Limping Child

By : Yasmine Demirauz ,Raghda Faraj

Afnan Alghamdi, Mawadda Zwawi

Definition

What does limping child mean?

It is defined as any deviation or asymmetry from a normal gait pattern for the childs age.

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Epidemiology

A limp at one hospital emergency department was the presenting complaint in 2% of children. It occurs twice as commonly in boys as in girls

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Gait cycle

The gait cycle is divided to two phases:

The stance phase: 60% of all gait cycle.

Heal >> foot >> toes

The swing phase: 40% of normal gait cycle.

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Diagnostic approach

The diagnosis of the cause of a limp is often made based on history, physical exam findings, laboratory tests, and radiological examination. If a limp is associated with pain it should be urgently investigated, while non-painful limps can be approached and investigated more gradually.

Young children have difficult determining the location of leg pain thus in this population knee pain equals hip pain.

A SCFE can usually be excluded on an X-ray of the hips. A ultrasound or xray guided aspiration of the hip joint maybe required to rule out an infectious process within the hip.

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Differential diagnosis

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history

The history for a child with a limp should be taken in details as following:

Onset, duration and progression? (acute-chronic)

Recent trauma and mechanism?

Associated pain and its characteristics? Accompanying weakness?

Time of day when limp is worse? ( rheumatologic-malignancy)

Can the child walk or bear weight?

Has the limp interfered with normal activities? (Severity)

Presence of systemic symptoms like fever, weight loss?

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Do not forget the medical history, BINDbirth history, immunization history, nutritional history, and developmental history

Also include the other essentialsdrug history , allergies and

Special Conditions
1 Transient Synovitis OsgoodSchlatter syndrome 2

Developmental Dysplasia of the Hip (DDH)

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Transient Synovitis
Definition:
Is a self-limiting condition in which there is an inflammation of the inner lining (the synovium) of the capsuleof the hip joint. Transient synovitis usually affects children between three and ten years old. It is the most common cause of sudden hip pain and limp in young children. Boys are affected two to four times as often as girls.

1- Unknown. 2- Recent viral infection(most commonly an upper respiratory tract infection) 3- Trauma

Causes:

Cont.

Symptoms:

1- pain in the hip, thigh, groin or knee on the affected side. 2-There may be a limp (or abnormal crawling in infants) with or without pain. 3-In small infants, the presenting complaint can be unexplained crying (for example, when changing a nappy). 4-Some children may have a slightly raised temperature; high fever and general malaise point to other, more serious conditions.

Signs:
1- the child typically holds the hip slightly bent, turned outwards and away from the middle line (flexion, external rotation and abduction). 2- Active and passive movements may be limited because of pain, especially abduction and internal rotation.
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3-The hip can be tender to palpation.

Diagnosis

There are no set standards for the diagnosis of suspected transient synovitis, so the amount of investigations will depend on the need to exclude other, more serious diseases

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Cont .
Inflammatory parameters in the blood may be slightly raised (these include erythrocyte sedimentation rate, C-reactive protein and white blood cell count), but raised inflammatory markers are strong predictors of other more serious conditions such as septic Arthritis

2-X-ray imaging 3-ultrasound scan of the hip can easily demonstrate fluid inside the joint capsule 4-magnetic resonance imaging (MRI scan) that can differentiate between septic arthritis and transient synovitis (for example, signal intensityof adjacent bone marrow
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Treatment

1-Rest

2- Non-weightbearing 3- Painkillers (NSAID).

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OsgoodSchlatter syndrome
(also known as tibial tubercle apophyseal traction injury) is an irritation of the patellar tendon at the tibial tuberosity

The condition is usually self-limiting and is caused by stress on the patellar tendon that attaches the quadriceps muscle at the front of the thigh to the tibial tuberosity This can cause multiple subacute avulsion fractures along with inflammation of the tendon, leading to excess bone growth in the tuberosity and producing a visible lump which can be very painful when hit.

