David C Koronkiewicz, D.O. IU Goshen Orthopedics and Sports Medicine The Limping Child David C Koronkiewicz, D.O. IU Goshen Orthopedics and Sports Medicine I0A 30th Winter Update 12-2-11

Definition Limp = Asymmetry Joint - Range of motion Bone - Deformity Pain Control

The Limping Child Diagnosis Mechanism

The Limping Child Pitfalls Being misled by the parents’ analysis Always a leg length discrepancy Being misled by the patient’s complaint Hip problems can case knee pain Complaints of pain

The Limping Child AGE Pitfalls COMPLAINS 5 LIMPS NEWBORN INFANT TODDLER CHILD PRE-TEEN TEENAGER ADULT Pitfalls Being misled by the parents’ analysis Always a leg length discrepancy Being misled by the patient’s complaint Hip problems can cause knee pain Complaints of pain COMPLAINS 5 LIMPS

The Limping Child Causes of limp -Physical exam Joint - Range of motion Bone - Deformity Pain -Hip Control -Physical exam -X-ray -‘Antalgic’ gait -Abductor lurch

Differential Diagnosis of the Acutely Limping Child Tumor Spinal cord tumors Tumors of bone Benign: osteoid osteoma, osteoblastoma Malignant: osteosarcoma, Ewing's s sarcoma Lymphoma Leukemia Inflammatory Juvenile rheumatoid arthritis Transient synovitis Systemic lupus erythematosus Trauma Fracture Stress fracture Toddler's fracture Soft tissue contusion Ankle sprain Infection Cellulitis Osteomyelitis Septic arthritis Lyme disease Tuberculosis of bone Gonorrhea Postinfectious reactive arthritis

Differential Diagnosis of the Acutely Limping Child Neurologic Cerebral palsy, especially mild hemi paresis Hereditary sensory motor neuropathies   Congenital Developmental dysplasia of the hip Sickle cell Congenitally short femur Clubfoot Developmental Legg-Calvé-Perthes disease Slipped capital femoral epiphysis Tarsal coalitions Osteochondritis dissecans (knee, talus)

Differential Diagnosis of the Acutely Limping Child by Age All Ages Septic arthritis Osteomyelitis Cellulitis Stress fracture Neoplasm (including leukemia) Neuromuscular Toddler (ages 1-3) Septic hip Developmental dysplasia of the hip Occult fractures Leg-length discrepancy

Differential Diagnosis of the Acutely Limping Child by Age Child (ages 4 to 10) Legg-Calvé-Perthes disease Transient synovitis Juvenile rheumatoid arthritis Adolescent (ages 11-16) Slipped capital femoral epiphysis Avascular necrosis of femoral head Overuse syndromes Tarsal coalitions Gonococcal septic arthritis

The Limping Child Too much to cover Hip Best Bets Age

The Limping Child Age 1 – 3 years Age 3 – 6 years Age 6 – 10 years

The Limping Child: Age 1 – 3 Best Bet DDH Developmental Dysplasia of the Hip CDH Congenital Dislocation of the Hip

The Limping Child: Age 1 – 3 DDH Physical findings Girl Asymmetrical skin folds Limited abduction

The Limping Child: Age 1 – 3 DDH Physical findings Short leg Pistoning Ortolani’s sign Barlow’s sign

The Limping Child: Age 1 – 3 DDH Barlow & Ortolani Tests The Limping Child: Age 1 – 3 DDH Feel Clunk Not hear click ! Ortoloni Barlow ( rollout the barrel)

The Limping Child: Age 1 – 3 DDH X-ray findings Delayed appearance of ossific nucleus Small ossific nucleus Dysplastic acetabulum Proximal displacement of femur 42 22

The Limping Child: Age 1 – 3 DDH Pavlik Harness Check at 3 weeks to confirm reduction Adjust position every 1-2 weeks Continue until the hips are clinically and radiolographically normal Treatment 0 – ½: Pavlik harness ½ – 1½: Closed reduction, cast 1 ½ - 5 or 8: Open reduction, pelvic osteotomy Older: Leave dislocated

The Limping Child: Age 3 – 6 2 s Best Bet Transient synovitis Septic arthritis Flu Tonsillitis

The Limping Child: Age 3 – 6 Transient synovitis Child refuses to walk Movement of hip is painful May have fever Moderately elevated WBC Lasts a few days Disappears without treatment

