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Limping Pediatric Diagnosis and Orthopedics: The Challenge of the Limping Child
Suraj Achar, MD, FAAFP
ACTIVITY DISCLAIMERThe material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.
The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.
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DISCLOSUREIt is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.
All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.
The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.
Suraj Achar, MD, FAAFP Professor, Department of Family Medicine and Public Health, Department of Orthopaedics, University of California, San Diego (UCSD); Professor, Department of Orthopedics, Rady Children’s Hospital, San Diego, California; Team Physician, UCSD Varsity Teams, San Diego Padres, San Diego Sockers, United States Olympic Training Center
Dr. Achar earned his medical degree from State University of New York (SUNY) Buffalo School of Medicine and Biomedical Sciences. He completed his residency and fellowship at the University of California, San Diego (UCSD). He is board-certified in family medicine and sports medicine, practicing at UCSD and Rady Children’s Hospital. His specialty topics include pediatric sports medicine and the legal aspects of medicine. At UCSD, Dr. Achar cares for a wide variety of patients, including professional and Olympic athletes. He is the editor of The 5-Minute Sports Medicine Consult and is consistently named a top doctor by the San Diego County Medical Society.
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Learning Objectives1. Use an evidence-based, systematic approach to diagnosing children
with deviations from normal age-appropriate gait patterns.
2. Order or provide appropriate laboratory tests and imaging studies to confirm diagnosis, as suggested by the history and physical examination.
3. Coordinate referral and follow-up care with a pediatric orthopedic surgeon, or other sub-specialist, as indicated by confirmation of the diagnosis.
4. Counsel parents on developmental milestones to evaluate in their children.
Audience Engagement SystemStep 1 Step 2 Step 3
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Epidemiology of the problemAdirim TA, Cheng TL, Overview of Injuries in
the young athlete. Sports Med 2003
• 27/51 million play team sports
– The hidden demographics of youth sports, ESPN July 2013
– Aspen Institute• > 1/3 injury doctor or nurse/year
– 20% of ER visits for age group
• Boys>Girls, Peak 10-12, > obesityhttp://espn.go.com/espn/story/_/id/9469252/hidden‐demographics‐youth‐sports‐espn‐magazinehttp://www.aspeninstitute.org/sites/default/files/content/images/sports/youth_web_graphic_sports.pnghttp://en.wikipedia.org/wiki/Health_issues_in_youth_sports#mediaviewer/File:Rocky_Mountain_High_School,_football_field.jpg
Youth sports participation2011‐>2016
Income Disparity
>100,000
68% (increasing)
50‐74K
53% (increasing)
<25K
34% (rapid drop)
↓Par cipa on
Team sports
41.5‐>36.9
Individual sports 53.249.8
https://en.wikipedia.org/wiki/FIFA_World_Cup#/media/File:FIFA_‐_replica_world_cup_trophy.JPG
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Limping: What is
the cause?
•minor trauma, apophysitis•minor trauma, apophysitisAcute < 1 week
•Older children will “play through” the pain
•Younger children (history?)
•Growth plate fracture, apophysis, osteochondrosis
•Infection /Inflammation Transient synovitis of the hip?
•Rheumatologic JRA (no simple test)
•Tumors benign to life threatening
•Older children will “play through” the pain
•Younger children (history?)
•Growth plate fracture, apophysis, osteochondrosis
•Infection /Inflammation Transient synovitis of the hip?
•Rheumatologic JRA (no simple test)
•Tumors benign to life threatening
Subacute >
(1 week)
(trivial to life threatening?)
Peds ED: Limp Ø trauma243, Med age 4
• What was the most common diagnosis?
• Transient synovitis or irritable hip were the most common diagnoses 40% • 77%: benign cause
• Painful or not?
• Painful in 80%• Pain Location: hip 34%, knee 19%
• Fischer SU, Beattie TF. The limping child: epidemiology, assessment and outcome. J Bone Joint Surg Br 1999;81:1029–1034
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How does the history help us?
