Definition

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Definition

• Limp is defined as an uneven, jerky, or laborious
  gait, usually caused by pain, weakness, or
  deformity .
• Limp can be caused by both benign and
  life-threatening conditions, the management
  varies from reassurance to major surgery
  depending upon the cause .

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EPIDEMIOLOGY

• The incidence was 4 per thousand.
• Malefemale ratio was 21.
• Median age was 4 years.
• Eighty percent of patients had pain pain
  localized to the hip, knee, and other areas of
  the leg in 34, 19, and 18 percent, respectively.
• 12 percent of patients were admitted to the
  hospital.

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DIFFERENTIAL DIAGNOSIS 

• Bones.
• Joints.
• Soft tissue.
• Neurological.

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• Bone
• Fractures.
• Legg-Calvé-Perthes.
• Slipped capital femoral epiphysis.
• Tumors.
• Vasoocclusive crisis of sickle cell disease

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• Joints
• Transient synovitis
• Septic arthritis
• Acute rheumatic fever
• Juvenile rheumatoid arthritis
• Henoch-Schönlein purpura
• Developmental dysplasia of the hip
• Hemarthrosis traumatic, hemophilia
• Lyme disease
• Systemic lupus erythematosis.

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• Soft tissue
• Viral myositis.
• Intramuscular vaccination.
• Cellulitis.
• Myositis.

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• Neurological
• Cerebral palsy
• Peripheral neuropathy
• Meningitis.
• Epidural abscess of the spine.

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• INFECTION
• Sepic arthritis
• Ostiomylitis
• descitis

• NON INFECTION
• Inflamation
• Trauma
• Tumor
• Bony deformitiy
• Aseptic necrosis

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The Limping Child
Total no. of admissions 304 286 patients
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HISTORY

• Duration and course of the limp?
• History of trauma ?
• Associated symptoms (e.g., fever, weight loss,
  anorexia, back pain, arthralgia, voiding or
  stooling problems)
• If pain is present, where is it located, when
  does it occur, and what its severity?
• Does the limp improve or worsen with activity?

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• Recent history of viral illness or streptococcal
  infection (post infectious arthritis).
• Recent history of new or increased sports
  activity
• Recent history of intramuscular injection (can
  cause muscle inflammation or sterile abscess)
• History of endocrine dysfunction (may predispose
  to slipped capital femoral epiphysis)
• Family history of connective tissue disorder,
  inflammatory bowel disease, hemoglobinopathy,
  bleeding disorder, or neuromuscular disorder

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• Limps of recent onset are more often due to
  trauma or acute infection.
• Limps of longer duration may be due to more
  chronic problems (e.g., developmental or
  neuromuscular problems).

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• Associated symptoms can help to narrow the
  differential diagnosis.
• Fever may be present in infection, rheumatologic
  conditions, or malignancy, whereas voiding or
  stooling problems suggest a spinal cord problem
  or pelvic mass, and back pain may indicate
  discitis or vertebral osteomyelitis.

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• The severity and constancy of the pain can help
  to narrow the differential diagnosis. Pain
  typically is severe, constant, localized, and
  consistently reproducible in fractures,
  dislocations, septic bacterial arthritis,
  osteomyelitis, and sickle cell disease.
• In contrast, pain typically is intermittent and
  less severe in juvenile rheumatoid arthritis,
  Perthes disease, slipped capital femoral
  epiphysis, and transient synovitis.

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PHYSICAL EXAMINATION

• General 
•  Examination of the skin may reveal the
  characteristic rash of serum sickness,
  Henoch-Schönlein purpura , acute rheumatic fever,
  or Lyme disease.

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• Neurologic and spine  
• The spine should be examined for abnormalites
  (kyphosis or scoliosis) or limited range of
  motion. Limitations or asymmetry on forward
  bending may indicate spinal cord tumors or
  discitis.
• Abnormalities in deep tendon reflexes may
  indicate peripheral neuropathy , or involvement
  of the central nervous system with spasticity.

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• Musculoskeletal 
• Examination of the musculoskeletal system
  should include evaluation of muscle strength,
  muscular atrophy, joint tenderness, bony
  tenderness, bony deformity, joint effusion, range
  of motion (active and passive).

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• Joint effusion / heat / erythema / restriction
  of movement - if all 4 signs are present then
  sepsis is likely
• Large joints more commonly affected than small
  joints.
• The majority of joint sepsis occurs in the hip or
  knee .
• Joints involved monoarticular/polyarticular -
  22 septic arthritis affects gt1 joint.

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Hip rotation

• Internal rotation of the hips is performed with
  the child in the prone position with the knees
  flexed the ankles and feet are then rotated away
  from the body to compare the amount of internal
  rotation in the symptomatic versus the
  asymptomatic hip.

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Hip rotation

• Decreased or absent hip rotation, a "lag of
  internal rotation," is particularly useful in
  raising the suspicion for slipped capital femoral
  epiphysis and Legg-Calvé-Perthes disease
• children with septic arthritis of the hip and
  even transient synovitis of the hip usually
  cannot tolerate this maneuver because of pain.

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Galeazzi test 

•  The Galeazzi test is useful in diagnosing
  developmental hip dysplasia or leg length
  discrepancy.
• This test is performed by putting the child
  in a supine position and then flexing the hips
  and knees by bringing the ankles to the buttocks
  .
• The test is positive when the knees are of
  different heights. Abnormal shortening of the leg
  can be caused by DDH, ischemia, Perthes disease.

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Trendelenburg test 

• Asking the child to stand on the affected leg,
  causes a pelvic tilt (the unaffected hip is
  lower).
• In children with slipped capital femoral
  epiphysis, Legg-Calvé-Perthes disease, or
  developmental dysplasia of the hip.