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Cont.

Sign and symptoms of OsgoodSchlatter disease include:

Pain, swelling and tenderness at the bony prominence on the upper shinbone, just below the kneecap

Knee pain that worsens with activity especially running, jumping and climbing stairs and improves with rest

Tightness of the surrounding muscles, especially the thigh muscles (quadriceps)

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Risk factors

Cont.

How is Osgood-Schlatter disease diagnosed?

the disease can be diagnosed clinically based on the typical symptoms and physical examination findings. X-ray testing is sometime performed in order to document the status of the calcification at the insertion of kneecap (patellar) tendon. Sometimes a tiny piece of the bone of the tibia actually is pulled away

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Lateral radiograph of the knee demonstrating fragmentation of the tibial tubercle with overlying soft tissue swelling

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Radiograph of a patient who is skeletally immature. The tubercle is elongated and fragmented

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Radiograph of a patient who is skeletally mature. Note that the tibial tubercle is enlarged and there is an ossicle. A bursa was overlying this

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Slipped capital femoral epiphysis (SCFE)

(SCFE)

is a hip problem that starts if the epiphysis (growing end) of the femur slips from the ball of the hip joint. SCFE may develop in one leg or it may occur in both legs but The left hip is affected more commonly than the right

Males have 2.4 times the risk compared with females.

Risk factors

Mechanical: local trauma, obesity.

Inflammatory conditions: neglected septic arthritis.

Hypothyroidism, hypopituitarism, growth hormone deficiency, 5/23/12 pseudohypoparathyroidism.

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Symptoms and signs

Limping

Stiffness in the hip

One leg may appear shorter than the other Knee pain

Hip pain

Hip stiffness

Outward-turning leg and Rotated foot

More severe cases of hip conditions are accompanied by extreme pain and the inability to move the affected leg

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Investigations

Anteroposterior and 'frog-leg' lateral X-rays show widening of epiphyseal line or displacement of the femoral head. Earliest findings include globular swelling of the joint capsule, irregular widening of the epiphyseal line and decalcification of the epiphyseal border of the metaphysis.

Epiphysis normally extends slightly cephalad to the upper border of the femoral neck.

Small amounts of slippage can be detected by the epiphyseal edge, becoming flush with the superior border of the neck.

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A Klein line is a line drawn along the superior border of the femoral neck that would normally pass through a portion of the femoral head. If not, slipped capital femoral epiphysis is diagnosed
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Lateral view showing an early slipped capital femoral epiphysis. Note the subtle posterior step-off of the epiphysis on the metaphysis at the physeal level (arrow).

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Manegment

No medical therapy is available for the treatment of slipped capital femoral epiphysis (SCFE) except symptomatic pain relief. Medications may include acetaminophen, nonsteroidal anti-inflammatory drugs, or narcotics, depending on the physician's preference

Possible Complications

This disorder is associated with a greater risk of osteoarthritis later in life

Chondrolysis (degeneration of the articular cartilage),

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avascular necrosis of the epiphysis,.

X-ray of a hip following operative percutaneous fixation of a slipped capital femoral epiphysis
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Limb Length Discrepancy

Differences between the lengths of the upper and/or lower arms and the upper and/or lower legs.

There are many causes of LLD. Some include:

Previous injury to a bone in the leg Bone infection Bone diseases (dysplasias) Inflammation (arthritis) other

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Continued

Symptoms

It depends on the cause and size of the difference..

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Treatment Options

1- a shoe lift

2-surgical repair

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Developmental Dysplasia of the Hip (DDH)

Its abnormal development of the hip with respect to instability of the hip joint and dysplasia (abnormal shape) of the acetabulum.

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Clinical manifestation

Presentation ranges from:

Instability on the newborn examination slight limited abduction in the infant. Asymmetric gait in the toddler. Activity-related pain in the adolescent. Osteoarthritis in the adult.

