The Limping Child
David C Koronkiewicz, D.O.
IU Goshen Orthopedics and Sports Medicine
I0A 30th Winter Update
12-2-11
Definition
Limp = Asymmetry
• Joint - Range of motion
• Bone - Deformity
• Pain
• Control
The Limping Child
•Diagnosis
•Mechanism
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 case knee pain
• Complaints of pain
The Limping Child
• Pitfalls
ADULT
TEENAGER
• Being misled
by the parents’
analysis
COMPLAINS
PRE-TEEN
• Always
a leg length discrepancy
• Being misled by the patient’s complaint
AGE
CHILD
5 cause knee pain
• Hip problems
can
• Complaints
of pain
TODDLER
INFANT
NEWBORN
LIMPS
The Limping Child
Causes of limp
• Joint - Range of motion
• Bone - Deformity
• Pain
-Hip
• Control
-Physical exam
-X-ray
-‘Antalgic’ gait
-Abductor lurch
Differential Diagnosis of the
Acutely Limping Child
Trauma
•
•
•
•
•
Fracture
Stress fracture
Toddler's fracture
Soft tissue contusion
Ankle sprain
Infection
•
•
•
•
•
•
•
Cellulitis
Osteomyelitis
Septic arthritis
Lyme disease
Tuberculosis of bone
Gonorrhea
Postinfectious reactive arthritis
Tumor
•Spinal cord tumors
•Tumors of bone
•Benign: osteoid osteoma, osteoblastoma
•Malignant: osteosarcoma, Ewing's s
sarcoma
•Lymphoma
•Leukemia
Inflammatory
•Juvenile rheumatoid arthritis
•Transient synovitis
•Systemic lupus erythematosus
Differential Diagnosis of the
Acutely Limping Child
Congenital
Neurologic
•
•
•
•
• Cerebral palsy, especially
mild hemi paresis
• Hereditary sensory
motor neuropathies
Developmental dysplasia of the hip
Sickle cell
Congenitally short femur
Clubfoot
Developmental
•
•
•
•
Legg-Calvé-Perthes disease
Slipped capital femoral epiphysis
Tarsal coalitions
Osteochondritis dissecans (knee,
talus)
Differential Diagnosis of the
Acutely Limping Child by Age
All Ages
Toddler (ages 1-3)
•
•
•
•
•
• Septic hip
• Developmental
dysplasia of the hip
• Occult fractures
• Leg-length
discrepancy
Septic arthritis
Osteomyelitis
Cellulitis
Stress fracture
Neoplasm (including
leukemia)
• Neuromuscular
Differential Diagnosis of the
Acutely Limping Child by Age
Child (ages 4 to 10)
Adolescent (ages 11-16)
• Legg-Calvé-Perthes
disease
• Transient synovitis
• Juvenile rheumatoid
arthritis
• Slipped capital femoral
epiphysis
• Avascular necrosis of
femoral head
• Overuse syndromes
• Tarsal coalitions
• Gonococcal septic arthritis
The Limping Child
Too much
Hipto cover
Best Bets
Age
The Limping Child
•
•
•
•
Age 1 – 3 years
Age 3 – 6 years
Age 6 – 10 years
Age 10 – 14 years
The Limping Child:
Age 1 – 3
Best Bet
• DDH
• Developmental Dysplasia of the Hip
• CDH
• Congenital Dislocation of the Hip
The Limping Child: Age 1 – 3
DDH
Physical findings
• Girl
• Asymmetrical skin folds
• Limited abduction
The Limping Child: Age 1 – 3
DDH
Physical findings
•
•
•
•
Short leg
Pistoning
Ortolani’s sign
Barlow’s sign
The Limping Child: Age 1 – 3
DDH
Feel Clunk
Not hear click !
Barlow
( rollout the barrel)
Ortoloni
The Limping Child: Age 1 – 3
DDH
X-ray findings
22•
•
•
•
42
Delayed appearance of ossific nucleus
Small ossific nucleus
Dysplastic acetabulum
Proximal displacement of femur
The Limping Child: Age 1 – 3
DDH
Treatment
Pavlik Harness
• 0 – ½:
Pavlik harness
• • Check
to confirm
½ – 1½:at 3 weeks
Closed reduction,
castreduction
• •Adjust
1-2 weeks
1 ½ - 5 position
or 8: Openevery
reduction,
pelvic osteotomy
Older:
Leave
• • Continue
until
thedislocated
hips are clinically and
radiolographically normal
The Limping Child:
Age 3 – 6
Best Bets
• Transient synovitis
• Septic arthritis
• Flu
• Tonsillitis
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
Transient Synovitis
• Benign, self-limited disorder
• Associated with recent URI in 32-50% of
children
• 30-40% of all non-traumatic limps
• Sterile inflammation causing joint effusion
• Lasts 2-7 days without intervention
• Male:Female is > 2:1
• Ages 2-6 (average 4)
Transient Synovitis
• Sudden onset of hip pain
• Don’t forget knee pain!!
