Devin Peterson, MD, FRCSC, Dip Sport Med
Associate Professor, McMaster University
McMaster University Medical Centre
David Braley Sport Medicine & Rehabilitation Centre
Faculty/Presenter Disclosure
• Faculty: Devin Peterson
• Program: 51st Annual Scientific Assembly
• Relationships with commercial interests:
• None
Disclosure of Commercial
Support
• This program has received no financial support
• This program has received no in-kind support
• Potential for conflict(s) of interest:
– None
Mitigating Potential Bias
• N/A
1.
2.
To assess and diagnose common causes of
childhood limping
To understand the management principles
of the limping child including timely
referral

Smooth energy-efficient
transfer of the body
through space
Limp: “to walk with a halting or irregular step”
 Funk
& Wagnall's
 Antalgic
Gait: body’s effort to compensate
for pain or instability in the stance-phase
limb by minimizing the duration and
magnitude of loading
 Trendelenburg
Gait: leaning of the head and
trunk toward the lower extremity affected by
the pathology
 Pain
 Weakness in the hip muscles
19 month old female referred because of limping
 Fifth
born
 Normal delivery/presentation
 Walking
at 14 months
 Always limped
 No
pain
 Healthy
 Negative
Family history
 Differential
diagnosis
 Top three:
 Hip dysplasia
 Neuromuscular disease
 Leg length discrepancy
 Dislocated:
the femoral head is not in contact with the acetabulum
 Dislocatable
the femoral head is within the acetabulum but can be forced out
 Subluxed
the femoral head is within the acetabulum but not in its proper
position
 Subluxable
the femoral head can be moved beyond its physiologic limits
within the acetabulum
 Dysplastic
although the femoral head is in the proper position the
acetabulum or head are abnormally developed
 History
 Risk
Factors
 Female
 Firstborn
 Breech
 Large baby
 Low amniotic fluid
 Family history

Physical
 Associated Conditions
o Foot deformity,
Torticollis
o Neuromuscular
disorders
o Syndromes
 Hip Examination
o Trendelenburg gait
o Skin folds
o Galeazzi sign
o Abduction
o Provocative maneuvers
- Ortolani, Barlow

Imaging
 Ultrasound
 < 6 months
 X-ray

Treatment





URGENT REFERRAL
Pavlik Harness
Closed Reduction
 Safe Zone
Open reduction
 Extra-articular blocks
 Intra-articular blocks
Osteotomies
 Pelvic
 Femoral + Shortening
Most common cause of hip pain in
childhood
 3% childhood risk
 Idiopathic
 Frequently associated with concurrent or
antecedent illness
 Right hip = left hip
 NEVER BILATERAL
 2:1 male:female

 History
 Age
varies (9 months to adolescence)
 Most between 3 and 8 years old
 Unilateral hip pain
 Can present with knee or thigh pain
 Limp vs non-weight bearing
 Physical
 May
have a low grade temperature
 Antalgic or Trendelenburg gait
 Flexed and externally rotated position
 Decreased ROM
 Especially abduction and internal rotation
 Laboratory
tests
 Non-specific
 Imaging
 Radiographs
usually normal
 Ultrasound may show effusion
 Diagnosis
of exclusion
 Treatment
 URGENT
REFERRAL
 Differential includes a septic joint
 Self limiting disorder
 May have symptoms for up to 10 days or
longer
 Bed rest until full ROM, no pain, limp free
 Crutches for older patients
 NSAIDS
 Gradual return to activity






Self limiting hip disorder
Caused by ischemia and subsequent necrosis
of the femoral head
Usually 4 to 8 years of age
Male to female ratio:
 4-5 to 1
Usually unilateral (88%)
Age and lateral head involvement are the key
to prognosis
 8 years of age seems to be the watershed
 <50% of lateral pillar involvement better
prognosis

Unilateral Perthes:





septic arthritis
sickle cell disease
spondyloepiphyseal dysplasia tarda
Gaucher’s disease
Bilateral Perthes:




Hypothyroidism
Multiple epiphyseal dysplasia
spondyloepiphyseal dysplasia tarda
sickle cell disease
 History
 May
be painless at first
 present with a limp only
 symptoms occur with subchondral
collapse/fracture
 Can present with knee or thigh pain
 Positive family history 1.6% – 20%
 1% - 3% of patients with transient synovitis
will develop Perthes
 Physical
gait: Trendelenburg
 decreased abduction/
internal hip rotation
 thigh, calf, and
buttock atrophy
 LLD

