1. Dr. FATEMA AL TAMIMI Pediatric rheumatology consultant.

4. Background The child with a limp is a common problem seen in pediatrics. A limp is defined as any deviation in walking pattern away from the expected normal pattern for the child’s age. A limp is a type of asymmetric abnormality of the gaitasymmetric abnormalitygait

5. Limping can be caused by three categorical processes: 1- Pain 2- Structural Abnormalities 3-Neuromuscular problems, including weakness or ataxia (cerebellar or sensory).

6. A 14 month old boy is brought to the office because the parents noticed a limp this morning …

7. Approach History Examination Investigation Management

8. Questions to ask on history Duration and Progression of Limp. Make sure to ask if it is getting better or worse History of Trauma Characterize any associated pain. Remember that often hip pathology is reflected by knee pain. Does the pain awaken the child from sleep? This finding is worrisome for malignancy. Search for other constitutional symptoms including fatigue, weight loss and night sweats. Is the pain unilateral or bilateral? Bilateral leg pain that occurs only at night and is not associated with any limp, pain or other symptoms during the day, may represent “growing pains”, a diagnosis of exclusion.

9. Characterize any associated weakness, swelling, redness, or stiffness suggesting ongoing inflammation. Characterize whether there is a time of day during which the limp is worse worse in the morning – may suggest Juvenile Idiopathic Arthritis worse in the evening – may suggest muscle fatigue and weakness constant – may suggest a structural cause including tumors

10. Systemic Symptoms: Any recent illnesses, fevers, or chills? A recent upper respiratory tract infection can suggest transient viral synovitis. A bacterial infection however can spread hematologically to cause septic arthritis or osteomyelitis. Think of Post-streptococcal reactive arthritis in the child with a recent Streptococcal throat infection. Family history of rheumatologic or neuromuscular disease Dietary intake including supplementation with Vitamin D. A deficiency can lead to pathological fractures and Rickets. How has the limp affected normal activities?

11. Examination General inspection + Gait Vital signs & anthropometric measurements Musculoskeletal examination +Back exam Neurological examination Evaluate leg lengths- anterior iliac spine to medial mallelous

12. Faber (Patrick’s Test) Flexion ABduction External Rotation Indications: Evaluation for Sacroiliac joint disease Technique: External Hip Rotation Patient lies supine KneeKnee on affected side flexed to 90 degrees FootFoot on affected side rests on opposite knee Examiner places one hand on opposite iliac crest Stabilizes Pelvis against tablePelvis Examiner places one hand on knee of affected side Examiner externally rotates hip on affected side KneeKnee pushed laterally and down

13. Galeazzi Maneuver

14. A positive galeazzi sign (unequal knee heights) suggests a unilaterally dislocated hip. It is important to remember that bilateral dislocations will likely appear symmetric, so this assessment should only be used in combination with the Ortolani and Barlow manuevers. The infant in this photo has a negative galeazzi -- the hips are normal.

15. Barlow Maneuver  Best done on a non-crying infant.

16.  The maneuver dislocates a dislocatable hip posteriorly.  The hip is flexed and the thigh is brought into an adducted position.  From that position the femoral head drops out of the acetabulum or can be gently pushed out of the socket. Barlow Maneuver

17. Ortolani Maneuver  Reduces a posteriorly dislocated hip.  The thigh is flexed and then adducted while pushing up with the fingers located over the trochanter posteriorly.  The femoral head is lifted anteriorly into the acetabulum.

19. Positive Ortolani  A clunk and a palpable jerk are felt as the femoral head is re-located.  A mild clicking sound is not a positive sign.  Most often positive in the first 1 to 2 months of age.

20. Limited Abduction  This would be a positive sign of developmental dysplasia of hip in the older infant.

21. Asymmetry of skin fold

22. Investigations Based upon your careful history and physical examination, the following tests may be helpful in assessing a child with a limp. CBC and differential count Erythrocyte Sedimentation Rate C Reactive Protein Joint Aspiration for cell count, differential, Gram’s stain, culture and sensitivity, protein, glucose, and crystals. Blood Cultures Imaging

23. *Note that a negative culture does not rule out a septic joint, as about one third of all septic joint aspirations will not recover an organism. Don’t forget that gonorrhea can be a source of septic joints in sexually active adolescents and you should request a special gonococcal culture of the aspirate (separate collection swab).

24. Imaging The first step is usually obtaining plain film radiographs or areas in question both AP and Lateral. It is often necessary to include the joint above and below the area of question. Films should be done weight bearing when possible. Hip films should have AP, and frog leg lateral Ultrasound of suspected septic joints, joint effusions or abscess Bone scan is a sensitive way to highlight increased metabolic activity seen in stress fractures, infection, fractures, and most tumors CT and MRI as indicated

25. CT scanning is effective for abdominal and pelvic pathology (eg, sacroiliac trauma) and bony pathology of the hip, knee, spine, and foot. Magnetic resonance imaging (MRI) is the study of choice for soft-tissue pathology. MRI is used for evaluation of bone tumors.

29. In children from two to ten years old, the most common cause of hip pain is transient synovitis (TS). This involves swelling or inflammation of the synovium of the hip

30. Legg-Calvé-Perthes disease typically affects boys between the ages of five and ten. It is also called osteonecrosis and avascular necrosis of the hip. It literally means death of bone. The ball of the hip dies because the blood supply has been cut off. When this happens, the femoral head and acetabulum will change their shapes over one to three years. The ball of the femur will flatten out. This problem with the hip is often missed at first. It is frequently misdiagnosed as synovitis of the hip.

31. Osgood Schlatters disease is a very common cause of knee pain in children and young athletes usually between the ages of 10 and 15. It occurs due to a period of rapid growth, combined with a high level of sporting activity. is an irritation of the patellar ligament at the tibial tuberosity.patellar ligamenttibial tuberosity

32. is a medical term referring to a fracture through the physis (the growth plate), which results in slippage of the overlying epiphysismedical

33. he femoral epiphysis remains in the acetabulum (hip socket), while the metaphysis (end of the femur) move in an anterior direction with external rotation.

37. Treatment Treatment for a limp depends on its cause, but will usually involve pain relief.