2Aims and ObjectivesHow to assess the limping child who presents to the GPInvestigationsCommon diagnosesBasic management
3The Limping Child A common reason for a child to present Long list of potential diagnoses, some of which demand urgent treatmentHow do they present?What are the potential diagnoses?How should they be diagnosed and managed?
4Gait DifferencesThe gait of a child is different from that of an adult for the first 3 yrsChildren 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.
5Developmental stages of gait Age (months) Developmental stage10-12 Cruises while holding on to objects12-14 Walks short distances, stands unaided17-21 Walks on 1 foot long enough to walk up steps30-36 Balances on 1 foot for >1s36 Develops sufficient balance to attain a normal gait pattern
6Common Causes 0-3 years old #/soft tissue injury (toddler’s #/NAI) Osteomyelitis or septic arthritisDevelopmental dysplasia of the hip
7Common Causes 3-10 years old Trauma Transient synovitis/irritable hip Osteomyelitis or septic arthritisPerthes disease
8Common causes 10-15 years old Trauma Osteomyelitis or septic arthritis Slipped upper femoral epiphysisChondromalaciaPerthes’
10What questions should you ask? Child presents with a limp
11History – Q’s to ask Duration and progression of limp? Recent trauma and mechanism? Beware limitations of paediatric history, possibility of unintentional traumaAssociated pain and its characteristics?Accompanying weakness?Time of day when limp is worse?Can the child walk or bear weight?
12History – 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 historyAlso include the other essentials— DHx and allergies and FHx
14pGALS Pain or stiffness in joints/mm/back? Gait/general: Temp, observe gait including on tiptoes and heelsArms – N/ALegs: Knee effusion, ‘bend + straighten you knee’ – crepitus?, apply passive flexion (90deg) with internal rotation of hip
15pGALS Spine: observe from behind, ‘can you bend and touch your toes?’ Observe curve of spine from side and behind
17Examination 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)
18Examination 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
19ExaminationMoveAssess ROM, laxity, stiffness with guarding, pain, discomfort, and fluidityAssess gait with the child barefoot.Any discomfort as the child bends downHips: move normally? Internally rotate symmetrically, no pain?
20Don’t forget!Both intra-abdominal pathology and testicular torsion may present simply as a limp – examine abdomen and testicles in boys!!
27Transient SynovitisAcute onset, after a respiratory illness (weak evidence)Affects young children (boys more than girls) most oftenMost common cause of acute hip pain in young children age 3-10Usually unilateralMay refuse to walk/limp
28Transient SynovitisUsually no pain at rest + passive movements only painful at extreme rangesFBC + ESR normal or slightly elevatedXR may be normalUSS may show effusionMain treatment rest + physioNSAIDs useful, can shorten the duration of symptoms in children, usually resolves within 2 weeks
30Septic 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.
32Septic arthritis BCs +ve, raised WCC + CRP XR show delayed changes Bony changes not evident for daysBy 28 days, 90% show some abnormality.About 40-50% focal bone loss is necessary to cause detectable lucency on plain films
33Septic arthritis - MxJoint aspiration is the definitive diagnostic procedure and the most common pathogen isolated is Staph aureusEmergency orthopaedic consultation with subsequent aspiration, arthroscopy, drainage + debridement required.Antibiotics are required as adjunctive treatment.
36Perthes’ diseaseSelf-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 weightshort staturelow socio-economic classpassive smoking.Unilateral in 85% of cases
37Perthes’ disease Presents with pain in hip or knee, causes limp. Pain (often in knee), + effusion (from synovitis).On examination all movements at hip limitedNo 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.
38Perthes’ disease Classic x-ray features: Sclerosis, fragmentation and eventual flattening of the proximal femoral epiphysisAbsent in early diseaseMay be initially misdiagnosed as irritable hip
39Perthes’ diseaseRadionuclide bone scan/MRI helps evaluate for avascular necrosisIf 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 osteotomyDone with or without rotation to redirect the ball of the femoral head into the socket of the acetabulum
42Slipped 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)
43Slipped 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.
44Slipped capital femoral epiphysis XR shows widening and irregularity of the plate of the femoral epiphysis.The displacement of the epiphyseal plate is medial and superiorSurgical pinning of the hip is usually required and should be done quickly.
46DDH Risk Factors Female Breech position Caesarean section 1st child PrematurityOligohydramniosFamily historyClub feet, spina bifida and infantile scoliosis
47DDH Must be detected early Delayed identification leads to more prolonged morbidityClassic screening tests are Barlow and OrtolaniOrtolani assesses if the hip is dislocatedBarlow assesses whether the hip is dislocatable.Asymmetrical skin creases in the thigh or buttockUnequal leg length
48DDH Up to 60% of abnormal hips become normal without Tx after 1mth USS usually doneMx depends on age
49DDH - 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.
50DDH - 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
52NeoplasmOsteogenic sarcoma causes acute unremitting limp/limb pain, often involves the distal femur + proximal tibiaLeukaemia causes ill defined migratory bone or joint pain + generalised weaknessNeuroblastoma can produce nerve impingementAppropriate treatment is multidisciplinary and involves referral to paediatric oncology and orthopaedics.
54Juvenile 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 DxTreatment is multidisciplinary, involves paediatric rheum, ophthal, ortho, rehabilitation specialists + OTs