1. The limping child an orthopedic perspective
Devin Peterson, MD, FRCSC, Dip Sport Med
Associate Professor, McMaster University
McMaster University Medical Centre
David Braley Sport Medicine & Rehabilitation Centre

2. Faculty/Presenter Disclosure
Faculty: Devin Peterson
Program: 51st Annual Scientific Assembly
Relationships with commercial interests:
None 2

3. Disclosure of Commercial Support
This program has received no financial support
This program has received no in-kind support
Potential for conflict(s) of interest:
None 3

4. Mitigating Potential Bias
N/A 4

5. objectives To assess and diagnose common causes of childhood limping
To understand the management principles of the limping child including timely referral

6. Normal Gait
Smooth energy-efficient transfer of the body through space

8. Limp: “to walk with a halting or irregular step”
Funk & Wagnall's

9. Pathological Gaits

10. Antalgic Gait: body’s effort to compensate for pain or instability in the stance-phase limb by minimizing the duration and magnitude of loading

11. Trendelenburg Gait: leaning of the head and trunk toward the lower extremity affected by the pathology
Pain
Weakness in the hip muscles

12. Common causes of limping seen in early childhood

13. 19 month old female referred because of limping

14. Fifth born
Normal delivery/presentation
Walking at 14 months
Always limped
No pain
Healthy
Negative Family history

15. Differential diagnosis
Top three:
Hip dysplasia
Neuromuscular disease
Leg length discrepancy

17. Developmental Dysplasia of the Hip (DDH)

18. Dislocated: Dislocatable Subluxed Subluxable Dysplastic
the femoral head is not in contact with the acetabulum
Dislocatable
the femoral head is within the acetabulum but can be forced out
Subluxed
the femoral head is within the acetabulum but not in its proper position
Subluxable
the femoral head can be moved beyond its physiologic limits within the acetabulum
Dysplastic
although the femoral head is in the proper position the acetabulum or head are abnormally developed

19. History
Risk Factors
Female
Firstborn
Breech
Large baby
Low amniotic fluid
Family history

20. Physical
Associated Conditions
Foot deformity, Torticollis
Neuromuscular disorders
Syndromes
Hip Examination
Trendelenburg gait
Skin folds
Galeazzi sign
Abduction
Provocative maneuvers
Ortolani, Barlow

21. Imaging
Ultrasound
< 6 months
X-ray

23. Treatment URGENT REFERRAL Pavlik Harness Closed Reduction Safe Zone
Open reduction
Extra-articular blocks
Intra-articular blocks
Osteotomies
Pelvic
Femoral + Shortening

24. Transient synovitis Most common cause of hip pain in childhood
3% childhood risk
Idiopathic
Frequently associated with concurrent or antecedent illness
Right hip = left hip
NEVER BILATERAL
2:1 male:female

25. History
Age varies (9 months to adolescence)
Most between 3 and 8 years old
Unilateral hip pain
Can present with knee or thigh pain
Limp vs non-weight bearing

26. Physical
May have a low grade temperature
Antalgic or Trendelenburg gait
Flexed and externally rotated position
Decreased ROM
Especially abduction and internal rotation
Laboratory tests
Non-specific

27. Imaging
Radiographs usually normal
Ultrasound may show effusion
Diagnosis of exclusion

28. Treatment
urgent referral
Differential includes a septic joint
Self limiting disorder
May have symptoms for up to 10 days or longer
Bed rest until full ROM, no pain, limp free
Crutches for older patients
NSAIDS
Gradual return to activity

29. Legg-Calve-Perthes Disease (perthes)

30. Self limiting hip disorder
Caused by ischemia and subsequent necrosis of the femoral head
Usually 4 to 8 years of age
Male to female ratio:
4-5 to 1
Usually unilateral (88%)
Age and lateral head involvement are the key to prognosis
8 years of age seems to be the watershed
<50% of lateral pillar involvement better prognosis

31. Differential Diagnosis
Unilateral Perthes:
septic arthritis
sickle cell disease
spondyloepiphyseal dysplasia tarda
Gaucher’s disease
Bilateral Perthes:
Hypothyroidism
Multiple epiphyseal dysplasia

32. History
May be painless at first
present with a limp only
symptoms occur with subchondral collapse/fracture
Can present with knee or thigh pain
Positive family history 1.6% – 20%
1% - 3% of patients with transient synovitis will develop Perthes