Transient Synovitis Benign, self-limited disorder Associated with recent URI in 32-50% of children 30-40% of all non-traumatic limps Sterile inflammation causing joint effusion Lasts 2-7 days without intervention Male:Female is > 2:1 Ages 2-6 (average 4)

Transient Synovitis Sudden onset of hip pain Don’t forget knee pain!! Afebrile/low-grade fever (<38.5) Usually able to ambulate with a limp Antalgic gait Hip is flexed and externally rotated with mildly decreased ROM 5% bilateral presentation 25% with unilateral presentation with effusion on contralateral hip by ultrasound

Transient Synovitis Laboratory Evaluation WBC count <12,000 Mildly elevated ESR (<40); CRP (<2) X-Ray Joint space widening Discrepancies >2mm between sides Ultrasound: Joint effusion and/or synovial swelling giving an increase in the synovial capsular complex distance Distance btwn the posterior surface of the anterior fibrous joint capsule and the anterior bony surface of the femoral neck Bilateral joint effusions in up to 25% of cases of asymtpmatic contralateral hip J Bone Joint Surg 1999; 81:1662; J Bone Joint Surg 2006; 88A:1253

The Limping Child: Age 3 – 6 WIDENED JOINT SPACE Septic arthritis Child refuses to walk Movement of hip is painful May have fever Elevated WBC Progressively sicker Progressive joint destruction

Transient Synovitis www.emedicine.com/ped/images/1686.JPG

Transient Synovitis Treatment Self-limited after 2-7 days Bed rest Ibuprofen Decreased pain by 2.5 days Vs Placebo Mean duration of pain ibuprofen: 2 days placebo: 4.5 days 80% of all patients with resolution by 7 days Annals of Emergency Medicine 2002; 40:3:297

Transient Synovitis Prognosis Generally good Questionable association with long term increased risk for developing Legg-Calve-Perthes disease (1-2%) Recurrance in 4-15% have been reported

Septic Arthritis Medical Emergency Single most important prognostic factor for a good outcome is early treatment!!! Direct entry of bacteria into the joint S/p puncture injury; hematogenous; contiguous Hematogenous osteomyelitis spread is most common in neonates/infants Blood vessels traverse from the metaphysis to the epiphysis in infants. Physis formation disrupts this connection >50% of neonates with osteomyelitis have associated septic arthritis

Septic Arthritis Most common organism: Staph aureus Neonates: group B strep; gram (-) bacilli Adolescent: Neisseria gonorrhoeae Sickle Cell Disease: Salmonella Acute inflammatory response TNF-alpha, IL-1, proteases: destroy the articular cartilage Continues after eradication of the bacteria Associated with high risk of avascular necrosis of the hip Joint pressure compressing the blood vessels supplying the cartilage and femoral head

Septic Arthritis Fetal breech presentation predisposes to sebsequent development of septic arthritis of the hip. The Pediatric Infectious Disease Journal 2005; 24:650-652 Propensity for group B strep osteomyelitis to involve the right proximal humerus in infants J Pediatrics 1978; 93:578-583

Septic Arthritis Usually in previously healthy children < 5 years Early peak in the first months of infancy 1/3 of pts with URI’s within the past month Acute painful joint with erythema, warmth, swelling and pain on passive movement (knee) Up to 8% is multifocal Fever > 38.5 Usually unable to bear weight Antalgic gait present if able to bear weight Knee is most common joint Hip, ankle, wrist, elbow, shoulder

Septic Arthritis Septic arthritis of the hip DOES NOT present with erythema, warmth or swelling Hip is flexed in external rotation and abduction Relieves intracapsular pressure Infants often present with paradoxical irritability, malaise and/or pseudoparalysis of the affected limb Gentle motion aggravates Vs soothes Do not necessarily have fevers

Septic Arthritis Elevated WBC, ESR, CRP CRP accurate negative predictor of disease Inc. dramatically within 6 hrs after a trigger Peaks on D#2 and resolves by D# 7-10 Blood Culture positive in 40-50%+

Septic Arthritis Aspiration of the hip: definitive diagnosis Cloudy, turbid WBC count >50,000; predominately neutrophils Glucose levels < ½ of serum levels 50% with positive gram stain 50-70% with positive culture Specific media needed to isolate N. gonorrhoeae

The Limping Child: Age 3 – 6 Septic Arthritis Bacteria White cells Enzymes Enzymes Destroy cartilage Irreversable joint damage

Septic Arthritis Radiographic Findings Xray findings seen 10 days into disease Osteopenia, marked joint space loss, soft-tissue swelling Ultrasound (both hips) Visualize joint effusions at onset CT/MRI Good to r/o abscesses and assess for concurrent osteomyelitis

