1. The Limping Child
Chrissie Ashdown

2. Aims and Objectives
How to assess the limping child who presents to the GP
Investigations
Common diagnoses
Basic management

3. The Limping Child A common reason for a child to present
Long list of potential diagnoses, some of which demand urgent treatment
How do they present?
What are the potential diagnoses?
How should they be diagnosed and managed?

4. Gait Differences
The gait of a child is different from that of an adult for the first 3 yrs
Children typically take more steps/minute at a slower speed than adults to compensate for immature balance.
Toddlers tend to flex hips, knees, + ankles more than adults in order to lower their centre of gravity + improve their balance.

5. Developmental stages of gait
Age (months) Developmental stage
10-12 Cruises while holding on to objects
12-14 Walks short distances, stands unaided
17-21 Walks on 1 foot long enough to walk up steps
30-36 Balances on 1 foot for >1s
36 Develops sufficient balance to attain a normal gait pattern

6. Common Causes 0-3 years old #/soft tissue injury (toddler’s #/NAI)
Osteomyelitis or septic arthritis
Developmental dysplasia of the hip

7. Common Causes 3-10 years old Trauma Transient synovitis/irritable hip
Osteomyelitis or septic arthritis
Perthes disease

8. Common causes 10-15 years old Trauma Osteomyelitis or septic arthritis
Slipped upper femoral epiphysis
Chondromalacia
Perthes’

9. Other Dx Haematological eg Sickle cell
Infective eg pyomyositis/discitis
Metabolic eg rickets
Neoplastic eg acute lymphoblastic leukaemia
Neuromuscular eg cerebral palsy
1ary anatomical eg limb length inequality
Rheumatological eg juvenile idiopathic arthritis

10. What questions should you ask?
Child presents with a limp

11. History – Q’s to ask Duration and progression of limp?
Recent trauma and mechanism? Beware limitations of paediatric history, possibility of unintentional trauma
Associated pain and its characteristics?
Accompanying weakness?
Time of day when limp is worse?
Can the child walk or bear weight?

12. History – Q’s to ask Has the limp interfered with normal activities?
Presence of systemic symptoms - fever, weight loss?
Do not forget PMHx, BIND—birth history, imms, nutritional history, developmental history
Also include the other essentials— DHx and allergies and FHx

13. Examination

14. pGALS Pain or stiffness in joints/mm/back?
Gait/general: Temp, observe gait including on tiptoes and heels
Arms – N/A
Legs: Knee effusion, ‘bend + straighten you knee’ – crepitus?, apply passive flexion (90deg) with internal rotation of hip

15. pGALS Spine: observe from behind, ‘can you bend and touch your toes?’
Observe curve of spine from side and behind

16. Look, feel, move

17. Examination Look Feverish?
Can they stand? Spine straight? Pelvis level?
Deformity, erythema, swelling, effusion,
limitation of motion, asymmetry.
shoes - unusual wear on soles, asymmetry, point of initial foot strike, assess fit.
Older children - scoliosis, midline dimples, hairy patches, (?spinal pathology)

18. Examination Feel Can they localise the pain?
Measure true leg length - anterior superior iliac spines to medial malleoli.
Assess thigh or calf circumference if asymmetry suggests atrophy.
Feel for warmth, fluctuance, palpable masses, stiffness, focal tenderness

19. Examination
Move
Assess ROM, laxity, stiffness with guarding, pain, discomfort, and fluidity
Assess gait with the child barefoot.
Any discomfort as the child bends down
Hips: move normally? Internally rotate symmetrically, no pain?

20. Don’t forget!
Both intra-abdominal pathology and testicular torsion may present simply as a limp – examine abdomen and testicles in boys!!

21. Diagnoses

22. Trauma Diagnosis is by plain x ray as a primary investigation.
Anteroposterior and lateral views are indicated.
A+E usually indicated

23. Toddler’s #

24. Toddler’s # Subtle undisplaced spiral # of the tibia
Usually pre-school
Sudden twist after an unwirnessed fall

25. Toddler’s #
Local tenderness over tibial shaft may be present or on gentle strain on the tibia
In 1 series 5/37 # not present on initial x-ray
Immobolise, expectant Mx

26. Transient synovitis

27. Transient Synovitis
Acute onset, after a respiratory illness (weak evidence)
Affects young children (boys more than girls) most often
Most common cause of acute hip pain in young children age 3-10
Usually unilateral
May refuse to walk/limp

28. Transient Synovitis
Usually no pain at rest + passive movements only painful at extreme ranges
FBC + ESR normal or slightly elevated
XR may be normal
USS may show effusion
Main treatment rest + physio
NSAIDs useful, can shorten the duration of symptoms in children, usually resolves within 2 weeks

29. Septic arthritis/osteomyelitis

30. Septic Arthritis Most often hip, knee, ankle, shoulder, elbow.
Most often children <2yrs.
Early features often non-specific.
Child often very unwell.
Pain often present at rest, resistance to attempted movement of the hip.
Older children usually reluctant to weight bear, may be more aware of referred pain in the knee.
Hip is kept flexed, abducted and externally rotated.

