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THE CHILD WITH A LIMP Madesa Espana, MD, FAAP
Pediatric Emergency Medicine St. Joseph’s Regional Medical Center Paterson, New Jersey
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LIMP An uneven, jerky or laborious gait, usually caused by pain, weakness or deformity. 4/1000 visits in a pediatric ED
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A CHILD WITH A LIMP Epidemiology Median age: 4 years old
Male:female ratio: 2:1 Most common diagnosis: Transient synovitis Pain is present in 80% of cases Localization: hip and knee Benign cause: 77%
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THE CHILD WITH A LIMP HISTORY Duration Trauma Fever
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THE CHILD WITH A LIMP HISTORY Location of the pain
Pain characteristics Constant severe pain Intermittent mild to moderate pain Bilateral pain Modifying factors
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THE CHILD WITH A LIMP HISTORY Other symptoms Morning stiffness
Incontinence, weakness or sciatica Recent viral or bacterial illness Recent medications Endocrine and other systemic diseases
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THE CHILD WITH A LIMP PHYSICAL EXAMINATION General appearance
Ill or toxic appearing Fever Obvious discomfort/pain at rest
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THE CHILD WITH A LIMP PHYSICAL EXAMINATION Gait evaluation
Phases of a gait Stance: time when the foot is in contact with the surface Heel-strike to toe flat (contact) Foot-flat to heel-off (mid-stance) Heel-lift to toe off (propulsion) Swing: time from toe-off to heel strike
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THE CHILD WITH A LIMP PHYSICAL EXAMINATION
Young child (<4 years) vs. adult gait Increased flexion of the hips, knees and ankles Rotation of the feet externally, wider base of support Faster cadence, slower velocity, shorter stride length Smaller percentage of the gait cycle is spent in single limb stance
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THE CHILD WITH A LIMP PYSICAL EXAMINATION Gait examination
Expose the legs Bare feet or wearing only a pair of socks Listening to the gait Cadence Foot slap Scraping
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THE CHILD WITH A LIMP PHYSICAL EXAMINATION Gait examination
Observe several gait cycles Includes jumping/hopping
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Gait evaluation
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THE CHILD WITH A LIMP PHYSICAL EXAMINATION Musculoskeletal
Muscle strength Muscular atrophy Bony tenderness Bony deformity
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THE CHILD WITH A LIMP PHYSCIAL EXAMINATON Musculoskeletal
Active and passive ROM Joint swelling/tenderness Muscle tenderness Tenderness on the tendons, insertions sites
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THE CHILD WITH A LIMP PHYSICAL EXAMINATION Musculoskeletal
Back and spine Hip Thigh Knee Leg Ankle Foot
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THE CHILD WITH A LIMP PHYSICAL EXAMINATION Musculoskeletal
Limb length discrepancy Hip rotation Galeazzi test Trendelenburg test FABERE test
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THE CHILD WITH A LIMP PHYSICAL EXAMINATION Skin Bruises
Rashes and other lesions Swelling Redness Tenderness
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THE CHILD WITH A LIMP PHYSICAL EXAMINATION Lymphatic Lymphadenopathy
Localized vs. systemic Lymphadenitis Lymphangitis
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THE CHILD WITH A LIMP PHYSICAL EXAMINATION Neurologic Muscle strength
Muscle tone DTR’s
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THE CHILD WITH A LIMP PHYSICAL EXAMINATION Gastroentestinal
Abdominal tenderness Abdominal swelling Genitourinary Testicular or scrotal pain/swelling Inguinal swelling
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THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES Age of the child
Location of abnormal findings Duration of symptoms Type of gait abnormality
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THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES OSSEOUS Fractures
Salter-Harris or growth plate injuries Toddler’s: tibia, calcaneous and cuboid Stress Incomplete: buckle, greenstick Complete Plastic or bowing deformity Avulsion Child abuse: bucket-handle fractures
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THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES OSSEOUS Apophysitis
Sinding-Larsen-Johnson disease Kohler disease Sever disease Freiberg disease Osgood-schlater disease
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THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES OSSEOUS
Vasoocclussive crisis of SCD Slipped capital femoral epiphysis Legg-Calve-Perthes disease
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THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES TUMORS Leukemia Lymphoma
Spinal cord tumor Osteogenic sarcoma Ewing’s sarcoma Osteoid sarcoma Metastatic neuroblastoma
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THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES ARTICULAR
Transient synovitis of the hip Septic arthritis Osteochondritis dessicans Acute rheumatic fever Juvenile rheumatoid arthritis
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THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES ARTICULAR Serum sickness
Discitis Developmental dysplasia of the hip Chondromalacia of the patella Hemarthrosis: traumatic, hemophilia
