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THE CHILD WITH A LIMP Madesa Espana, MD, FAAP Pediatric Emergency Medicine St. Joseph’s Regional Medical Center Paterson, New Jersey.

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Presentation on theme: "THE CHILD WITH A LIMP Madesa Espana, MD, FAAP Pediatric Emergency Medicine St. Joseph’s Regional Medical Center Paterson, New Jersey."— Presentation transcript:

1 THE CHILD WITH A LIMP Madesa Espana, MD, FAAP Pediatric Emergency Medicine St. Joseph’s Regional Medical Center Paterson, New Jersey

2 LIMP An uneven, jerky or laborious gait, usually caused by pain, weakness or deformity. An uneven, jerky or laborious gait, usually caused by pain, weakness or deformity. 4/1000 visits in a pediatric ED 4/1000 visits in a pediatric ED

3 A CHILD WITH A LIMP Epidemiology Epidemiology –Median age: 4 years old –Male:female ratio: 2:1 –Most common diagnosis: Transient synovitis –Pain is present in 80% of cases –Localization: hip and knee –Benign cause: 77%

4 THE CHILD WITH A LIMP HISTORY HISTORY –Duration –Trauma –Fever

5 THE CHILD WITH A LIMP HISTORY HISTORY –Location of the pain –Pain characteristics  Constant severe pain  Intermittent mild to moderate pain  Bilateral pain  Modifying factors

6 THE CHILD WITH A LIMP HISTORY HISTORY –Other symptoms  Morning stiffness  Incontinence, weakness or sciatica  Recent viral or bacterial illness  Recent medications  Endocrine and other systemic diseases

7 THE CHILD WITH A LIMP PHYSICAL EXAMINATION PHYSICAL EXAMINATION –General appearance  Ill or toxic appearing  Fever  Obvious discomfort/pain at rest

8 THE CHILD WITH A LIMP PHYSICAL EXAMINATION PHYSICAL EXAMINATION –Gait evaluation  Phases of a gait –Stance: time when the foot is in contact with the surface  Heel-strike to toe flat (contact)  Foot-flat to heel-off (mid-stance)  Heel-lift to toe off (propulsion) –Swing: time from toe-off to heel strike

9 THE CHILD WITH A LIMP PHYSICAL EXAMINATION PHYSICAL EXAMINATION –Young child (<4 years) vs. adult gait  Increased flexion of the hips, knees and ankles  Rotation of the feet externally, wider base of support  Faster cadence, slower velocity, shorter stride length  Smaller percentage of the gait cycle is spent in single limb stance

10 THE CHILD WITH A LIMP PYSICAL EXAMINATION PYSICAL EXAMINATION –Gait examination  Expose the legs  Bare feet or wearing only a pair of socks  Listening to the gait –Cadence –Foot slap –Scraping

11 THE CHILD WITH A LIMP PHYSICAL EXAMINATION PHYSICAL EXAMINATION –Gait examination  Observe several gait cycles  Includes jumping/hopping

12 Gait evaluation

13 THE CHILD WITH A LIMP PHYSICAL EXAMINATION PHYSICAL EXAMINATION –Musculoskeletal  Muscle strength  Muscular atrophy  Bony tenderness  Bony deformity

14 THE CHILD WITH A LIMP PHYSCIAL EXAMINATON PHYSCIAL EXAMINATON –Musculoskeletal  Active and passive ROM  Joint swelling/tenderness  Muscle tenderness  Tenderness on the tendons, insertions sites

15 THE CHILD WITH A LIMP PHYSICAL EXAMINATION PHYSICAL EXAMINATION –Musculoskeletal  Back and spine  Hip  Thigh  Knee  Leg  Ankle  Foot

16 THE CHILD WITH A LIMP PHYSICAL EXAMINATION PHYSICAL EXAMINATION –Musculoskeletal  Limb length discrepancy  Hip rotation  Galeazzi test  Trendelenburg test  FABERE test

17 THE CHILD WITH A LIMP PHYSICAL EXAMINATION PHYSICAL EXAMINATION –Skin  Bruises  Rashes and other lesions  Swelling  Redness  Tenderness

18 THE CHILD WITH A LIMP PHYSICAL EXAMINATION PHYSICAL EXAMINATION –Lymphatic  Lymphadenopathy –Localized vs. systemic  Lymphadenitis  Lymphangitis

