The Limping ChildThe Limping ChildThe Limping ChildThe Limping Child

Chrissie AshdownChrissie Ashdown

Aims and Objectives• How to assess the limping child

who presents to the GP• Investigations• Common diagnoses• Basic management

The Limping Child• A common reason for a child to present• Long list of potential diagnoses, some

of which demand urgent treatment• How do they present?• What are the potential diagnoses?• How should they be diagnosed and

managed?

Gait Differences• The gait of a child is different from that of an

adult for the first 3 yrs• Children typically take more steps/minute at

a slower speed than adults to compensate for immature balance.

• Toddlers tend to flex hips, knees, + ankles more than adults in order to lower their centre of gravity + improve their balance.

Developmental stages of gait

• Age (months) Developmental stage• 10-12 Cruises while holding on to objects • 12-14 Walks short distances, stands unaided• 17-21 Walks on 1 foot long enough to walk

up steps• 30-36 Balances on 1 foot for >1s • 36 Develops sufficient balance to attain a

normal gait pattern

Common Causes• 0-3 years old

– #/soft tissue injury (toddler’s #/NAI)– Osteomyelitis or septic arthritis – Developmental dysplasia of the hip

Common Causes• 3-10 years old

– Trauma – Transient synovitis/irritable hip– Osteomyelitis or septic arthritis – Perthes disease

Common causes• 10-15 years old

– Trauma – Osteomyelitis or septic arthritis – Slipped upper femoral epiphysis – Chondromalacia – Perthes’

Other Dx• Haematological eg Sickle cell• Infective eg pyomyositis/discitis• Metabolic eg rickets• Neoplastic eg acute lymphoblastic

leukaemia• Neuromuscular eg cerebral palsy• 1ary anatomical eg limb length

inequality• Rheumatological eg juvenile idiopathic

arthritis

What questions What questions should you ask?should you ask?What questions What questions should you ask?should you ask?

Child presents with a limpChild presents with a limp

History – Q’s to ask• Duration and progression of limp? • Recent trauma and mechanism? Beware

limitations of paediatric history, possibility of unintentional trauma

• Associated pain and its characteristics? • Accompanying weakness? • Time of day when limp is worse? • Can the child walk or bear weight?

History – Q’s to ask• Has the limp interfered with normal

activities? • Presence of systemic symptoms - fever,

weight loss? • Do not forget PMHx, BIND—birth history,

imms, nutritional history, developmental history

• Also include the other essentials— DHx and allergies and FHx

ExaminationExaminationExaminationExamination

pGALS• Pain or stiffness in joints/mm/back?• Gait/general: Temp, observe gait

including on tiptoes and heels• Arms – N/A• Legs: Knee effusion, ‘bend +

straighten you knee’ – crepitus?, apply passive flexion (90deg) with internal rotation of hip

pGALS• Spine: observe from behind,• ‘can you bend and touch your

toes?’• Observe curve of spine from side

and behind

Look, feel, moveLook, feel, moveLook, feel, moveLook, feel, move

Examination• Look

– Feverish?– Can they stand? Spine straight? Pelvis level?– Deformity, erythema, swelling, effusion, – limitation of motion, asymmetry. – shoes - unusual wear on soles, asymmetry,

point of initial foot strike, assess fit. – Older children - scoliosis, midline dimples,

hairy patches, (?spinal pathology)

Examination• Feel

– Can they localise the pain?– Measure true leg length - anterior

superior iliac spines to medial malleoli. – Assess thigh or calf circumference if

asymmetry suggests atrophy. – Feel for warmth, fluctuance, palpable

masses, stiffness, focal tenderness

Examination• Move

– Assess ROM, laxity, stiffness with guarding, pain, discomfort, and fluidity

– Assess gait with the child barefoot. – Any discomfort as the child bends

down – Hips: move normally? Internally rotate

symmetrically, no pain?

Don’t forget!• Both intra-abdominal

pathology and testicular torsion may present simply as a limp – examine abdomen and testicles in boys!!

DiagnosesDiagnosesDiagnosesDiagnoses

Trauma• Diagnosis is by plain x ray as a

primary investigation. • Anteroposterior and lateral views

are indicated. • A+E usually indicated

Toddler’s #Toddler’s #Toddler’s #Toddler’s #

Toddler’s #• Subtle undisplaced spiral # of the

tibia• Usually pre-school• Sudden twist after an unwirnessed

fall

Toddler’s #• Local tenderness over tibial shaft

may be present or on gentle strain on the tibia

• In 1 series 5/37 # not present on initial x-ray

• Immobolise, expectant Mx

Transient synovitisTransient synovitisTransient synovitisTransient synovitis

Transient Synovitis• Acute onset, after a respiratory

illness (weak evidence)• Affects young children (boys more

than girls) most often• Most common cause of acute hip

pain in young children age 3-10 • Usually unilateral• May refuse to walk/limp

Transient Synovitis• Usually no pain at rest + passive

movements only painful at extreme ranges

• FBC + ESR normal or slightly elevated • XR may be normal • USS may show effusion • Main treatment rest + physio • NSAIDs useful, can shorten the duration

of symptoms in children, usually resolves within 2 weeks

Septic Septic arthritis/osteomyelitisarthritis/osteomyelitis

Septic Septic arthritis/osteomyelitisarthritis/osteomyelitis

Septic Arthritis• Most often hip, knee, ankle, shoulder, elbow. • Most often children <2yrs. • Early features often non-specific. • Child often very unwell. • Pain often present at rest, resistance to

attempted movement of the hip. • Older children usually reluctant to weight

bear, may be more aware of referred pain in the knee.