32. Septic arthritis BCs +ve, raised WCC + CRP XR show delayed changes
Bony changes not evident for days
By 28 days, 90% show some abnormality.
About 40-50% focal bone loss is necessary to cause detectable lucency on plain films

33. Septic arthritis - Mx
Joint aspiration is the definitive diagnostic procedure and the most common pathogen isolated is Staph aureus
Emergency orthopaedic consultation with subsequent aspiration, arthroscopy, drainage + debridement required.
Antibiotics are required as adjunctive treatment.

34. Perthes’ Disease

36. Perthes’ disease
Self-limiting hip disorder caused by varying degrees of ischaemia and subsequent necrosis of the femoral head.
Most often affects boys (80%) and those aged 5-10 yrs.
Increased risk with:
low birth weight
short stature
low socio-economic class
passive smoking.
Unilateral in 85% of cases

37. Perthes’ disease Presents with pain in hip or knee, causes limp.
Pain (often in knee), + effusion (from synovitis).
On examination all movements at hip limited
No history of trauma.
Roll test; with patient lying supine, roll the hip of the affected extremity into external + internal rotation.
Should invoke guarding or spasm, especially with internal rotation.

38. Perthes’ disease Classic x-ray features:
Sclerosis, fragmentation and eventual flattening of the proximal femoral epiphysis
Absent in early disease
May be initially misdiagnosed as irritable hip

39. Perthes’ disease
Radionuclide bone scan/MRI helps evaluate for avascular necrosis
If AVN is shown, bracing, physio + protection of the hip may be indicated.
Surgery to contain the femoral head within the acetabular cup sometimes necessary – femoral varus osteotomy
Done with or without rotation to redirect the ball of the femoral head into the socket of the acetabulum

40. Slipped Capital Femoral Epipysis

42. Slipped capital femoral epiphysis
Usually occurs at the onset of puberty and most often in children who are either very tall and thin, or short and obese.
Other risk factors include Afro-Caribbean, boys, family history.
One quarter of cases are bilateral.
Prepubescent male children (12-15 yrs)

43. Slipped capital femoral epiphysis
Hip, thigh and knee pain.
Often initially a several week history of vague groin or thigh discomfort.
May be able to weight bear, but is painful.
Flexion of hip often also causes external rotation.
May be leg shortening.

44. Slipped capital femoral epiphysis
XR shows widening and irregularity of the plate of the femoral epiphysis.
The displacement of the epiphyseal plate is medial and superior
Surgical pinning of the hip is usually required and should be done quickly.

45. Developmental Dysplasia of the Hip (DDH)

46. DDH Risk Factors Female Breech position Caesarean section 1st child
Prematurity
Oligohydramnios
Family history
Club feet, spina bifida and infantile scoliosis

47. DDH Must be detected early
Delayed identification leads to more prolonged morbidity
Classic screening tests are Barlow and Ortolani
Ortolani assesses if the hip is dislocated
Barlow assesses whether the hip is dislocatable.
Asymmetrical skin creases in the thigh or buttock
Unequal leg length

48. DDH Up to 60% of abnormal hips become normal without Tx after 1mth
USS usually done
Mx depends on age

49. DDH - Management 0-6 months- Pavlik harness
Attempts to place hips in the human position by flexing them more than 90 degrees (preferably degrees) and maintaining relatively full, but gentle abduction (50-70 degrees).
Redirects the femoral head towards the acetabulum and spontaneous relocation of the femoral head occurs typically in 3-4 weeks.

50. DDH - Management
> 6m requires closed reduction and use of a Spica cast - used to immobilize the hip joints and it usually extends from the mid-chest down to below the knee.
This cast is usually left in place for 6-8 weeks

51. Neoplasm

52. Neoplasm
Osteogenic sarcoma causes acute unremitting limp/limb pain, often involves the distal femur + proximal tibia
Leukaemia causes ill defined migratory bone or joint pain + generalised weakness
Neuroblastoma can produce nerve impingement
Appropriate treatment is multidisciplinary and involves referral to paediatric oncology and orthopaedics.

53. Juvenile Rheumatoid Arthritis

54. Juvenile rheumatoid arthritis
Autoimmune disease may present affecting a single ankle or knee (pauciarticular)
Presence of assoc. systemic findings eg high fever, salmon coloured pink rash, eye inflammation are also useful in Dx
Treatment is multidisciplinary, involves paediatric rheum, ophthal, ortho, rehabilitation specialists + OTs

55. Red flags!!

56. Red flags Child <3y Unable to weight bear Fever Systemic illness
>9y with pain or restricted hip movements

57. Irritable hip v septic arthritis
Factors for predicting septic arthritis
Fever >38.5
Cannot weight bear
ESR>40 in 1st hr
WCC>12

58. That’ll do for now!
Any Questions?