• Afebrile/low-grade fever (<38.5)
• Usually able to ambulate with a limp
• Antalgic gait
• Hip is flexed and externally rotated with mildly
decreased ROM
• 5% bilateral presentation
• 25% with unilateral presentation with effusion
on contralateral hip by ultrasound
Transient Synovitis
Laboratory Evaluation
• WBC count <12,000
• Mildly elevated ESR (<40); CRP (<2)
• X-Ray
• Joint space widening
• Discrepancies >2mm between sides
• Ultrasound:
• Joint effusion and/or synovial swelling giving an increase in
the synovial capsular complex distance
– Distance btwn the posterior surface of the anterior fibrous
joint capsule and the anterior bony surface of the femoral
neck
• Bilateral joint effusions in up to 25% of cases of
Jasymtpmatic
Bone Joint Surgcontralateral
1999; 81:1662;hip
J Bone Joint Surg 2006; 88A:1253
The Limping Child:
Age 3 – 6
WIDENED JOINT SPACE
Septic arthritis
•
•
•
•
•
•
Child refuses to walk
Movement of hip is painful
May have fever
Elevated WBC
Progressively sicker
Progressive joint destruction
Transient Synovitis
www.emedicine.com/ped/images/1686.JPG
Transient Synovitis
Treatment
• Self-limited after 2-7 days
• Bed rest
• Ibuprofen
• Decreased pain by 2.5 days Vs Placebo
• Mean duration of pain
– ibuprofen: 2 days
– placebo: 4.5 days
• 80% of all patients with resolution by 7 days
Annals of Emergency Medicine 2002; 40:3:297
Transient Synovitis
• Prognosis
• Generally good
• Questionable association with long term
increased risk for developing Legg-CalvePerthes disease (1-2%)
• Recurrance in 4-15% have been reported
Septic Arthritis
Medical Emergency
• Single most important prognostic factor for a good
outcome is early treatment!!!
• Direct entry of bacteria into the joint
• S/p puncture injury; hematogenous; contiguous
• Hematogenous osteomyelitis spread is most
common in neonates/infants
• Blood vessels traverse from the metaphysis to the
epiphysis in infants. Physis formation disrupts this
connection
• >50% of neonates with osteomyelitis have
associated septic arthritis
Septic Arthritis
• Most common organism: Staph aureus
• Neonates: group B strep; gram (-) bacilli
• Adolescent: Neisseria gonorrhoeae
• Sickle Cell Disease: Salmonella
• Acute inflammatory response
• TNF-alpha, IL-1, proteases: destroy the articular
cartilage
• Continues after eradication of the bacteria
• Associated with high risk of avascular necrosis
of the hip
• Joint pressure compressing the blood vessels
supplying the cartilage and femoral head
Septic Arthritis
• Fetal breech presentation predisposes to
sebsequent development of septic
arthritis of the hip. The Pediatric
Infectious Disease Journal 2005; 24:650652
• Propensity for group B strep
osteomyelitis to involve the right
proximal humerus in infants
• J Pediatrics 1978; 93:578-583
Septic Arthritis
•
•
•
•
Usually in previously healthy children < 5 years
Early peak in the first months of infancy
1/3 of pts with URI’s within the past month
Acute painful joint with erythema, warmth,
swelling and pain on passive movement (knee)
• Up to 8% is multifocal
• Fever > 38.5
• Usually unable to bear weight
• Antalgic gait present if able to bear weight
• Knee is most common joint
• Hip, ankle, wrist, elbow, shoulder
Septic Arthritis
• Septic arthritis of the hip DOES NOT present
with erythema, warmth or swelling
• Hip is flexed in external rotation and abduction
• Relieves intracapsular pressure
• Infants often present with paradoxical
irritability, malaise and/or pseudoparalysis of
the affected limb
• Gentle motion aggravates Vs soothes
• Do not necessarily have fevers
Septic Arthritis
• Elevated WBC, ESR, CRP
• CRP accurate negative predictor of
disease
• Inc. dramatically within 6 hrs after a
trigger
• Peaks on D#2 and resolves by D# 7-10
• Blood Culture positive in 40-50%+
Septic Arthritis
Aspiration of the hip: definitive diagnosis
• Cloudy, turbid
• WBC count >50,000; predominately
neutrophils
• Glucose levels < ½ of serum levels
• 50% with positive gram stain
• 50-70% with positive culture
• Specific media needed to isolate N.
gonorrhoeae
The Limping Child: Age 3 – 6
Septic Arthritis
Bacteria
White cells
Enzymes
Enzymes
Destroy cartilage
Irreversable joint damage
Septic Arthritis
Radiographic Findings
• Xray findings seen 10 days into disease
• Osteopenia, marked joint space loss, softtissue swelling
• Ultrasound (both hips)
• Visualize joint effusions at onset
• CT/MRI
• Good to r/o abscesses and assess for
concurrent osteomyelitis
Septic Arthritis
Septic Arthritis Antibiotic Treatment
Age
Organism
Antibiotics
staphylococcus,
group B
1st generation
<12 mos
streptococcus, and
cephalosporin
gram-negative bacilli
6 mos.
to 5 yrs
S. aureus,S.
pneumonae, Group
A streptococcus, H
influenzae
5-12 yrs S. aureus
12-18
yrs.