Constant painFractures
infections, sickle crisis
Night symptomsNeoplastic: leukemia, osteogenic sarcoma, osteoid osteoma
Preference to crawl foot pain?
Ill appearance
Infectious or inflammatory etiology
(fever)
Besides words?
Invincible Children?Factors behind injury!• Pressure to compete!
• 5 y/o who practice soccer everyday
• Female gymnasts & dancer
• overtrain & undereat
• 500,000 kids who use AAS/yearly
• Biomechanical factors
• surface area/mass
• head/body
• Equipment too big
• Vulnerable growing cartilage:
• Apophysitis, Physeal injuries
• Complex motor skills‐> Improper mechanics?
• Swimmers
• Throwers‐slider!
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History
• Age
• Onset: Night pain?
• Location of pain?
• Constitutional symptoms:
• Trauma?
• Growing pains???
http://en.wikipedia.org/wiki/Transverse_myelitis#mediaviewer/File:Transverse_myelitis_MRI.jpg
AES Question #1
• What is c/w growing pains?
A. Focal PE findings
B. Fever
C. Able to play sports
D. Night pain wakes child up
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6 y/o boy 1994: Rady Childrens SD• Fall off skateboard
• Unable to ambulate
• Knee pain xray nl?
• Dx: contusion Home
• Radiology: Day 2
• Noted lesion
• Faxed to PMD
• What happened?
http://en.wikipedia.org/wiki/File:Ewing_sarcoma_tibia_child.jpghttp://en.wikipedia.org/wiki/File:Samfax.jpg
Birth to 2 years
Infection
• Septic Arthritis
• Osteomyelitis
Developmental
• DDH
Trauma
• Child abuse
• 50% of abuse related skeletal injuries occur <12m
• (unintentional fractures rare <12m)
• Fracture
Misc
• CP
• Neuromuscular Disease
2-10 years
Infectious Inflammatory
• Transient synovitis of hip
• Septic arthritis
• Sickle cell
• Osteomyelitis
• JRA
Trauma
• Physeal Fractures/Toddlers Fracture
• Puncture Wound/Sprain/Contusion
Osteochondroses
• LCP
Neoplasia (0.8-2%)
• Leukemia, Osteosarcoma
Age?
Age?
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6 year old with heel pain, Korean
• 6 y/o previously healthy F
• Fever 6 days t max 40.4C
• Foot pain 3 days
• PMHx
• FOP states she had a front tooth pulled by dentist 6 days ago with subsequent swelling of the gums
• Diff Dx?
PE
• BP 95/56 | P: 125 | T: 37.4 C (99.3 °F) | RR: 28
• Severe TTP posterior aspect of right heel; limited dorsiflexion of right foot d/t pain
• Cried after squeezing
• Redness heel?
• Diff Dx & plan?
• Labs• CRP 3.20 (*) 0.00‐0.99 mg/dl
• ESR: 74 (*) 0‐15 mm
• WBC 17.2 (*) 4.0‐12.0 TH/uL
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What next?
• Small incision over the lateral aspect of the heel• fluoroscopic guidance into the heel and aspirated3 mm of purulent
material that was
• bigger incision was then slightly made and a curette was used to debride the calcaneus.
• The wound was then copiously irrigated. Antibiotics were then given. A drain was then placed
• 3+ Group A Beta Streptococcus (Abnormal)
https://en.wikipedia.org/wiki/Hemolysis_(microbiology)https://en.wikipedia.org/wiki/Streptococcal_pharyngitis
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Comparison of Imaging Modalities in Diagnosis of Osteomyelitis
Imaging modality Sensitivity (%) Specificity (%)
MRI 88 93
Bone Scan 76 99
Plain radiographs 24 79
AES Question #2
6 month old ER evaluation
• Parents: Fussy child won’t move leg
• No reported trauma
• X-ray: Femur fracture
• Family no idea how this could happen???