 Imaging

X-ray, bone scan,
MRI
 Treatment
 TIMELY REFERRAL
 Principles of treatment
are maintenance of
ROM & containment (good coverage of
the head by the acetabulum) of the femoral
head through the evolution of healing
 May be obtained by non-operative means
o relative rest
o pain control
o physiotherapy
o traction
o abduction splinting at night

Containable Hip
 adductor release
 Femoral varus/pelvic
osteotomies

Non-Containable Hip
 Hip/Late-presenting
patient with deformity
 Hinge abduction
 Chiari/lateral shelf
 Cheilectomy
 Femoral
abduction/extension
osteotomy
 OCD, non-operative,
revascularization,
removal, ORIF
 First
description: Young 1889
 3-5% in general population have a larger
than normal meniscus
 Almost all in lateral, but reported in medial
 20% bilateral and 10% associated with OCD
of lateral femoral condyle

THREE SEGMENTS
• Anterior horn
• Body
• Posterior horn
Attached to tibial
plateau, primarily
through Coronary
Ligament
Attached to the
capsule except
at popliteal
hiatus
 Clinical
Presentation
 History:
 Asymptomatic
 “Snapping knee syndrome”
 Meniscal tear symptoms
 Physical:
 Snapping knee with gait
 Meniscal signs
 X-ray
 Widened
lateral joint space,
squaring of lateral femoral
condyle, cupping of lateral
tibial plateau
 MRI
 Verify
diagnosis and assess
damage
 Asymptomatic:
observe
 Symptomatic:
 TIMELY
REFERRAL UNLESS LOCKED KNEE
THEN URGENT
 Non-operative: restricted activity, bracing,
physiotherapy
 Operative:
 Partial meniscal “saucerization”
 Repair of tear
 Apophysitis
of the Hip and Pelvis
 Sinding-Larsen-Johansson: inferior pole of
patella
 Osgood-Schlatter Disease: tibial tuberosity
disturbance
 Sever Disease: calcaneal apophysitis
 Iselin Disease: apophysitis of the fifth
metatarsal
 Tibial
tuberosity disturbance
 Partial avulsion (microscopic fractures) of
the ossification center and overlying
hyaline cartilage
 Epidemiology
 10
– 15 years old
 Boys > girls
 > 10% of teenagers
 History
 Pain
localized to tubercle
 Worse with direct blows to the are and
activity
 Physical
 Antalgic
gait may be present
 Prominent tubercle + local swelling
 Tenderness localized to tubercle
Lovell and Winter’s Pediatric Orthopaedics 5th edition
 Treatment
 Spontaneous
resolution at maturity
 20% may have pain with kneeling
 surgery for loose ossicles
 Reassurance
 Symptomatic treatment/activity modification
 NSAIDS, stretching, knee pads/braces, foot
orthosis, casts
 TIMELY REFERRAL
 Acquired
potentially reversible lesion of
subchondral bone resulting in delamination
and sequestration with or without articular
cartilage involvement and instability
 Juvenile and Adult forms
 Adult form is typically progressive and
unremitting
 May occur in almost any joint in upper or
lower extremity
 Very common in the knee
 15-29
per 100,000
 May be bilateral in 25% of cases
 Male: female ratio
 5:3
 >70% are in the classical area
 Posterolateral aspect of the medial
femoral condyle
 Idiopathic
 Theories
include:
 Genetics
 Inflammation
 Ischemia
 Ossification
 Repetitive trauma (stress reaction causing
a stress fracture in the underlying
subchondral bone)


History
 Juvenile
 Poorly localized pain
 Exacerbated by exercise
 May present with
symptoms of instability
(swelling, stiffness,
catching, locking)
 Limp
Physical
 Antalgic gait
 Effusion
 Crepitus
 Painful ROM
 Quads atrophy
 Maximum tenderness
usually anteromedial knee
 Wilson sign
 Pain with internal tibial
rotation
 X-rays
AP
 Lateral
 Notch
 MRI + gadolinium
 Lesion size
 Status of the cartilage and subchondral bone
 Bone edema and high signal zone beneath
fragment
 Loose bodies
 Technetium bone scan