Septic Arthritis Antibiotic Treatment Age Organism Antibiotics <12 mos staphylococcus, group B streptococcus, and gram-negative bacilli 1st generation cephalosporin 6 mos. to 5 yrs S. aureus,S. pneumonae, Group A streptococcus, H influenzae 2nd or 3rd generation cepahlosporin 5-12 yrs S. aureus 1st generatin cephalosporin 12-18 yrs. N. gonorrhoeae, S. aureus oxacillin/cephalosporin

Septic Arthritis Treatment IV antibiotics times 2-4 weeks Can change to PO if clinically imp with normalizing ESR/CRP on IV therapy, but NOT with septic arthritis of the hip Joint drainage Low-dose dexamethasone for 4 days Pediatric Infectious Disease Journal 2003;22:883-888

The Limping Child: Age 3 – 6 Septic Arthritis Treatment Kill the bacteria Antibiotics Eliminate the white cells Incision and drainage Don’t delay 48 hour window

Septic Arthritis Prognosis Good outcome Poor outcome Initiation of treatment within 4 days of symptom onset Poor outcome Initiation of treatment after 5 or more days Severe joint destruction: osteonecrosis Lifelong joint pain increased after activities Decreased ROM Leg length discrepancies Lifelong limp

Septic Arthritis Vs Transient Synovitis Caird et al. Journal of Bone and Joint Surgery. 2006 CHOP Prospective study WBC> 12,000/mm3 ESR> 40 mm/hr CRP> 2 mg/dL Temp> 38.5 Oral Refusal to bear weight Kocher et al. Journal of Bone and Joint Surgery. 1999 Boston Children’s Retrospective study WBC> 12,000/mm3 ESR> 40 mm/hr Temp > 38.5 Oral Refusal to bear weight

Septic Arthritis Vs Transient Synovitis Individual Factor results: No child with a temperature >38.5 was found to have transient synovitis CRP > 2mg/dL was the only independent risk factor strongly associated with septic arthritis after backward elimination 86% of patients with ESR < 40 mm/hr had transient synovitis 71% of patients with CRP < 2mg/dL or WBC < 12,000/mm3 had transient synovitis

The Limping Child: Age 3 – 6 Transient Synovitis vs. Septic Arthritis How to tell the difference? Four predictors History of fever Refusal to weight-bear ESR > 40 mm/hr WBC > 12,000 If in doubt Review in 12 hours Do incision and drainage! Kocher, Kasser, et al. JBJS 86-A: 1629, 2004

The Limping Child: Age 3 – 6 Septic Arthritis The Worst Scenario Destruction of articular cartilage Destruction of femoral head Destruction of femoral neck

The Limping Child: Age 3 – 6 Septic Arthritis

The Limping Child: Age 6 - 10 3 Best Bet Legg-Calvé-Perthes Disease

Legg-Calve-Perthes Disease Avascular necrosis of the capital femoral epiphysis. Hypothesized to arise from repeated interruptions of the vascular supply to the femoral head. Male:Female is 4:1. Most common between 4-10 years of age. 10% of cases are familial Present with limp (most common presentation) with decreased internal rotation of the hip.

Legg-Calve-Perthes Disease Positive Trendelenburg test. Pelvic tilt (affected side is lower) when standing on the affected leg. Pain can radiate to hip, thigh or knee. often insidious and can lead to disuse of affected limb

The Limping Child: Age 6 – 10 Perthes Disease Physical findings Boy Limp Antalgic gait Pain with passive motion Limited abduction Positive Trendelenburg sign

The Limping Child: Age 6 – 10 Perthes Disease X-ray findings Perhaps nothing MRI Irregular consistency Flattening Lateral bump/ridge Lateral hinging

Legg-Calve-Perthes 4 Distinct Radiographic Stages Synovitis/Necrosis: Initial joint space widening and irregularity of the physis. Ischemia of the epiphysis resulting in dead bone. Ave age 5.6 years Fragmentation. Fracturing of the weakened demineralized epiphysis. Epiphysis may collapse resulting in a shortened limb. Ave age 6.1 years

Legg-Calve-Perthes 4 Distinct Radiographic Stages (cont.) Re-ossification. Begins at the margins of the epiphysis. Ave age 7 years Remodeling. Newly formed head is soft. At risk for poor prognosis if not allowed to heal. Ave age 9.1 years MRI better at detecting early disease