19 THE CHILD WITH A LIMP PHYSICAL EXAMINATION PHYSICAL EXAMINATION –Neurologic  Muscle strength  Muscle tone  DTR’s

20 THE CHILD WITH A LIMP PHYSICAL EXAMINATION PHYSICAL EXAMINATION –Gastroentestinal  Abdominal tenderness  Abdominal swelling –Genitourinary  Testicular or scrotal pain/swelling  Inguinal swelling

21 THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES –Age of the child –Location of abnormal findings –Duration of symptoms –Type of gait abnormality

22 THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES –OSSEOUS  Fractures –Salter-Harris or growth plate injuries –Toddler’s: tibia, calcaneous and cuboid –Stress –Incomplete: buckle, greenstick –Complete –Plastic or bowing deformity –Avulsion –Child abuse: bucket-handle fractures

23 THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES –OSSEOUS  Apophysitis –Sinding-Larsen-Johnson disease –Kohler disease –Sever disease –Freiberg disease –Osgood-schlater disease

24 THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES –OSSEOUS  Vasoocclussive crisis of SCD  Slipped capital femoral epiphysis  Legg-Calve-Perthes disease

25 THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES –TUMORS  Leukemia  Lymphoma  Spinal cord tumor  Osteogenic sarcoma  Ewing’s sarcoma  Osteoid sarcoma  Metastatic neuroblastoma

26 THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES –ARTICULAR  Transient synovitis of the hip  Septic arthritis  Osteochondritis dessicans  Acute rheumatic fever  Juvenile rheumatoid arthritis

27 THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES –ARTICULAR  Serum sickness  Discitis  Developmental dysplasia of the hip  Chondromalacia of the patella  Hemarthrosis: traumatic, hemophilia

28 THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES –ARTICULAR  Henoch-Schonlein purpura  Lyme disease  SLE  Patellar dislocation

29 THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES –SOFT TISSUE  Contusion  Muscle strain  Sprain  Tendonitis  Viral myositis  Foreign body

30 THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES –SOFT TISSUE  Cellulitis  Abscess  Pyomyositis  IM vaccination  Insect envenomation  Plantar warts

31 THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES –SOFT TISSUE  Bunion  Ingrown toenail  Baker’s cyst rupture  Myositis ossificans  Bursitis  Benign hypermobility syndrome

32 THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES –NEUROLOGICAL  Meningitis/Intracranial abscess  Cerebral palsy  Peripheral neuropathy  Epidural abscess  Spinal cord tumor  Complex regional pain syndrome (reflex sympathetic dystrophy)

33 THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES –INTRA-ABDOMINAL  Appendicitis  PID  Pelvic abscess  Psoas abscess  Perirectal abscess  Iliac adenitis

34 THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES –GENITO-URINARY  Incarcerated inguinal hernia  Testicular torsion  STD’s

35 THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES –PSYCHIATRIC  Conversion disorder  Malingering

36 THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES –DERMATOLOGIC  Erythema multiforme –VASCULAR  Henoch-schonlein purpura

37 THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES LIFE OR LIMB-THREATENING CAUSES OF LIMP IN CHILDREN Septic arthritisSCFE OsteomyelitisFracture OsteomyelitisFracture TumorsAppendicitis Testicular torsionDiscitis MeningitisEpidural abscess Developmental dysplasia of the hip

38 CAUSES OF LIMP IN CHILDREN OF ALL AGES ACUTE ACUTE – Contusion –Foreign body –Fracture –Osteomyelitis –Reactive arthritis –Septic arthritis –Transient synovitis –Lyme arthritis –Poor shoe fit CHRONIC CHRONIC –Rheumatic disease  JRA  Acute rheumatic fever  SLE  Inflammatory bowel disease

39 THE CHILD WITH A LIMP SEPTIC ATHRITIS SEPTIC ATHRITIS –Clinical signs/symptoms  Fever  Pain  Decreased ROM  Minor trauma

40 THE CHILD WITH A LIMP SEPTIC ARTHRITIS SEPTIC ARTHRITIS –Clinical signs/symptoms  Toxic or ill appearance  Painful ROM  Joint effusion  Warmth/erythema

41 THE CHILD WITH A LIMP SEPTIC ARTHRITIS SEPTIC ARTHRITIS –Laboratory findings  Elevated WBC count with left shift  Elevated ESR  Elevated CRP  Positive blood culture

