of internal rotation • External rotation on flexion • Slippage of other hip • in one third of patients Apley’s System of Orthopedics and Fractures

26. SCFE • X-rays diagnosis: Apley’s System of Orthopedics and Fractures

27. SCFE http://reference.medscape.com/

28. SCFE • Treatment • Manipulation to try to reduce the slip may cause AVN • Fixation in situ • ? Fix the other hip • Complications: • Avascular Necrosis • Coxavara • Slippage of opposite hip • Secondary osteoarthritis http://bestpractice.bmj.com/

29. 3 – 12 years • Acute osteomyelitis: • Constitutional symptoms • WBC, CRP, ESR • X-ray may initially be normal • MRI

30. 5 – 18 years • Trauma – place related to age • Household - early • Playground - childhood • School and Sports 0 older child - teenager • RTA – teenager • A prick or a splinter in sole of foot

31. Time algorithm Infection Trauma SCFE Perthes DDH 11 15 9 12 7 8 6 10 13 14 1 5 2 3 4 years