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History

History of presenting illness (who notice, affect his life severity-, when notice first time). Risk factors:

Limited fetal mobility(breech position, oligohydramnios, and firstborn infan). Breech positioning: the greatest risk factor. Female sex: four times more than male infants. Family history of DDH. Other factors to be considered: birth order and musculoskeletal abnormalities related to tight intrauterine packaging (eg, torticollis and metatarsus adductus).

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Physical Exam

The examination findings of DDH vary according to age:

Birth- 3 m.:

+ve Ortolani and Barlow tests Asymmetric leg folds (inguinal, gluteal, thigh, popliteal) Apparent shortening of the femur (Galeazzi, sign) Associated findings: Metatarsus adducts, Clubfoot, Torticollis.

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3 -12 months:

Limitation of hip abduction in 90 of flexion Marked asymmetry of leg creases

After the child begins to walk:

Excessive lumbar lordosis Prominent greater trochanter Gluteus medius lurch +ve Trendelenburg sign Short leg limp, with toe-heel gait >>> out-toeing
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Barlow and Ortolani

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Asymmetric inguinal folds

A. B.

Normal inguinal folds do not extend beyond the anal aperture (*). The inguinal fold on the right extends beyond the anal aperture, suggesting possible developmental dysplasia of the right hip. The inguinal folds on both sides extend beyond the anal aperture, suggesting bilateral developmental dysplasia of the hip. 5/23/12

C.

Galeazzi test

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The patient is positioned as shown. The knee is lower on the affected side because of posterior displacement in the developmentally dysplastic hip (arrow).

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Trendelenburg test

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The Klisic test for hip dislocation

Placing the index finger on ASIS and the middle finger on the greater trochanter. An imaginary line between these two points should point toward or above the umbilicus. The line will pass below the umbilicus if 5/23/12

Investigation

Ultrasonography:

Primary technique for assessing the morphology and stability of the hip until three to five months of age.

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Plain radiographs:

After three months of age, plain radiographs are more valuable in the evaluation. radiographic findings include:

Lateral and superior positioning of the ossified portion of the femoral head and neck Increased acetabular index (>40 in newborn or infant) Delayed appearance of the femoral ossific nucleus on the involved side or dissimilar sizes of the femoral ossific nuclei

Other imaging:

computed tomography (CT)

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TREATMENT

Goals of treatment :

Obtain and maintain concentric reduction of the hip to provide an optimal environment for the development of the femoral head and acetabulum.

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AGE LESS THAN SIX MONTHS:

Abduction splints (Pavlik harness)

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AGE 6 TO 18 MONTHS:

Closed or open reduction usually necessary. The success rate for the Pavlik harness treatment in children in this age group is less than 50 percent, and there is a higher risk of osteonecrosis.

AGE 18 MONTHS AND OLDER :

Open reduction is usually needed. long-term problems (stiffness, failure of treatment, residual dysplasia, and osteonecrosis) are greater in older patients than in those who are treated earlier.

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Summary
Limping in children is never normal. Physicians providing care to children need to be knowledgeable regarding the diagnosis and management of limping. A systematic approach should include a thorough history and physical examination, and, if necessary, appropriate imaging studies and laboratory testing. A timely diagnosis will result in a more optimal outcome

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Thank ! You

Developmental Dysplasia of the Hip

)(DDH

Introduction

Its abnormal development of the hip with respect to instability of the hip joint and dysplasia (abnormal shape) of the acetabulum.

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Clinical manifestation

Presentation ranges from:

Instability on the newborn examination slight limited abduction in the infant. Asymmetric gait in the toddler. Activity-related pain in the adolescent. Osteoarthritis in the adult.

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History

History of presenting illness (who notice, affect his life severity-, when notice first time). Risk factors:

Limited fetal mobility(breech position, oligohydramnios, and firstborn infan). Breech positioning: the greatest risk factor. Female sex: four times more than male infants. Family history of DDH. Other factors to be considered: birth order and musculoskeletal abnormalities related to tight intrauterine packaging (eg, torticollis and metatarsus adductus).

