Presentation on theme: "The Limping Child Chrissie Ashdown. Aims and Objectives How to assess the limping child who presents to the GP Investigations Common diagnoses Basic management."— Presentation transcript:
The Limping Child Chrissie Ashdown
Aims and Objectives How to assess the limping child who presents to the GP Investigations Common diagnoses Basic management
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?
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.
Developmental stages of gait Age (months) Developmental stage Cruises while holding on to objects Walks short distances, stands unaided Walks on 1 foot long enough to walk up steps Balances on 1 foot for >1s 36 Develops sufficient balance to attain a normal gait pattern
Common Causes 0-3 years old –#/soft tissue injury (toddler’s #/NAI) –Osteomyelitis or septic arthritis –Developmental dysplasia of the hip
Common Causes 3-10 years old –Trauma –Transient synovitis/irritable hip –Osteomyelitis or septic arthritis –Perthes disease
Common causes years old –Trauma –Osteomyelitis or septic arthritis –Slipped upper femoral epiphysis –Chondromalacia –Perthes’
What questions should you ask? Child presents with a limp
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?
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
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
pGALS Spine: observe from behind, ‘can you bend and touch your toes?’ Observe curve of spine from side and behind
Look, feel, move
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)
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
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?
Don’t forget! Both intra-abdominal pathology and testicular torsion may present simply as a limp – examine abdomen and testicles in boys!!
Trauma Diagnosis is by plain x ray as a primary investigation. Anteroposterior and lateral views are indicated. A+E usually indicated
Subtle undisplaced spiral # of the tibia Usually pre-school Sudden twist after an unwirnessed fall
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
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
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
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.
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
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.
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
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.
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
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
Slipped Capital Femoral Epipysis
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)
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.
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.
Developmental Dysplasia of the Hip (DDH)
DDH Risk Factors Female Breech position Caesarean section 1st child Prematurity Oligohydramnios Family history Club feet, spina bifida and infantile scoliosis
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
DDH Up to 60% of abnormal hips become normal without Tx after 1mth USS usually done Mx depends on age
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.
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
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.
Juvenile Rheumatoid Arthritis
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
Red flags Child <3y Unable to weight bear Fever Systemic illness >9y with pain or restricted hip movements
Irritable hip v septic arthritis Factors for predicting septic arthritis –Fever >38.5 –Cannot weight bear –ESR>40 in 1 st hr –WCC>12