33. Physical Imaging gait: Trendelenburg
decreased abduction/ internal hip rotation
thigh, calf, and buttock atrophy
LLD
Imaging
X-ray, bone scan, MRI

34. Treatment
Timely referral
Principles of treatment are maintenance of ROM & containment (good coverage of the head by the acetabulum) of the femoral head through the evolution of healing
May be obtained by non-operative means
relative rest
pain control
physiotherapy
traction
abduction splinting at night

35. Operative Treatments Containable Hip adductor release
Femoral varus/pelvic osteotomies
Non-Containable Hip
Hip/Late-presenting patient with deformity
Hinge abduction
Chiari/lateral shelf
Cheilectomy
Femoral abduction/extension osteotomy
OCD, non-operative, revascularization, removal, ORIF

36. Discoid Meniscus First description: Young 1889
3-5% in general population have a larger than normal meniscus
Almost all in lateral, but reported in medial
20% bilateral and 10% associated with OCD of lateral femoral condyle

37. Anatomy Three Segments Anterior horn Body Posterior horn
Attached to tibial plateau, primarily through Coronary Ligament
Figure 1
Attached to the capsule except at popliteal hiatus

38. Diagnosis Clinical Presentation History: Asymptomatic
“Snapping knee syndrome”
Meniscal tear symptoms
Physical:
Snapping knee with gait
Meniscal signs

39. X-ray
Widened lateral joint space, squaring of lateral femoral condyle, cupping of lateral tibial plateau
MRI
Verify diagnosis and assess damage

40. Treatment Options Asymptomatic: observe Symptomatic:
TIMELY REFERRAL UNLESS LOCKED KNEE THEN URGENT
Non-operative: restricted activity, bracing, physiotherapy
Operative:
Partial meniscal “saucerization”
Repair of tear

41. Common causes of limping seen in LATE childhood

42. Apophyseal Conditions

43. Apophysitis of the Hip and Pelvis
Sinding-Larsen-Johansson: inferior pole of patella
Osgood-Schlatter Disease: tibial tuberosity disturbance
Sever Disease: calcaneal apophysitis
Iselin Disease: apophysitis of the fifth metatarsal

44. Osgood Schlatter Disease
Tibial tuberosity disturbance
Partial avulsion (microscopic fractures) of the ossification center and overlying hyaline cartilage
Epidemiology
10 – 15 years old
Boys > girls
> 10% of teenagers

45. History
Pain localized to tubercle
Worse with direct blows to the are and activity
Physical
Antalgic gait may be present
Prominent tubercle + local swelling
Tenderness localized to tubercle

46. Lovell and Winter’s Pediatric Orthopaedics 5th edition

47. Treatment
Spontaneous resolution at maturity
20% may have pain with kneeling
surgery for loose ossicles
Reassurance
Symptomatic treatment/activity modification
NSAIDS, stretching, knee pads/braces, foot orthosis, casts
TIMELY REFERRAL

48. Osteochondritis dissecans (OCD)

49. Introduction
Acquired potentially reversible lesion of subchondral bone resulting in delamination and sequestration with or without articular cartilage involvement and instability
Juvenile and Adult forms
Adult form is typically progressive and unremitting
May occur in almost any joint in upper or lower extremity
Very common in the knee

50. Epidemiology 15-29 per 100,000 May be bilateral in 25% of cases
Male: female ratio
5:3
>70% are in the classical area
Posterolateral aspect of the medial femoral condyle

51. Etiology Idiopathic Theories include: Genetics Inflammation Ischemia
Ossification
Repetitive trauma (stress reaction causing a stress fracture in the underlying subchondral bone)

52. Clinical Presentation
Physical
Antalgic gait
Effusion
Crepitus
Painful ROM
Quads atrophy
Maximum tenderness usually anteromedial knee
Wilson sign
Pain with internal tibial rotation
History
Juvenile
Poorly localized pain
Exacerbated by exercise
May present with symptoms of instability (swelling, stiffness, catching, locking)
Limp

53. Diagnostic Studies X-rays AP Lateral Notch MRI + gadolinium
Lesion size
Status of the cartilage and subchondral bone
Bone edema and high signal zone beneath fragment
Loose bodies
Technetium bone scan

56. Management Nonoperative Open physis = good prognosis?
Activity modification
Immobilization?
Rehabilitation
Local and systemic pain management
Review every 3-6 months or sooner if symptoms worsening
Repeat MRI every 6 months?
TIMELY REFERRAL if no improvement or worsening, URGENT IF LOCKED KNEE