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GAIT EVALUATION 
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RADIOLOGIC EVALUATION

• Plain radiographs  Most children who limp
  require radiographic evaluation.
• Both anteroposterior and lateral views should
  be obtained. The frog-leg view of the pelvis
  provides the lateral view of the femoral heads.

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• Ultrasonography  Ultrasonography is an excellent
  technique for identifying small joint effusions
  of the hip and should be used when plain
  radiographs are normal but the suspicion of
  septic arthritis remains high.
• A difference of more than 2 mm between the
  anterior joint capsule and the femoral neck is
  considered significant.

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• Ultrasonography also may be used to guide
  aspiration of the hip (e.g., isolated unilateral
  hip effusion in a febrile child).
• Bilateral effusions suggest a systemic arthritic
  disorder or transient synovitis because as many
  as one-quarter of patients with symptomatically
  unilateral transient synovitis have bilateral
  effusions.

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• Radionuclide scans 
• Bone scintigraphy is a sensitive means of
  detecting alterations in the metabolic rate of
  bone and thus a sensitive means of localizing
  pathology.
• However, bone scintigraphy lacks specificity
  because such alterations in bone metabolism can
  occur in Legg-Calvé-Perthes disease,
  osteomyelitis, osteoid osteoma, and malignant
  bone tumors.

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Osteomyelitis
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CT and MRI

• CT scanning is useful in the diagnosis of deep
  soft tissue infections of the paraspinal and
  retroperitoneal regions.
• MRI is useful in the evaluation of the spine
  (for discitis or spinal tumors), soft tissue
  tumors and abscesses in the paraspinal and
  retroperitoneal regions, osteomyelitis of the
  pelvis and long bones, and in Legg-Calvé-Perthes
  disease

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LABORATORY EVALUATION 

• Complete blood count (CBC), ESR (or CRP), and
  blood culture are useful in the evaluation of
  febrile patients and those in whom infection is
  being considered
• . CBC and ESR (or CRP) also should be considered
  in the evaluation of the afebrile child with a
  several day history of limp and no abnormalities
  on plain radiography.

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ESR

• Nonspecific test of inflammation
• Not reliable in neonates
• Elevated in 48-72 hrs returns to baseline 2-4
  weeks
• No change with antibiotic therapy.
• Not good for early evaluation of tx

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CRP

• Rises within 6 hrs and peaks 30-50hrs
• Half life 47hrs
• Makes this marker of greater value for early
  diagnosis and resolution of inflammation
• CRP is elevated in trauma, in otitis
  media(22bacterial 65 viral)

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Cultures

• Blood cultures
• yield organisms 30-50 of cases
• Decreases w/ previous antibiotic therapy
• Aspiration of joint fluid
• Gram stain, leukocyte cell count, PMNs
• Cell counts 80,000 100,000/ml likely septic
  arthritis
• Gram stain can give you early diagnosis
• 1/3 are positive

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The Limping ChildAge 1 3
1

• DDH
• Developmental Dysplasia of the Hip
• CDH
• Congenital Dislocation of the Hip

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The Limping Child Age 1 3DDH

• Physical findings
• Girl
• Asymmetrical skin folds
• Limited abduction
• Short leg
• Ortolanis sign
• Barlows sign

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The Limping ChildAge 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

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Transient synovitis

• Commonly occurs after a respiratory illness.
• X ray image may be normal
• Ultrasound may show effusion
• Main treatment is bed rest and physiotherapy.
• Non-steroidal anti-inflammatory drugs are useful
  for treatment and can shorten the duration of
  symptoms in children

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Septic arthritis or osteomyelitis

• Blood cultures are commonly positive
• Raised white cell count and C reactive protein,
  which normalises more rapidly than erythrocyte
  sedimentation rate once infection is brought
  under control
• X ray images show delayed changes. Radiographic
  evidence of acute osteomyelitis first is
  suggested by overlying soft tissue oedema at 3-5
  days after infection. Bony changes are not
  evident for 14-21 days and initially manifest as
  periosteal elevation followed by cortical or
  medullary lucencies.
• By 28 days, 90 of patients show some
  abnormality.

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Septic arthritis
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• Joint aspiration is the definitive diagnostic
  procedure and the most common pathogen isolated
  is Staphylococcus aureus
• Emergency orthopaedic consultation with
  subsequent aspiration, arthroscopy, drainage and
  debridement is required. Antibiotics are required
  as adjunctive treatment.

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The Limping Child Age 6 10Perthes Disease

• X-ray findings
• Perhaps nothing
• Irregular consistency
• Flattening
• Lateral bump/ridge
• Lateral hinging

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The Limping Child Age 6 10Perthes Disease
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The Limping Child Age 6 10Perthes Disease
50 need a Total Hip by age 50
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The Limping Child Age 10 14SCFE

• Most common in obese or rapidly growing
  prepubescent male children (aged 12-15 years)
• There is 25 bilateral involvement
• X ray 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.

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

• Osteogenic sarcoma causes an acute unremitting
  limp or limb pain and often involves the distal
  femur and proximal tibia
• A haematological problem, such as leukaemia,
  causes ill defined migratory bone or joint pain
  and generalised weakness.
• Appropriate treatment is multidisciplinary and
  involves referral to paediatric oncology and
  orthopaedics.

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Juvenile rheumatoid arthritis

• Autoimmune disease that may present affecting a
  single ankle or knee (pauciarticular)
• Presence of associated systemic findings such as
  high fever, a salmon coloured pink rash and eye
  inflammation are also useful in diagnosis
• Treatment is also multidisciplinary and involves
  the paediatric rheumatologists, ophthalmologists,
  orthopaedic surgeons, rehabilitation specialists,
  and occupational therapists

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Thank you
The Limping Child