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

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

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

Mitigating Potential Bias N/A 4

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

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

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

Pathological Gaits

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

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

Common causes of limping seen in early childhood

19 month old female referred because of limping

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

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

Developmental Dysplasia of the Hip (DDH)

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

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

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

Imaging Ultrasound < 6 months X-ray

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

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

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

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

Imaging Radiographs usually normal Ultrasound may show effusion Diagnosis of exclusion

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

Legg-Calve-Perthes Disease (perthes)

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

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

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

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

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

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

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

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

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

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

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

Common causes of limping seen in LATE childhood

Apophyseal Conditions

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

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

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

Lovell and Winter’s Pediatric Orthopaedics 5th edition

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

Osteochondritis dissecans (OCD)

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

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

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

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

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

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

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

The Painful flatFOOT: tarsal coalition

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

physical Gait Antalgic Flexibility Toe standing Sitting/supine Subtalar ROM

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

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

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

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

Slipped Capital Femoral Epiphysis (SCFE)

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

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

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

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

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

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

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

Stress fractures

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

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

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

Common causes of limping seen at various ages

Bone and soft tissue Tumors

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

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

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

Management Referral Urgency dependent on tumor type

Septic joints

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

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

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

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