57. Operative
Indications
Lesions not responding to nonoperative management
Unstable lesions?
Detached lesions

58. The Painful flatFOOT: tarsal coalition

59. HISTORY
Tarsal coalition is an abnormal connection between some of the tarsal bones
May be painful
Can be associated with increased ankle sprains

60. physical Gait Antalgic Flexibility Toe standing Sitting/supine
Subtalar ROM

61. Flexible Flatfoot
Arch returns with sitting or tiptoe standing
Normal subtalar and midtarsal motion

62. Tarsal Coalition
Arch may not return with sitting or tiptoe standing
May be painful to move or palpate subtalar joint or other tarsal bones
Subtalar motion often decreased

63. imAGING Normal in flexible flatfoot
Oblique views and Harris view may help view a coalition
May need an MRI or CT to make diagnosis

64. TREATMENT Tarsal Coalition TIMELY REFERRAL Rest/activity modification
Antiinflammatories
Physiotherapy?
Orthotics
Casts
Surgery: resection or fusion

65. Slipped Capital Femoral Epiphysis (SCFE)

66. The slip normally occurs during adolescent growth phase
Mechanical or systemic factors may be present
Commonly obese
Endocrinopathies (eg. 1o & 2o hypothyroidism, panhypopituitarism, GH, hypogonadal conditions, & renal osteodystrophy

67. Male > female
Left > right
Bilateral involvement may occur
Second slip presents within 18 months in 88%

68. History Chronic and/or acute Limp
May present with knee or thigh pain instead of hip/groin pain

69. Physical
Gait: Trendelenburg
Shortened/external rotation
Decreased abduction/internal hip rotation
Passive flexion leads to thigh abduction and external rotation
Imaging
X-ray, CT, MRI

70. X-rays Physeal plate widening & irregularity
Decrease in epiphyseal height
Blanch sign of Steel
Crescent-shaped area of increased density in the proximal femoral neck
Femoral metaphysis appears laterally displaced
Klein’s line
Southwick angles

71. Imaging
Frog-leg lateral
avoid in acute situation
Cross-table lateral

72. Treatment - Acute Prophylactic Pinning EMERGENT REFERRAL
Immediate bed rest
Insertion of one or more screws
in situ fixation
Designed to fuse the epiphysis on the metaphysis to prevent further slipping
Prophylactic Pinning
Known metabolic/endocrine disorders?
Inability to follow-up

73. Stress fractures

74. Stress fractures Stress Fractures in Skeletally Immature Patients
Walker et. al.: JPO 1996
34 stress fractures
Tibia (47%), fibula, femur, radius, humerus, MT

75. History
Pain often associated with an increase in activity
Be wary of female triad
Physical
Antalgic gait may be present
Tenderness localized

76. Radiographs
Rapid bony response may be present
Bone Scan
Helpful in questionable situations
Treatment (depends on causative factors)
Urgent referral
Modification of activities
Immobilization

77. Common causes of limping seen at various ages

78. Bone and soft tissue Tumors

79. Bone and Soft Tissue Tumors
History
Pain
Night pain
History of trauma may delay diagnosis
Osteoid Osteoma pain relieved by NSAIDs
Constitutional Symptoms
Fever, night sweats, anorexia, weight loss
eg. Ewing sarcoma
Soft tissue mass may not be symptomatic

80. Physical Exam
Gait disturbance
Muscle atrophy
Neurovascular exam
Range of motion
Mass
Size, tenderness, pulsation, mobility, bruits, tenderness, erythema, consistency
Lymph nodes

81. Investigations
Bloodwork
CBC, ESR, CRP, serum alkaline phosphatase, serum and urine calcium & phosphorus, LDH
Imaging
X-ray
Bone Scan
CT/MRI

82. Management
Referral
Urgency dependent on tumor type

83. Septic joints

84. History
Pain
Refusal to bear weight
Limping
Recent illness
Decreased immunity
eg. chickenpox
Trauma

85. Physical Exam
Temperature
Antalgic gait
Disuse of a part
Erythema/swelling
Tenderness
Decreased ROM

86. Laboratory tests
CBC
WBC
CRP
ESR
Blood cultures
Aspirates (Gram stain, Culture)
Imaging
X-rays
Ultrasound
Bone Scan CT
MRI

87. Treatment
Emergent referral
Stop tissue destruction ASAP
Decrease bacterial load and irrigation of the joint
Identify the Organism
Select appropriate antibiotic