Legg-Calve-Perthes                                                                                             radiology.creighton.edu/.../case19/index.htm

Legg-Calve-Perthes

Legg-Calve-Perthes Revascularization phase Avascular phase

Legg-Calve-Perthes Bilateral disease in up to 24% of cases Contralateral hip usually involved within 3 years of disease onset, but can present after 5 years 1/3 of cases present with BIL hip involvement in the same stage Questions the previously held belief that the disease in one hip puts the contralateral hip at risk Retrospective review J Pediatric Orthopaedics 2002; 22:458-463 Girls more likely to have bilateral disease

Legg-Calve-Perthes Treatment 50% recover without treatment Maintaining containment of the femoral head within the acetabulum Abduction splints/casts and non-weight bearing state Surgically with an osteotomy of the proximal femur

Legg-Calve-Perthes Prognostic factors Better prognosis if child presents before 6 years of age: extended period of time allowed for remodeling Obesity is associated with a poor prognosis Extent of epiphyseal necrosis present: <50% necrosis with better outcome Bilateral disease not associated with a worse prognosis

The Limping Child: Age 6 – 10 Perthes Disease

The Limping Child: Age 6 – 10 Perthes Disease 50% need a Total Hip by age 50

Legg-Calve-Perthes Natural history of early onset LCP disease. These radiographs were taken at age 2, 3, 5, 8 and 15 years. Courtesy of "Fundamentals of Pediatric Orthopedics", 2003, Lippincott Williams & Wilkins ©

The Limping Child: Age 10 – 14 Best Bet Slipped Capital Femoral Epiphysis (SCFE – sciffey)

Slipped Capital Femoral Epiphysis Non-inflammatory condition Femoral head displaced posteriorly from the femoral neck Age of onset: 10-17 years Overweight boys (1.5M:1F) African Americans>whites, hispanics

Slipped Capital Femoral Epiphysis Associated with endocrinopathies (growth hormone deficiency) in 8% If presenting under 10 years of age, hx of short stature or hypogonadism: endocrine evaluation

Slipped Capital Femoral Epiphysis Preceding history of trauma with acute pain/limp Subacute or chronic pain with insidious onset that can be referred to the hip or knee Pain increased with physical activity

Slipped Capital Femoral Epiphysis Examination Limb is held slightly flexed and externally rotated Often unable to fully flex hip Limited internal rotation and abduction of the hip Limited passive ROM secondary to pain Bilateral in up to 30% Positive Trendelenburg test

Slipped Capital Femoral Epiphysis Radiography X-ray of both hips Mild, moderate or severe depending on degree of femoral head slip compared to the femoral head diameter (<1/3=mild; 1/3-2/3=moderate; >2/3=severe)

Xray Findings Displacement of neck on head Mainly anterior Somewhat superior Decreased projected femoral head height Chronicity Inferior new bone Superior rounding off of metaphysis Curved neck

Slipped Capital Femoral Epiphysis Klein’s line

Slipped Capital Femoral Epiphysis

Slipped Capital Femoral Epiphysis

Slipped Capital Femoral Epiphysis                                                              www.pedsortho.ca/images/scfe.JPG

The Limping Child: Age 10 – 14 SCFE Always get a frog lateral view Always check the other side

CastroAP

The Limping Child: Age 10 – 14 SCFE Pediatric orthopaedic surgeons See 6 per year General orthopaedic surgeons See 1 every 6 years Same as fixing a fracture

The Limping Child: Age 10 – 14 SCFE Classification Acute or chronic Acute on chronic Stable or unstable Severity of displacement Slip angle Bilaterality 10 – 15% at presentation

Useful Classification Stable Walks in Unstable Wheels in No reduction One screw Bone in one piece Slow plastic deformation of the growth plate Closed reduction Two screws Bone in two pieces Physeal fracture

Slipped Capital Femoral Epiphysis Treatment Non-weight bearing with crutches to prevent further slip Surgical fixation Prognosis Usually good prognosis Increased risk of subsequent acute chondrolysis or avascular necrosis of the hip

Fixation SCFE

Fixation SCFE

The Contralateral Hip Out of 100 patients: 10 are bilateral at presentation 10 will slip on the other side later 5 will have painless slips on the other side

Follow-up for Bilaterality Follow radiolographically Every three months For 18 months Screw removal- controversial

Best Bets The Limping Child Age 1 – 3 years - DDH Age 3 – 6 years - Septic arthritis Age 6 – 10 years - Perthes Disease Age 10 – 14 years - SCFE Best Bets

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