1. A PPROACH TO THE L IMPING CHILD DR FATMA AL TAMIMI. PEDIATRIC RHEUMATOLOGY CONSULTANT.

2. O BJECTIVES Definition. Causes. Differential diagnosis. Common disorder of limping.

3. L IMP An uneven, jerky or laborious gait, usually caused by pain, weakness or deformity. 4/1000 visits in a pediatric ED

4. E PIDEMIOLOGY 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%

5. THE CHILD WITH A LIMP 1- History 2- Physical examination. 3- Differential diagnosis.

6. HISTORY Duration Trauma Fever Location of the pain Pain characteristics Constant severe pain Intermittent mild to moderate pain Bilateral pain Modifying factors

7. Other symptoms Morning stiffness Incontinence, weakness or sciatica Recent viral or bacterial illness Recent medications Endocrine and other systemic diseases

8. PHYSICAL EXAMNATION General appearance Ill or toxic appearing Fever Obvious discomfort/pain at rest

9. PHYSICAL EXAMNATION 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 Observe several gait cycles. Includes jumping/hopping.

10. G AIT EVALUATION

11. Gait examination Expose the legs Bare feet or wearing only a pair of socks Listening to the gait Cadence Foot slap Scraping

12. 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

13. PHYSICAL EXAMNATION Musculoskeletal Muscle strength Muscular atrophy Bony tenderness Bony deformity Active and passive ROM Joint swelling/tenderness Muscle tenderness Tenderness on the tendons, insertions sites

14. PHYSICAL EXAMNATION Skin Bruises Rashes and other lesions Swelling Redness Tenderness Lymphatic Lymphadenopathy Neurologic Muscle strength Muscle tone DTR’s

15. PHYSICAL EXAMNATION Gastroentestinal Abdominal tenderness Abdominal swelling Genitourinary Testicular or scrotal pain/swelling Inguinal swelling

16. DIFFERENTIAL DIAGNOSES ACCORDING TO AGE.

17. DIFFERENTIAL DIAGNOSES A CUTE OR CHRONIC ?! Contusion Foreign body Fracture Osteomyelitis Reactive arthritis Septic arthritis Transient synovitis Lyme arthritis Poor shoe fit Rheumatic disease JRA Acute rheumatic fever SLE Inflammatory bowel disease ACUTE CHRONIC

18. S EPTIC A RTHRITIS Hot, swelled, acute tender joint. More difficult to identify at hip. Raised ESR,CRP,WCC. Need urgent aspiration and IV AB. Usually S.areus.

19. TODDLERS FRACTUR Typically age<3 years. Pain, unwilling to wt bear. May be minimal trauma, often twisting injury. Tender swelling lower leg. Spiral, distal third of tibia. Long leg cat for 4 weeks.

21. PERTHES DISAES *Avascular necrosis of femoral head. *Boys:Girls>>5:1. *Age4-8 years. *limp+/- pain. *reduced abduction in internal rotation.

23. TRANSIENT SYNOVITIS Most common cause of hip pain in children. Usually after viral UPTI. Limp, reduce ROM, pain. Diagnosis by exclusion. Normal WCC,ESR,CRP and Xray. Self limiting usually after7-10 day. Analgesia and rest.

24. 2- YEAR - OLD GIRL WITH TRANSIENT SYNOVITIS OF LEFT HIP. SHOWS LOWER SIGNAL INTENSITY OF LEFT FEMORAL HEAD THAN OF RIGHT FEMORAL HEAD ( ARROW ). S YNOVIAL THICKENING APPEARS AS THICKER ENHANCING RIM OF SYNOVIUM ( ARROWHEADS ).

25. SLIPPED UPPER FEMORAL EPIPHYSIS During adolescence growth spout. Posterior slipping or femoral head epiphysis. Increase incidence of obese. 25%bilateraly. Limp. Hip/thigh/knee pain. Risk of osteomylitis and AVN. Surgical fixed.

26. X-Ray showing a left sided SUFE

27. O STEOMYLITIS Infection of the metaphysis of long bones(distal femur, proximal tibia). Due to haematogenous spread of pathogen. Swollen over infected wound. S.aureus, streptococcus and H.influnzae. It can end with SA.

28. THANKS ?????