Nonoperative
 Open physis = good prognosis?
 Activity modification
 Immobilization?
 Rehabilitation
 Local and systemic pain management
 Review every 3-6 months or sooner if
symptoms worsening
 Repeat MRI every 6 months?
 TIMELY REFERRAL if no improvement or
worsening, URGENT IF LOCKED KNEE
Operative
 Indications
 Lesions not responding to nonoperative
management
 Unstable lesions?
 Detached lesions
Tarsal coalition is an abnormal connection
between some of the tarsal bones
 May be painful
 Can be associated with increased ankle sprains
 Gait
 Antalgic
 Flexibility
 Toe
standing
 Sitting/supine
 Subtalar ROM
Flexible Flatfoot
 Arch returns with
sitting or tiptoe
standing
 Normal subtalar and
midtarsal motion
Tarsal Coalition
 Arch may not return
with sitting or tiptoe
standing
 May be painful to
move or palpate
subtalar joint or other
tarsal bones
 Subtalar motion often
decreased
 Normal
in flexible
flatfoot
 Oblique views and
Harris view may help
view a coalition
 May need an MRI or
CT to make diagnosis
 Tarsal
Coalition
 TIMELY REFERRAL
 Rest/activity modification
 Antiinflammatories
 Physiotherapy?
 Orthotics
 Casts
 Surgery: resection or fusion
 The
slip normally
occurs during
adolescent growth
phase
 Mechanical
or
systemic factors may
be present


Commonly obese
Endocrinopathies (eg.
1o & 2o
hypothyroidism,
panhypopituitarism,
GH, hypogonadal
conditions, & renal
osteodystrophy
 Male
 Left
> female
> right
 Bilateral
involvement may occur
 Second slip presents within 18 months in 88%
 History

Chronic and/or acute

Limp

May present with knee or thigh pain instead of
hip/groin pain
 Physical
 Gait:
Trendelenburg
 Shortened/external rotation
 Decreased abduction/internal hip rotation
 Passive flexion leads to thigh abduction and
external rotation
 Imaging
 X-ray,
CT, MRI
X-rays





Physeal plate widening &
irregularity
Decrease in epiphyseal
height
Blanch sign of Steel
 Crescent-shaped area of
increased density in the
proximal femoral neck
Femoral metaphysis
appears laterally displaced
 Klein’s line
Southwick angles
 Imaging


Frog-leg lateral
 avoid in acute
situation
Cross-table lateral
Treatment - Acute




EMERGENT REFERRAL
Immediate bed rest
Insertion of one or more
screws
 in situ fixation
Designed to fuse the
epiphysis on the metaphysis
to prevent further slipping
Prophylactic Pinning


Known
metabolic/endocrine
disorders?
Inability to follow-up
 Stress
Fractures in Skeletally Immature
Patients
 Walker et. al.: JPO 1996
 34
stress fractures
 Tibia (47%), fibula, femur, radius, humerus,
MT
 History
 Pain
often associated with an increase in
activity
 Be wary of female triad
 Physical
 Antalgic
gait may be present
 Tenderness localized
 Radiographs
 Rapid
bony response may be
present
 Bone Scan
 Helpful in questionable
situations
 Treatment (depends on
causative factors)
 URGENT REFERRAL
 Modification of activities
 Immobilization
 History
 Pain
Night pain
 History of trauma may delay diagnosis
 Osteoid Osteoma pain relieved by NSAIDs
 Constitutional Symptoms
 Fever, night sweats, anorexia, weight loss
 eg. Ewing sarcoma
 Soft tissue mass may not be symptomatic

 Physical
Exam
 Gait disturbance
 Muscle atrophy
 Neurovascular exam
 Range of motion
 Mass
 Size, tenderness, pulsation, mobility,
bruits, tenderness, erythema, consistency
 Lymph nodes
 Investigations
 Bloodwork
CBC, ESR, CRP,
serum alkaline
phosphatase,
serum and urine
calcium &
phosphorus, LDH
 Imaging
 X-ray
 Bone Scan
 CT/MRI

 Management
 Referral

Urgency dependent on tumor type
 History
 Pain
Refusal to bear weight
 Limping
 Recent illness
 Decreased immunity
 eg. chickenpox
 Trauma

 Physical
Exam
 Temperature
 Antalgic gait
 Disuse of a part
 Erythema/swelling
 Tenderness
 Decreased ROM

Laboratory tests
 CBC
 WBC
 CRP
 ESR
 Blood cultures
 Aspirates (Gram stain,
Culture)

Imaging
 X-rays
 Ultrasound
 Bone Scan
 CT
 MRI
 Treatment
 EMERGENT
REFERRAL
 Stop tissue destruction ASAP
 Decrease bacterial load and irrigation of
the joint
 Identify the Organism
 Select appropriate antibiotic