1. Afraa Al-sabbagh Consultant Paediatrician Peterborough Hospital
The Child with a limp
Afraa Al-sabbagh
Consultant Paediatrician Peterborough Hospital

2. Limp in a child
Limp is uneven or laborious gait caused by pain, weakness or deformity.
Never normal
Common in childhood, accounting for 4:1000 visits in one A&E.
History of trauma or fever will decide further management.
The cause of gait disturbance in 425 pediatric patients. Pediatr Emerg Care. 1985;1(1):7.

3. Limping Child
Prospective study evaluated 243 children < 14 years presented with limp and no history of trauma:
Boys > girls by 2:1
Median age was 4
Transient synovitis most common diagnoses
Most patients (77 %) had a benign cause
1999 Nov;81(6): The limping child: epidemiology, assessment and outcome.Fischer SU, Beattie TF. Accident and Emergency Department, Royal Hospital for Sick Children, Edinburgh, Scotland, UK.

4. Approach to a Child with Limp
History
Duration
Characteristics
Pain
Fever
Other features

5. Approach to a child with a limp
Duration
Recent onset
trauma
acute infection
Chronic limp
Perthes disease
Slipped Upper Femoral Epiphysis (SUFE)
Systemic illness e.g rheumatic disease or tumor

6. Approach to Limp Pain characteristics
Constant severe pain
fractures, septic arthritis, osteomyelitis.
Intermittent, less severe pain
JIA, Perthes, SUFE, transient synovitis.
Pain at night
neoplastic conditions
Bilateral pain-seen in myositis
Pain worsens with activity
stress fracture, overuse injury, or hypermobility syndrome
Pain improves with activity
rheumatologic conditions and complex regional pain syndrome

7. Other features Morning stiffness-JIA
Back pain- discitis, vertebral osteomyelitis
Recent viral or streptococcal illness
post-infectious arthritis
myositis,
Henoch-Schönlein purpura
hypothyroidism, panhypopituitarism, and hypogonadism
slipped upper femoral epiphysis.

8. Fever Osteomyelitis, Septic arthritis- Temp >38.5 C.
Transient Synovitis ? low grade fever
Leukaemia
Hx of fever or recent illness may obscure traumatic aetiology and visa versa.
Retrospective study of 163 infants and children with OM of the long bones, a history of preceding blunt trauma was elicited in one-third of cases. Dich VQ, Nelson JD, Haltalin KCSOAm J Dis Child. 1975;129(11):1273.

9. Causes of limp Osseous Neurological Other Articular Soft tissue
Osteomyelitis
Fractures
NAI
Vasoocclusive crisis of SC
Slipped Femoral Epiphysis
Perthe’s disease
Leukemia
Metastatic Neuroblastoma
Neurological
Complex regional pain syndrome
Spinal cord tumors
Other
Conversion disorder
Articular
Transient Synovitis of the hip
Septic arthritis
JIA
HSP
Discitis
Soft tissue
Myositis
Muscle strain
Abdominal
Psoas abscess
Pelvic abscess

10. Examination General examination: Well or unwell On parents lap
Watch children playing and walking
Examine gait
Walking
Running
Hopping
Walk on heel then toes

11. Examination
Spine
Upper and lower limb examination (musculoskeletal and neurological examination), pGALS
Abdominal examination
Genitalia
Skin

16. 6 week old male
2 day history swelling left thigh, child not moving leg
No history trauma
Apyrexial well normal baby
Swollen left thigh
#femur
NAI

17. 6 week old baby What is your diagnosis?
How will you manage this child?

19. Metaphyseal "corner" fractures, as shown here (white arrows), are highly suggestive of child abuse. Metaphyseal corner fracture of the distal femur (arrows). This classic metaphyseal lesion occurs when the extremity is pulled or twisted, or the child is shaken. The resultant shearing force undercuts an isolated fragment of the metaphysis that includes the subperiosteal bone collar. When viewed tangentially, the lesion appears as a triangular fragment of the metaphysis (ie, the "corner" fracture).

20. Child abuse
Fractures due to child abuse seen in < than three years of age
50 % occur in children younger than 12 months
long bones most commonly injured, femur, humerus, and tibia
Diaphyseal fractures are 4X more common than metaphyseal fractures (more specific)
Skeletal survey is required in these cases and referral to social services.
(do not forget underlying bone conditions such as OI)

21. Case 15 month old female Sister of a 3 year old girl with JIA
Her sister came for a routine appointment and mum mentioned her odd gait
Was reassured by the physiotherapist who looks after her sister ? Normal toddler’s gait.

23. Developmental Dysplasia of the Hip
May present with limp
Second year of life
In one series of 148 children with a limp who presented to a paediatric orthopedic clinic, six children had DDH
Children with unilateral DDH
child may walk on the toes of the affected side to compensate for the shortened thigh.
Trendelenburg gait
decreased hip abduction.
positive Galeazzi test
? extra skin folds on the affected limb (common reason why children referred to the paediatric clinic for hip assessment).

24. 2½ year old female Fell from sofa onto floor
Non weight bearing left leg but crawling
Mum is concerned about her ankle
Missed toddlers # crawling?
X-ray ankle reported as normal

26. 2½ year old female
What is your diagnosis?

