James Pegrum (Peggers)
MB BS BSc MSc (SEM) MRCS (Eng) Diploma in MM (UIAA)
Overview
 The limping child
 Assessment of limping child
 Key conditions and their concepts
Limping children
 Causes?
 What is the biggest
worry?
 How do you
diagnose it?
Limping Child
Age
Potential problem
0-5
Septic arthritis
DDH / CDH
5-10
Perthes
Trauma
10-15
SUFE
Trauma
Who needs admitting?
Limping child assessment
 History
 Trauma
 DDH Female, FH, First Born, breech
 Systemically unwell any URTI, viral sx
 Pregnancy and birthing
 Vaccination and milestones
 Examination
 Observations
 Examination of all joints and Back/hips/knees/feet/sole
 Septic screen rest of patient - ask paeds
 Investigation
 Bloods CRP/ESR/WCC
 AP Pelvis and frog-leg lateral
 Consider XR other joints

Tib-fib in toddlers – Toddlers #
Case 1
 13 year old chubby boy
 Painful knee after PE 7 days ago
 No trauma
 Limping on presentation
Radiology Limping Child
Classification
 Clinical
 Loder’s


Weight bearing at presentation
Non weight bearing at presentation
 Radiological
 Degree of slip



Mild <30%
Moderate 30-60%
Severe >60%
Clinically
 History
 Weight bearing status and time frame
 Risk factors
 Obesity / osteodystrophy / Hypothyroidism
 Examination
 A hip that ER and abducts with flexion
 Investigations
 Rule out endocrinopathies pathologies
 radiographs
Operative Management
Case 2
 6 year old boy
 Left sided limp last 2 weeks
 No history of trauma
 Inflammatory markers normal
 Afebrile
Clinically
 Idiopathic AVN of the proximal femoral epiphysis in childhood
 Why this age?
 Change in blood supply from metaphyseal to epiphyseal
 History
 Bilateral in 20%
 Other causes of AVN
 Clinically
 Reduced range of movement
 Investigations
 Causes of AVN
Classification
 Multiple and complex
 Waldenstrom – pathological stages
 Initial vascular event – may have cresent sign on radiographs
 Fragmentation
 Re-ossification or resolution
 Remodelling or healed
 Herring classification / Catterall – radiographic fragmentation
 A – no collapse of lateral pillar
 B - <50% collapse (I-II)
 C - > 50% c0ollapse (III-IV)
Management
Symptomatic relief
2. Head containment
3. Restoration of movement
1.



Age < 6 years conservative management
Age 6-9 severe grades osteotomy and cover femoral head
Age 9 operative containment in most
Case 3
 3 year old girl
 24 hours history of fever malaise
 Reluctance to weight bear
Septic Arthritis
Clinically
 History
 Recent URTI
 Vaccination Hx
 RF – prematurity and C section
 Examination
 Fevers no other source
 Irritable hip held in FABERs position
 Investigations
 Bed side
 Bloods
 Radiology
Likelihood of septic Arthritis?
 Kocher 1999 JBJS (Am)
 Not weight bearing / fever / WCC > 12 / ESR > 40
Features
% chance of Septic arthritis
0
0.2
1
3
2
40
3
93.1
4
99.6
Septic arthritis Aspiration
 Rapid joint destruction
 Send for
 MC&S
 Urgent Gram stain
 Crystals
 Treatment
• Aspirate
• Antibiotics
• Joint washout
Case 4
 A 2 year old with a limp
 1st born, breech position
 No trauma
Classification
 Dislocated
 Dislocatable – Barlow positive
 Subluxable – Barlow Suggestive
Clinically
 History
 Pregnancy / Birth / mile stones
 RF – 1st born, female, FH, oligohydramnios,
breech
 Clinically
 Reduced abduction
 Barlow – dislocates hip by adduction and
depression in flexed hip
 Ortolani – reduces hip by elevation and
abduction
 Radiology
 US if < 6months
Management
1. Early concentric reduction
2. Head coverage to allow normal development of head and acetabulum

Non operative



<6/12 – pavlik harness if reducible
6-18/12 – hip spica
Operative



Arthrogram and closed reduction
Open reduction
Open reduction +/- pelvis or femoral osteotomy
Summary
 Reviewed the Differentials of a limping child
 Septic arthritis
 DDH
 Perthes
 SUFE
 Broadly assessed by age
 Management options