N. gonorrhoeae, S.
aureus
2nd or 3rd
generation
cepahlosporin
1st generatin
cephalosporin
oxacillin/cephalo
sporin
Septic Arthritis
Treatment
• IV antibiotics times 2-4 weeks
• Can change to PO if clinically imp with
normalizing ESR/CRP on IV therapy, but
NOT with septic arthritis of the hip
• Joint drainage
• Low-dose dexamethasone for 4 days
• Pediatric Infectious Disease Journal
2003;22:883-888
The Limping Child: Age 3 – 6
Septic Arthritis
Treatment
1. Kill the bacteria
•
Antibiotics
2. Eliminate the white cells
•
Incision and drainage
3. Don’t delay
•
48 hour window
Septic Arthritis
• Prognosis
• Good outcome
• Initiation of treatment within 4 days of symptom
onset
• Poor outcome
• Initiation of treatment after 5 or more days
• Severe joint destruction: osteonecrosis
• Lifelong joint pain increased after activities
• Decreased ROM
• Leg length discrepancies
• Lifelong limp
Septic Arthritis Vs Transient Synovitis
• Kocher et al. Journal
of Bone and Joint
Surgery. 1999
• Boston Children’s
• Retrospective study
•
•
•
•
WBC> 12,000/mm3
ESR> 40 mm/hr
Temp > 38.5 Oral
Refusal to bear
weight
• Caird et al. Journal
of Bone and Joint
Surgery. 2006
• CHOP
• Prospective study
•
•
•
•
•
WBC> 12,000/mm3
ESR> 40 mm/hr
CRP> 2 mg/dL
Temp> 38.5 Oral
Refusal to bear
weight
Septic Arthritis Vs Transient Synovitis
Individual Factor results:
• No child with a temperature >38.5 was found
to have transient synovitis
• CRP > 2mg/dL was the only independent
risk factor strongly associated with septic
arthritis after backward elimination
• 86% of patients with ESR < 40 mm/hr had
transient synovitis
• 71% of patients with CRP < 2mg/dL or
WBC < 12,000/mm3 had transient synovitis
The Limping Child: Age 3 – 6
Transient 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
The Limping Child: Age 3 – 6
Septic Arthritis
The Worst Scenario
• Destruction of articular cartilage
• Destruction of femoral head
• Destruction of femoral neck
The Limping Child: Age 3 – 6
Septic Arthritis
The Limping Child:
Age 6 - 10
Best Bet
Legg-Calvé-Perthes Disease
Legg-Calve-Perthes Disease
• Avascular necrosis of the capital femoral
epiphysis.
• Hypothesized to arise from repeated
interruptions of the vascular supply to the
femoral head.
• Male:Female is 4:1.
• Most common between 4-10 years of age.
• 10% of cases are familial
• Present with limp (most common presentation)
with decreased internal rotation of the hip.
Legg-Calve-Perthes Disease
• Positive Trendelenburg test.
• Pelvic tilt (affected side is lower) when
standing on the affected leg.
• Pain can radiate to hip, thigh or knee.
• often insidious and can lead to disuse
of affected limb
The Limping Child: Age 6 – 10
Perthes Disease
Physical findings
•
•
•
•
•
•
Boy
Limp
Antalgic gait
Pain with passive motion
Limited abduction
Positive Trendelenburg sign
The Limping Child: Age 6 – 10
Perthes Disease
• X-ray findings
• Perhaps nothing
• MRI
•
•
•
•
Irregular consistency
Flattening
Lateral bump/ridge
Lateral hinging
Legg-Calve-Perthes
4 Distinct Radiographic Stages
• Synovitis/Necrosis: Initial joint space
widening and irregularity of the physis.
Ischemia of the epiphysis resulting in dead
bone. Ave age 5.6 years
• Fragmentation. Fracturing of the weakened
demineralized epiphysis. Epiphysis may
collapse resulting in a shortened limb. Ave
age 6.1 years
Legg-Calve-Perthes
4 Distinct Radiographic Stages (cont.)
• Re-ossification. Begins at the margins of the
epiphysis. Ave age 7 years
• Remodeling. Newly formed head is soft. At
risk for poor prognosis if not allowed to heal.