• Should you contact CPS for suspected abuse?
1. Yes
2. No
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Trauma?Toddlers fractures—CAST(childhood accidental spiral tibial fractures)
trivial trauma that can cause this injury may often be unknown or overlooked by the caregiver Distal ½ of tibia43% of initial x-rays negativeUndisplaced & spiral
Misleading!Retrospective Study:
163 infants and children with osteo-myelitis of the long boneshistory of preceding blunt trauma was elicited in 1/3?
What is wrong with this image?
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Physical Exam
• Temperature
• Gait Eval?
• + Joint exam
• Physical Bone survey
Active 10yo F: L knee pain 3‐4 months. Pain started with soccer, but has increased to pain with just walking around.
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Swelling L knee ~ 2 weeks ago which has since resolved after ice & motrin. Mom has tried to back child off from activities, but pushing through & has continued most activities, but with less force.
No prior injury. No numbness, weakness or tingling. ROS: neg
10 y/o soccer player: shoe stuck?
• STRENGTH TESTING: 1/5 strength in knee flexion and extension
• SLJ?
• What to do?
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Surgery vs non‐op?
Non Operative Complications• <ROM
• weakness due to prolonged immobilization
• Risk of OA
• Loss of terminal extension or persistent extension lag
• usually does not compromise function or the ability to return to sport.
• Nonunion is rare
Operative Complications• Infection
• failure of hardware (eg, wires breaking)
• < ROM
• Nonunion
• osteonecrosis
AES Question #3 - Laboratory Analysis:
• Which test is not as useful in the limping child workup
1. CBC
2. ESR
3. C-reactive protein• Days vs hours• ESR (mm/h) < Age (y) +10 (if female)
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• Del Beccaro MA, Champoux AN, Bockers T, Mendelman PM. Septic arthritis versus transient synovitis of the hip: the value of screening laboratory tests. Ann Emerg Med 1992; 21:1418.
Days post inflammatory response
CRP
ESR
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Presidential Fitness Test
A Pill for all ills?
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9 y/o Left knee pain x 2 months, No trauma, 1‐2 x day intermittent, no RxOnset: sitting for a long time and stands up “locking of knee”, also in middle of running
Exam limited flexion, negative Wilson test, X‐ray nl
12 y/o competitive
male Baseball player2
years of right thigh/knee
pain
• No trauma but had 9/10 non-radiating, “aching” and “punching” pain at night
• Sometimes also at baseball practice• Improved with ibuprofen (30min)
• PCP and Urgent care ibuprofen• PCP and diagnosed with growing pains
and then Osgood Schlatter disease after initial x-rays of hip and knee were negative for acute pathology
• Pain persisted over 2 years• He had no associated constitutional
symptoms
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Inspection: Marked atrophy of right quadriceps and calf musculature when compared to left.
Palpation: Unremarkable
ROM: Unremarkable
Strength: ⅘ strength to extension of right knee
Exam
Imaging
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Advanced Imaging
Rx & response
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12 y/o female runner with heel pain
• Diffuse heel pain
• 2 months
• training
• PE:
• squeeze test
• Tight heel cord
Severʼs Disease‐ Traction ApophysitisAnalogous to Osgood‐Schlatterʼs Disease
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Severʼs Disease
• History
• Occurs during peak growth spurt.
• Running and jumping sports, particularly soccer..
• Physical Exam
• + squeeze test & tight heel cords.
• X‐ray‐serve to r/o other pathology
Treatment & Prognosis
• P®ICE
• Heel lifts
• Stretching & strengthening exercises
• Acetaminophen/NSAIDS
• Symptoms resolve in 98%
• RTP 2 months
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14 month old boy
• HPI:• R toes outward?
• PMHx & Birth Hx-wnl• Development Hx: wnl • Child began walking at age 12
months.