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Physical

The examination findings of DDH vary according to age:

Birth- 3 m.:

+ve Ortolani and Barlow tests Asymmetric leg folds (inguinal, gluteal, thigh, popliteal) Apparent shortening of the femur (Galeazzi, sign) Associated findings: Metatarsus adducts, Clubfoot, Torticollis.

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3 -12 months:

Limitation of hip abduction in 90 of flexion Marked asymmetry of leg creases

After the child begins to walk:

Excessive lumbar lordosis Prominent greater trochanter Gluteus medius lurch +ve Trendelenburg sign Short leg limp, with toe-heel gait >>> out-toeing

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Barlow and Ortolani

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Asymmetric inguinal folds

A.

Normal inguinal folds do not extend beyond the anal aperture (*). The inguinal fold on the right extends beyond the anal aperture, suggesting possible developmental dysplasia of the right hip. The inguinal folds on both sides extend beyond the anal aperture, suggesting bilateral developmental dysplasia of the hip.

B.

C.

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Galeazzi test

The patient is positioned as shown. The knee is lower on the affected side because of posterior displacement in the developmentally dysplastic hip (arrow). 5/23/12

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Trendelenburg test

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The Klisic test for hip dislocation

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Placing the index finger on ASIS and the middle finger on the greater trochanter. An imaginary line between these two points should point toward or above the umbilicus. The line will pass below the umbilicus if the hip is dislocated.

Investigation

Ultrasonography:

Primary technique for assessing the morphology and stability of the hip until three to five months of age.

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Plain radiographs:

After three months of age, plain radiographs are more valuable in the evaluation. radiographic findings include:

Lateral and superior positioning of the ossified portion of the femoral head and neck Increased acetabular index (>40 in newborn or infant) Delayed appearance of the femoral ossific nucleus on the involved side or dissimilar sizes of the femoral ossific nuclei

Other imaging:

computed tomography (CT)

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TREATMENT

Goals of treatment :

Obtain and maintain concentric reduction of the hip to provide an optimal environment for the development of the femoral head and acetabulum.

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AGE LESS THAN SIX MONTHS:

Abduction splints (Pavlik harness)

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AGE 6 TO 18 MONTHS:

Closed or open reduction usually necessary. The success rate for the Pavlik harness treatment in children in this age group is less than 50 percent, and there is a higher risk of osteonecrosis.

AGE 18 MONTHS AND OLDER :

Open reduction is usually needed. long-term problems (stiffness, failure of treatment, residual dysplasia, and osteonecrosis) are greater in older patients than in those who are treated earlier.

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Irritable hip
Transient synovitis

Introduction

Irritable hip is a common childhood condition that causes symptoms such as hip pain and limping. Affect boys and girls of any age. Affects boys twice than girls. It's most often seen in boys aged 4-10. Usually a mild condition & don't require specific treatment.

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Symptoms

Symptoms for less than a week Main symptom is pain in one of the hips. The pain isn't usually severe, but it may prevent the child from placing weight on the affected leg, and it may cause them to limp. Children unable to speak, the only noticeable symptom may be them crying at night. Slightly higher temperature than normal.

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Examination

the affected leg tends to be held in the position of greatest ease, typically, one of flexion, abduction and slight external rotation. Movement is restricted especially extension and adduction which both increase intracapsular pressure. The child is otherwise well.

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Laboratory:

May be mild elevation of: WBC, ESR,CRP Plain x-ray

Radiology:

Usually normal. Performed to exclude other conditions.

Ultrasound May show effusion Shows variable pattern Routine use not indicated

Bone scan

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Treatment

Conservative. Bed rest and analgesia until full ROM achieved NSAIDs. Traction only for severe cases that fail to settle. Partial weight bearing on crutches until limp resolves. Usual resolve within 2 weeks.

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