Ave age 9.1 years
• MRI better at detecting early disease
Legg-Calve-Perthes
radiology.creighton.edu/.../case19/index.htm
Legg-Calve-Perthes
Legg-Calve-Perthes
Revascularization
phase
Avascular phase
Legg-Calve-Perthes
Bilateral disease in up to 24% of cases
• Contralateral hip usually involved within 3 years of
disease onset, but can present after 5 years
• 1/3 of cases present with BIL hip involvement in the
same stage
• Questions the previously held belief that the disease
in one hip puts the contralateral hip at risk
• Retrospective review
– J Pediatric Orthopaedics 2002; 22:458-463
• Girls more likely to have bilateral disease
Legg-Calve-Perthes
Treatment
• 50% recover without treatment
• Maintaining containment of the femoral
head within the acetabulum
• Abduction splints/casts and non-weight
bearing state
• Surgically with an osteotomy of the
proximal femur
Legg-Calve-Perthes
Prognostic factors
• Better prognosis if child presents before 6
years of age: extended period of time allowed
for remodeling
• Obesity is associated with a poor prognosis
• Extent of epiphyseal necrosis present: <50%
necrosis with better outcome
• Bilateral disease not associated with a worse
prognosis
The Limping Child: Age 6 – 10
Perthes Disease
The Limping Child: Age 6 – 10
Perthes Disease
50% need a Total Hip by age 50
Legg-Calve-Perthes
Natural history of early onset LCP disease. These radiographs were taken at
age 2, 3, 5, 8 and 15 years. Courtesy of "Fundamentals of Pediatric
Orthopedics", 2003, Lippincott Williams & Wilkins ©
The Limping Child:
Age 10 – 14
Best Bet
Slipped Capital Femoral Epiphysis
(SCFE – sciffey)
Slipped Capital Femoral Epiphysis
• Non-inflammatory condition
• Femoral head displaced posteriorly
from the femoral neck
• Age of onset: 10-17 years
• Overweight boys (1.5M:1F)
• African Americans>whites,
hispanics
Slipped Capital Femoral Epiphysis
• Associated with endocrinopathies
(growth hormone deficiency) in 8%
• If presenting under 10 years of
age, hx of short stature or
hypogonadism: endocrine
evaluation
Slipped Capital Femoral Epiphysis
• Preceding history of trauma with
acute pain/limp
• Subacute or chronic pain with
insidious onset that can be referred
to the hip or knee
• Pain increased with physical
activity
Slipped Capital Femoral Epiphysis
Examination
• Limb is held slightly flexed and externally
rotated
• Often unable to fully flex hip
• Limited internal rotation and abduction
of the hip
• Limited passive ROM secondary to pain
• Bilateral in up to 30%
• Positive Trendelenburg test
Slipped Capital Femoral Epiphysis
Radiography
• X-ray of both hips
• Mild, moderate or severe depending
on degree of femoral head slip
compared to the femoral head
diameter (<1/3=mild; 1/32/ =moderate; >2/ =severe)
3
3
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
Slipped Capital Femoral Epiphysis
Klein’s line
Slipped Capital Femoral Epiphysis
Slipped Capital Femoral Epiphysis
Slipped Capital Femoral Epiphysis
www.pedsortho.ca/images/scfe.JPG
The Limping Child: Age 10 – 14
SCFE
Always get a frog lateral view
Always check the other side
CastroAP
The Limping Child: Age 10 – 14
SCFE
• Pediatric orthopaedic surgeons
• See 6 per year
• General orthopaedic surgeons
• See 1 every 6 years
• Same as fixing a fracture
The Limping Child: Age 10 – 14
SCFE
Classification
• Acute or chronic
• Acute on chronic
• Stable or unstable
• Severity of displacement
• Slip angle
• Bilaterality
• 10 – 15% at presentation
Useful Classification
Stable
Walks in
No in
reduction
• Bone
one piece
One
screw
• Slow
plastic
deformation
of the growth plate
Unstable
Wheels in
Closed reduction
•Bone
two pieces
Twoinscrews
• Physeal fracture
Slipped Capital Femoral Epiphysis
• Treatment
• Non-weight bearing with crutches to prevent
further slip
• Surgical fixation
• Prognosis
• Usually good prognosis
• Increased risk of subsequent acute
chondrolysis or avascular necrosis of the hip
Fixation SCFE
Fixation SCFE
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
Follow-up for Bilaterality
• Follow radiolographically
• Every three months
• For 18 months
• Screw removal- controversial
The Limping Child
•
•
•
•
Age 1 – 3 years
Age 3 – 6 years
Age 6 – 10 years
Age 10 – 14 years
- DDH
- Septic arthritis
- Perthes Disease
- SCFE
Best Bets
THANK YOU