42 THE CHILD WITH A LIMP SEPTIC ARTHRITIS SEPTIC ARTHRITIS –Laboratory findings  Synovial fluid analysis –Volume > 3.5 ml –Clarity: opaque –Color: yellow to green –WBC: > 100,000/mm3, >75% PMN’s –Gram stain/Culture: positive –Total protein: 3 – 5 g/dl –Glucose: <25 mg/dl –LDH: variable compared to blood level

43 THE CHILD WITH A LIMP SEPTIC ARTHRITIS SEPTIC ARTHRITIS –Common organisms  Staphylococcus aureus  Beta hemolytic streptococcus  Group A strep  Hemophilus influenzae  Neisseria gonorrhea

44 THE CHILD WITH A LIMP SEPTIC ARTHRITIS SEPTIC ARTHRITIS –Radiologic findings  Plain films: –Soft tissue swelling –Widened joint space –Periosteal reaction of the adjacent bone, suggestive of osteomyelitis

45 THE CHILD WITH A LIMP SEPTIC ARTHRITIS SEPTIC ARTHRITIS –Radiologic findings  Ultrasonography –Increased joint space and amount of joint fluid –Increased vascularity  CT scan –Joint effusion –Increased vascularity –Erosion of the cartillage –Periosteal reaction or osteomyelitis

46 THE CHILD WITH A LIMP SEPTIC ARTHRITIS SEPTIC ARTHRITIS –Radiologic findings  MRI  Radionuclide studies

47 CAUSES OF LIMP IN PRE- SCHOOL CHILDREN ACUTE ACUTE –Fractures  Abusive injuries  Toddler’s fracture  Salter I fractures –Hemarthrosis –HSP –Septic hip –IM shots –Toxic synovitis CHRONIC CHRONIC –Blount disease –Cerebral palsy –Developmental dysplasia of the hip –Discitis –Kohler disease –Leg length discrepancy –Vertical talus

48 CAUSES OF LIMP IN SCHOOL- AGE CHILDREN ACUTE ACUTE –Fractures –Myositis CHRONIC CHRONIC –Legg-calve-Perthes disease –Baker cyst –Kohler disease –Leukemia –Spinal dysraphism (tethered cord) –Tarsal coalition

49 THE CHILD WITH A LIMP LEGG-CALVE-PERTHES DISEASE LEGG-CALVE-PERTHES DISEASE –Idiopathic vascular necrosis of the femoral head –More common in boys –Common in 5 – 9 years old, may affect 2 – 11 years old –Transitional stage of development of the vascular anatomy of the femur

50 THE CHILD WITH A LIMP LEGG-CALVE-PERTHES DISEASE LEGG-CALVE-PERTHES DISEASE –Preceding history of minor trauma –Predisposing factors  SCD  Steroid use  Hip dysplasia

51 THE CHILD WITH A LIMP LEGG-CALVE-PERTHES DISEASE LEGG-CALVE-PERTHES DISEASE –Radiologic studies  Plain films  Radioisotope studies  MRI

52 THE CHILD WITH A LIMP KOHLER DISEASE KOHLER DISEASE –Affects more boys than girls –Most common in 5 – 10 years old, as early as 2 years old –Impaired perfusion to the navicular bone of the talus –Inflammatory changes over the navicular bone

53 THE CHILD WITH A LIMP KOHLER DISEASE KOHLER DISEASE –Treatment  Weight bearing with below the knee cast followed by arch support

54 CAUSES OF LIMP IN ADOLESCENTS ACUTE ACUTE –Sprain –Strain –Tendonitis CHRONIC CHRONIC –Arthritis –Herniated disc –SCFE –Scoliosis –Spinal dysraphism –Spondylolisthesis –Chondromalacia –RSD –Osgood-Schlatter

55 THE CHILD WITH A LIMP OSGOOD-SCHLATTER DISEASE OSGOOD-SCHLATTER DISEASE –Over use injury affecting the insertion site of the patellar tendon on the anterior tibial tubercle –Inflammatory changes over the tubercle –Treatment goal: decrease the stress on the tubercle  Rest  Cast  Excision of an ossicle

56 Surface Anatomy of the Knee

57 Saggital view of the knee

58 Osgood-Schlatter Disease radiographs

59 THE CHILD WITH A LIMP SINDING-JOHANSSON-LARSEN DISEASE SINDING-JOHANSSON-LARSEN DISEASE –Traction tendinitis of the proximal attachment of the patellar tendon (inferior pole of the patella) –Boys more than girls –Age of presentation: 10 –16 years old –Overuse injury, athletes