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THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES ARTICULAR
Henoch-Schonlein purpura Lyme disease SLE Patellar dislocation
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THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES SOFT TISSUE Contusion
Muscle strain Sprain Tendonitis Viral myositis Foreign body
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THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES SOFT TISSUE Cellulitis
Abscess Pyomyositis IM vaccination Insect envenomation Plantar warts
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THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES SOFT TISSUE Bunion
Ingrown toenail Baker’s cyst rupture Myositis ossificans Bursitis Benign hypermobility syndrome
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THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES NEUROLOGICAL
Meningitis/Intracranial abscess Cerebral palsy Peripheral neuropathy Epidural abscess Spinal cord tumor Complex regional pain syndrome (reflex sympathetic dystrophy)
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THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES INTRA-ABDOMINAL
Appendicitis PID Pelvic abscess Psoas abscess Perirectal abscess Iliac adenitis
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THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES GENITO-URINARY
Incarcerated inguinal hernia Testicular torsion STD’s
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THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES PSYCHIATRIC
Conversion disorder Malingering
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THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DERMATOLOGIC VASCULAR
Erythema multiforme VASCULAR Henoch-schonlein purpura
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THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES
LIFE OR LIMB-THREATENING CAUSES OF LIMP IN CHILDREN Septic arthritis SCFE Osteomyelitis Fracture Tumors Appendicitis Testicular torsion Discitis Meningitis Epidural abscess Developmental dysplasia of the hip
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CAUSES OF LIMP IN CHILDREN OF ALL AGES
ACUTE Contusion Foreign body Fracture Osteomyelitis Reactive arthritis Septic arthritis Transient synovitis Lyme arthritis Poor shoe fit CHRONIC Rheumatic disease JRA Acute rheumatic fever SLE Inflammatory bowel disease
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THE CHILD WITH A LIMP SEPTIC ATHRITIS Clinical signs/symptoms Fever
Pain Decreased ROM Minor trauma
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THE CHILD WITH A LIMP SEPTIC ARTHRITIS Clinical signs/symptoms
Toxic or ill appearance Painful ROM Joint effusion Warmth/erythema
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THE CHILD WITH A LIMP SEPTIC ARTHRITIS Laboratory findings
Elevated WBC count with left shift Elevated ESR Elevated CRP Positive blood culture
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THE CHILD WITH A LIMP SEPTIC ARTHRITIS Laboratory findings
Synovial fluid analysis Volume > 3.5 ml Clarity: opaque Color: yellow to green WBC: > 100,000/mm3, >75% PMN’s Gram stain/Culture: positive Total protein: 3 – 5 g/dl Glucose: <25 mg/dl LDH: variable compared to blood level
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THE CHILD WITH A LIMP SEPTIC ARTHRITIS Common organisms
Staphylococcus aureus Beta hemolytic streptococcus Group A strep Hemophilus influenzae Neisseria gonorrhea
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THE CHILD WITH A LIMP SEPTIC ARTHRITIS Radiologic findings
Plain films: Soft tissue swelling Widened joint space Periosteal reaction of the adjacent bone, suggestive of osteomyelitis
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THE CHILD WITH A LIMP SEPTIC ARTHRITIS Radiologic findings
Ultrasonography Increased joint space and amount of joint fluid Increased vascularity CT scan Joint effusion Erosion of the cartillage Periosteal reaction or osteomyelitis
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THE CHILD WITH A LIMP SEPTIC ARTHRITIS Radiologic findings MRI
Radionuclide studies
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CAUSES OF LIMP IN PRE-SCHOOL CHILDREN
ACUTE Fractures Abusive injuries Toddler’s fracture Salter I fractures Hemarthrosis HSP Septic hip IM shots Toxic synovitis CHRONIC Blount disease Cerebral palsy Developmental dysplasia of the hip Discitis Kohler disease Leg length discrepancy Vertical talus
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CAUSES OF LIMP IN SCHOOL-AGE CHILDREN
ACUTE Fractures Myositis CHRONIC Legg-calve-Perthes disease Baker cyst Kohler disease Leukemia Spinal dysraphism (tethered cord) Tarsal coalition
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THE CHILD WITH A LIMP LEGG-CALVE-PERTHES DISEASE
Idiopathic vascular necrosis of the femoral head More common in boys Common in 5 – 9 years old, may affect 2 – 11 years old Transitional stage of development of the vascular anatomy of the femur
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THE CHILD WITH A LIMP LEGG-CALVE-PERTHES DISEASE
Preceding history of minor trauma Predisposing factors SCD Steroid use Hip dysplasia
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THE CHILD WITH A LIMP LEGG-CALVE-PERTHES DISEASE Radiologic studies
Plain films Radioisotope studies MRI
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THE CHILD WITH A LIMP KOHLER DISEASE Affects more boys than girls