• Hip is kept flexed, abducted and externally rotated.

Septic arthritis• BCs +ve, raised WCC + CRP• XR show delayed changes• Bony changes not evident for 14-21

days• By 28 days, 90% show some

abnormality. • About 40-50% focal bone loss is

necessary to cause detectable lucency on plain films

Septic arthritis - Mx• Joint aspiration is the definitive diagnostic

procedure and the most common pathogen isolated is Staph aureus

• Emergency orthopaedic consultation with subsequent aspiration, arthroscopy, drainage + debridement required.

• Antibiotics are required as adjunctive treatment.

Perthes’ DiseasePerthes’ DiseasePerthes’ DiseasePerthes’ Disease

Perthes’ disease• Self-limiting hip disorder caused by

varying degrees of ischaemia and subsequent necrosis of the femoral head.

• Most often affects boys (80%) and those aged 5-10 yrs.

• Increased risk with:– low birth weight– short stature– low socio-economic class– passive smoking.

• Unilateral in 85% of cases

Perthes’ disease• Presents with pain in hip or knee, causes limp. • Pain (often in knee), + effusion (from

synovitis). • On examination all movements at hip limited• No history of trauma. • Roll test; with patient lying supine, roll the hip

of the affected extremity into external + internal rotation.

• Should invoke guarding or spasm, especially with internal rotation.

Perthes’ disease• Classic x-ray features:

– Sclerosis, fragmentation and eventual flattening of the proximal femoral epiphysis

– Absent in early disease

• May be initially misdiagnosed as irritable hip

Perthes’ disease• Radionuclide bone scan/MRI helps

evaluate for avascular necrosis • If AVN is shown, bracing, physio +

protection of the hip may be indicated. • Surgery to contain the femoral head

within the acetabular cup sometimes necessary – femoral varus osteotomy

• Done with or without rotation to redirect the ball of the femoral head into the socket of the acetabulum

Slipped Capital Slipped Capital Femoral EpipysisFemoral EpipysisSlipped Capital Slipped Capital

Femoral EpipysisFemoral Epipysis

Slipped capital femoral epiphysis

• Usually occurs at the onset of puberty and most often in children who are either very tall and thin, or short and obese.

• Other risk factors include Afro-Caribbean, boys, family history.

• One quarter of cases are bilateral.• Prepubescent male children (12-15 yrs)

Slipped capital femoral epiphysis

• Hip, thigh and knee pain. • Often initially a several week history of

vague groin or thigh discomfort. • May be able to weight bear, but is

painful. • Flexion of hip often also causes external

rotation. • May be leg shortening.

Slipped capital femoral epiphysis

• XR shows widening and irregularity of the plate of the femoral epiphysis.

• The displacement of the epiphyseal plate is medial and superior

• Surgical pinning of the hip is usually required and should be done quickly.

Developmental Developmental Dysplasia of the Hip Dysplasia of the Hip

(DDH)(DDH)

Developmental Developmental Dysplasia of the Hip Dysplasia of the Hip

(DDH)(DDH)

DDH Risk Factors• Female • Breech position • Caesarean section • 1st child • Prematurity • Oligohydramnios • Family history • Club feet, spina bifida and infantile

scoliosis

DDH • Must be detected early • Delayed identification leads to more prolonged

morbidity • Classic screening tests are Barlow and Ortolani

– Ortolani assesses if the hip is dislocated– Barlow assesses whether the hip is dislocatable.

• Asymmetrical skin creases in the thigh or buttock • Unequal leg length

DDH• Up to 60% of abnormal hips

become normal without Tx after 1mth

• USS usually done • Mx depends on age

DDH - Management• 0-6 months- Pavlik harness• Attempts to place hips in the human position

by flexing them more than 90 degrees (preferably 100-110 degrees) and maintaining relatively full, but gentle abduction (50-70 degrees).

• Redirects the femoral head towards the acetabulum and spontaneous relocation of the femoral head occurs typically in 3-4 weeks.

DDH - Management• > 6m requires closed reduction and use

of a Spica cast - used to immobilize the hip joints and it usually extends from the mid-chest down to below the knee.

• This cast is usually left in place for 6-8 weeks

NeoplasmNeoplasmNeoplasmNeoplasm

Neoplasm • Osteogenic sarcoma causes acute

unremitting limp/limb pain, often involves the distal femur + proximal tibia

• Leukaemia causes ill defined migratory bone or joint pain + generalised weakness

• Neuroblastoma can produce nerve impingement

• Appropriate treatment is multidisciplinary and involves referral to paediatric oncology and orthopaedics.

Juvenile Rheumatoid Juvenile Rheumatoid ArthritisArthritis

Juvenile Rheumatoid Juvenile Rheumatoid ArthritisArthritis

Juvenile rheumatoid arthritis

• Autoimmune disease may present affecting a single ankle or knee (pauciarticular)

• Presence of assoc. systemic findings eg high fever, salmon coloured pink rash, eye inflammation are also useful in Dx

• Treatment is multidisciplinary, involves paediatric rheum, ophthal, ortho, rehabilitation specialists + OTs

Red flags!!Red flags!!Red flags!!Red flags!!

Red flags• Child <3y• Unable to weight bear• Fever• Systemic illness• >9y with pain or restricted hip

movements

Irritable hip v septic arthritis

• Factors for predicting septic arthritis– Fever >38.5– Cannot weight bear– ESR>40 in 1st hr– WCC>12

That’ll do for now!That’ll do for now!That’ll do for now!That’ll do for now!

Any Questions?Any Questions?