27. Toddlers fractures Following trivial injury
involve the distal half of the tibia
children refuse to bear weight
physical findings usually are subtle.
Bruising and deformity are absent
tenderness, swelling, or warmth may be present
Pain elicited by dorsiflexion of the ankle
radiographic finding, a faint lucent oblique line crossing the distal tibia and terminating medially
Initial radiographs may be normal in as many as 43 % of cases

28. Transient synovitis
Transient synovitis (TS) is the most common cause of hip pain in children
Typically presents between three and eight years
Presentation
symptoms for one to three days
Fever typically is absent or low-grade, and children are nontoxic in appearance,
Ultrasound can detect bilateral effusions in 25 percent of children
Children with TS have an antalgic gait and usually prefer to keep the hip in abduction and external rotation.
Management of TS
Conservative
nonsteroidal antiinflammatory drugs (NSAIDs) and return to full activity as tolerated.
Good prognosis with full recovery to be expected within one to four weeks.
Recurrence rates from 4%-15% have been reported

29. 5 year old male
Twisted leg whilst playing ‘chasey’ 4 days ago limping since on right leg
On examination of the right hip, flexion, internal rotation, abduction are reduced
Perthe’s Reduced abduction & internal rotation
XR- increased density of bony epiphysis, apparent widening of joint space.flattening, fragmentation and lateral displacement of epiphysis and broadening of metaphysis

31. 6 year old boy 6 month history limping right leg
Diagnosed x2 ‘Irritable Hip’
No history trauma or fever
Examination shows 2 cm leg length discrepancy, pain with hip extension & external rotation

33. 6 year old male
What is your diagnosis?

34. Legg-Calvé-Perthes On examination X-Ray
Iidiopathic avascular necrosis of the hip
Between 3 and 12 years. The peak incidence is between 5 & 7 years of age.
bilateral in 10% to 20 % of patients
Llimp of insidious onset
On examination
limited internal rotation and abduction of the hip.
Trendelenburg gait positive
X-Ray
early stages smaller, more dense-appearing epiphysis
later stages fragmentation and healing of femoral head, often with residual deformity

35. 11 year old boy 6 day history right hip pain increasing intensity
Pelvic XR normal, WCC, ESR , USS guided aspiration of hip normal
RLQ tenderness
Normal ROM hips
Tender right lumbar paraspinal region, unable to weight bear right leg

37. What is your diagnosis?
How will you manage this child?

39. Slipped Upper Femoral Epiphysis (SUFE)
Displacement of the capital femoral epiphysis from the femoral neck.
Typical patient is adolescent obese male
Age between 10 and 15 years.
Bilateral in 30-60% of cases.
Obesity and endocrine problems often a risk factor.
Presentation:
limp and hip pain
Limited hip movements in all directions
Trendelenburg test positive

40. Case 3 year old male, 3 week history of shoulder and leg pain.
Family reported on and off temperature and not being himself.
O/E no joint swelling, tenderness or deformity.
Intermittent limp.
CRP 300, ESR 102, FBC normal.
How will you manage, what’s your DDx?

42. Other causes of limp
Leukaemia — Bone and joint pain may be the presenting feature in 21% to 33 % of cases.
Radiographic changes are present in as many as 44 %
diffuse osteopenia, periosteal new bone formation, geographic lytic lesions.

43. 286 children diagnosed with ALL between 1992 and 2013.
Brix N, Rosthøj S, Herlin T, et al. Arthritis as presenting manifestation of Acute Lymphoblastic Leukemia in children. Arch Dis Child
Children with acute lymphoblastic leukaemia (ALL) may present with arthralgia or signs of arthritis.
286 children diagnosed with ALL between 1992 and 2013.
Fifty-three (18.5%) presented with localised joint pain. (half had objective signs of arthritis)
Reactive arthritis (19/53),
osteomyelitis (9/53)
juvenile idiopathic arthritis (8/53).
The clinical signs of leukaemia are less prominent, but non-articular pain should alert the clinician of a possible diagnosis of leukaemia.

45. Septic Arthritis Knee and hip are the joints most commonly affected.
A review of 425 children who were admitted in the A&Edepartment during a 12-month period for a gait disturbance, 14 (3 %) had septic arthritis.
Infants irritability and pseudoparalysis, with or without fever
Refusal to weight bear
febrile and ill-appearing,
Joint effusion, periarticular warmth and tenderness, and severe pain on range of motion.

46. Septic arthritis
ESR –the most sensitive test, elevated in 90 % of cases but lacks specificity.
Plain radiographs- may show joint effusion.
Bone scans rarely indicated.
Definitive diagnosis made by examination of synovial fluid.
In a retrospective comparison of 94 children with septic arthritis and 38 children with transient synovitis, the combination of ESR > 20 mm/hr and/or temperature greater than 37.5ºC detected 97%of those with septic arthritis.

47. Discitis Inflammation of the intervertebral disc
Aetiology is controversial, 60 % of biopsied discs (not necessary for diagnosis) grow bacteria usually Staphylococcus aureus
Children often recover without antibiotic therapy.
Rare condition. At a single centre, the incidence was one to two cases per 32,500 paediatric hospitalisations and clinic visits per year
Typically in children younger than five years.
Gradual onset back pain, limp, or refusal to crawl or walk, without systemic toxicity; fever usually is absent or low grade.

48. Diagnosis
Blood tests all normal apart from raised ESR in 90% of cases.
MRI
Aspiration of the affected disc for culture is not required.
IV antibiotics until the child shows improvement, followed by oral antibiotics.

49. Case: 7 year old child Calf pain for 2 days
Cough, runny nose & low grade temperature
WBC * /L
Hb g/L
PLT * /L
Lymphs * /L
Neuts * 1.0

50. Myositis During epidemics of influenza A and B.
Calf muscles typically affected.
The child may refuse to walk or walk on his or her toes, and refuse to dorsiflex the feet
Muscle enzymes elevated
Myoglobinuria and acute renal failure do not occur
Full clinical recovery seen in 3 to 10 days

53. The is the X-Ray of a child with mucopolysaccharidosis type VI.
X-Linked metabolic condition.
Treatment is enzyme replacement.

54. Thanks
Any questions?