Most common in 5 – 10 years old, as early as 2 years old Impaired perfusion to the navicular bone of the talus Inflammatory changes over the navicular bone
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THE CHILD WITH A LIMP KOHLER DISEASE Treatment
Weight bearing with below the knee cast followed by arch support
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CAUSES OF LIMP IN ADOLESCENTS
ACUTE Sprain Strain Tendonitis CHRONIC Arthritis Herniated disc SCFE Scoliosis Spinal dysraphism Spondylolisthesis Chondromalacia RSD Osgood-Schlatter
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THE CHILD WITH A LIMP OSGOOD-SCHLATTER DISEASE
Over use injury affecting the insertion site of the patellar tendon on the anterior tibial tubercle Inflammatory changes over the tubercle Treatment goal: decrease the stress on the tubercle Rest Cast Excision of an ossicle
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Surface Anatomy of the Knee
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Saggital view of the knee
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Osgood-Schlatter Disease radiographs
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THE CHILD WITH A LIMP SINDING-JOHANSSON-LARSEN DISEASE
Traction tendinitis of the proximal attachment of the patellar tendon (inferior pole of the patella) Boys more than girls Age of presentation: 10 –16 years old Overuse injury, athletes
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THE CHILD WITH A LIMP SINDING-JOHANSSON-LARSEN DISEASE
Radiologic findings Irregular calcification of the inferior pole of the patella Treatment Rest Cast
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THE CHILD WITH A LIMP SLIPPED CAPITAL FEMORAL EPIPYSIS (SCFE)
Epiphyseal dislocation in superolateral displacement and external rotation of the femoral metaphysis, Salter I injury Causes kinking of the epiphyseal vessels that leads to compromised blood to the epiphysis
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THE CHILD WITH A LIMP SCFE Incidence 10/100000
Boys: 13.5, Girls 8.5/100000 Regional and seasonal variation Initial presentation 20% bilateral hip 20 – 40% eventually develop bilateral involvement within 18 months of initial presentation
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THE CHILD WITH A LIMP SCFE Radiologic classification I: < 33%
II: 33 – 50% III: > 50% Displacement in relation to the femoral neck
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THE CHILD WITH A LIMP Treatment
Depends on the onset of symptoms and grade Internal fixation with single cannulated screw Prophylactic fixation of the unaffected hip Osteomy of the proximal femur
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SCFE radiographs
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THE CHILD WITH A LIMP LABORATORY STUDIES Blood tests CBC, differential
ESR CRProtein Blood culture Lyme studies ANA ASO
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THE CHILD WITH A LIMP LABORATORY STUDIES
Normal synovial fluid characteristics Highly viscous Clear Essentially acellular Protein concentration is 1/3 of plasma protein Glucose concentration is similar to plasma
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THE CHILD WITH A LIMP LABORATORY STUDIES
Components of synovial fluid analysis Clarity Color Viscosity Glucose content Protein content
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THE CHILD WITH A LIMP LABORATORY STUDIES
Components of synovial fluid analysis Microscopic examination WBC count Crystal search Gram satin Culture Routine bacterial culture GC culture Unusual organisms
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THE CHILD WITH A LIMP RADIOLOGIC TESTS Plain radiographs Affected site
Comparison views Skeletal survey
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THE CHILD WITH A LIMP RADIOLOGIC TESTS MRI Radionuclide studies
Ultrasonography CT scan
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THE CHILD WITH A LIMP DISPOSITION In-patient Out-patient
IV antibiotics Diagnostic work-up Surgical intervention Out-patient Observation with close follow up NSAID’s Sub-specialty referrals
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THE CHILD WITH A LIMP DISPOSITION Consultation Orthopedic
Joint aspiration Surgical intervention Hematology-Oncology Bone marrow aspiration Chemotherapy
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THE CHILD WITH A LIMP DISPOSITION Consultation Gynecologic Urology
Pelvic examination Surgical intervention Urology
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THE CHILD WITH A LIMP DISPOSITION Consultation Neurosurgery
Pediatric or general surgery Surgical intervention Infectious disease Choice of antibiotics Length of treatment
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THE CHILD WITH A LIMP DISPOSITION Consultation Rheumatology
Pain specialist Psychiatry Physiatry Physical/occupational therapy Orthotics
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THE CHILD WITH A LIMP DISPOSITION
Diagnoses that require immediate intervention Septic arthritis Osteomyelitis Meningitis Epidural abscess
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THE CHILD WITH A LIMP DISPOSITION
Diagnoses that require immediate intervention Fractures Dislocated patella SCFE Developmental dysplasia of the hip
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THE CHILD WITH A LIMP DISPOSITION
Diagnoses that require immediate intervention Neoplasms/tumors Testicular torsion Appendicitis PID with tuboovarian abscess Discitis
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