60 THE CHILD WITH A LIMP SINDING-JOHANSSON-LARSEN DISEASE SINDING-JOHANSSON-LARSEN DISEASE –Radiologic findings  Irregular calcification of the inferior pole of the patella –Treatment  Rest  Cast

61 THE CHILD WITH A LIMP SLIPPED CAPITAL FEMORAL EPIPYSIS (SCFE) SLIPPED CAPITAL FEMORAL EPIPYSIS (SCFE) –Epiphyseal dislocation in superolateral displacement and external rotation of the femoral metaphysis, Salter I injury –Causes kinking of the epiphyseal vessels that leads to compromised blood to the epiphysis

62 THE CHILD WITH A LIMP SCFE SCFE –Incidence  10/ –Boys: 13.5, Girls 8.5/  Regional and seasonal variation  Initial presentation 20% bilateral hip –20 – 40% eventually develop bilateral involvement within 18 months of initial presentation

63 THE CHILD WITH A LIMP SCFE SCFE –Radiologic classification  I: < 33%  II: 33 – 50%  III: > 50%  Displacement in relation to the femoral neck

64 THE CHILD WITH A LIMP Treatment Treatment –Depends on the onset of symptoms and grade –Internal fixation with single cannulated screw –Prophylactic fixation of the unaffected hip –Osteomy of the proximal femur

65 SCFE radiographs

66 THE CHILD WITH A LIMP LABORATORY STUDIES LABORATORY STUDIES –Blood tests  CBC, differential  ESR  CRProtein  Blood culture  Lyme studies  ANA  ASO

67 THE CHILD WITH A LIMP LABORATORY STUDIES LABORATORY STUDIES –Normal synovial fluid characteristics  Highly viscous  Clear  Essentially acellular  Protein concentration is 1/3 of plasma protein  Glucose concentration is similar to plasma

68 THE CHILD WITH A LIMP LABORATORY STUDIES LABORATORY STUDIES –Components of synovial fluid analysis  Clarity  Color  Viscosity  Glucose content  Protein content

69 THE CHILD WITH A LIMP LABORATORY STUDIES LABORATORY STUDIES –Components of synovial fluid analysis  Microscopic examination –WBC count –Crystal search –Gram satin  Culture –Routine bacterial culture –GC culture –Unusual organisms

70 THE CHILD WITH A LIMP RADIOLOGIC TESTS RADIOLOGIC TESTS –Plain radiographs  Affected site  Comparison views  Skeletal survey

71 THE CHILD WITH A LIMP RADIOLOGIC TESTS RADIOLOGIC TESTS –MRI –Radionuclide studies –Ultrasonography –CT scan

72 THE CHILD WITH A LIMP DISPOSITION DISPOSITION –In-patient  IV antibiotics  Diagnostic work-up  Surgical intervention –Out-patient  Observation with close follow up  NSAID’s  Sub-specialty referrals

73 THE CHILD WITH A LIMP DISPOSITION DISPOSITION –Consultation  Orthopedic –Joint aspiration –Surgical intervention  Hematology-Oncology –Bone marrow aspiration –Chemotherapy

74 THE CHILD WITH A LIMP DISPOSITION DISPOSITION –Consultation  Gynecologic –Pelvic examination –Surgical intervention  Urology –Surgical intervention

75 THE CHILD WITH A LIMP DISPOSITION DISPOSITION –Consultation  Neurosurgery  Pediatric or general surgery –Surgical intervention  Infectious disease –Choice of antibiotics –Length of treatment

76 THE CHILD WITH A LIMP DISPOSITION DISPOSITION –Consultation  Rheumatology  Pain specialist  Psychiatry  Physiatry –Physical/occupational therapy –Orthotics

77 THE CHILD WITH A LIMP DISPOSITION DISPOSITION –Diagnoses that require immediate intervention  Septic arthritis  Osteomyelitis  Meningitis  Epidural abscess

78 THE CHILD WITH A LIMP DISPOSITION DISPOSITION –Diagnoses that require immediate intervention  Fractures  Dislocated patella  SCFE  Developmental dysplasia of the hip

79 THE CHILD WITH A LIMP DISPOSITION DISPOSITION –Diagnoses that require immediate intervention  Neoplasms/tumors  Testicular torsion  Appendicitis  PID with tuboovarian abscess  Discitis


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