• PE
• Asymmetric skin-folds• Limited abduction L
What test can lead to diagnosis?
AP Pelvis
Broken Shentonʼs line
> Acetabular Angle
https://en.wikipedia.org/wiki/Hip_dysplasia
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Developmental Dysplasia of the Hip (DDH)
• Definition• Spectrum of abnormalities
• Instability -> frank dislocation
• Acetabular malformations
• Before or after birth?
AES Question #4
Which of the following is not a risk factor for DDH?
1. Male sex
2. Breech presentation
3. Torticollis
4. 1st birth
5. Club foot
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DDH: Incidence and Etiology?• Genetics vs Environment?
• North American Indians: 25‐50/1,000
• Chinese & Black Africans~0
• Hx: Japan: 3.5%‐>0.2%
• Papoose board
• Familial incidence ~ 20%
https://en.wikipedia.org/wiki/Papoose#/media/File:Edward_S._Curtis_Collection_People_007.jpgJapan: 3.5%->0.2% when cradle board was discouraged
What is the best test to identify developmental dysplasia of the hip in a 2-week-old newborn?
Ortolani & Barlow tests
Dynamic ultrasound
X‐ray studies
All of the above
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Diagnosis DDH: 0-8w
• Ortolani
• BarlowClick vs Clunk?
Ultrasound
• Costly!/Training?
• Screening: • > 6 weeks c inconclusive
exam
• Confirm reduction/Monitor • (real time Ortolani/Barlow)
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Pavlik harness.
• Czech orthopedic Surgeon 1958
• Efficacy!• 90% success in 2-4w
• +ortolani predictor!
• Positioning & risk?
• Duration • 3m<3m, or 2x age for infants
Most sensitive
sign of late DDH
1. Asymmetry of thigh folds
2. Asymmetry of hip abduction
3. Clear discrepancy of knee heights
AES Question #5
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Missed DDHMed/legal Implications
• Leading cause of malpractice lawsuits
• DDH exam
• every well visit until walking
• Explain to parents
• Document!
• Double diaper ?
Case 25 y/o
boyAcute L thigh pain
• Onset: 2am?
• ROS:
• PE• Temp 99.4 AVSS• Irritable
• Hip flexed, abducted and ER
• TTP ant thigh• Antalgic gait• Painful ROM
• Dx: cellulitis?
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Case 2: Evaluation?
• Day 1(8hrs post symptoms)• WBC 16,000
• Day 2 • ESR-34• CRP< 0.5 (0-1.0mg/dl =nl)• WBC-11.6 49s,0b
AES Question #6
What is the gold standard diagnostic test? ARS
1. CBC
2. C-reactive protein
3. Blood culture
4. Hip aspiration
5. Ultrasound
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Transient synovitis of the hip(toxic synovitis)
• Dx of exclusion!!!• Septic arthritis?
• Most common cause of the limping child?
• Self limiting!
• Etiology?
• Age range 18m-12y
• Boys>girls (2:1)
• BL in 5%
Transient synovitis of the hipHistory
HxHx
URI, pharyngitis or mild trauma??
URI, pharyngitis or mild trauma??
Acute Onset < 2 weeks
Acute Onset < 2 weeks
All patients limp‐>All patients limp‐>refusal to ambulate?refusal to ambulate?
Night pain?Night pain?
Radiation to thigh, or knee?
Radiation to thigh, or knee?
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Synovitis: Exam
Low grade fever
(<101F) c nl VS
Low grade fever
(<101F) c nl VS
• Modified Log Roll >30°Painful ROMPainful ROM
• Flexion, abduction, ER
• (maximizes joint volume)
Hip position?
Hip position?
TSHDx studies (Significant Overlap!)
• WBC?
• ESR (CRP)-
% of pts with ESR >30mm/hr
Del Beccaro, Ann Emerg Med
• X-ray-• medial joint clear space?
• Ultrasound –• hip joint effusion in 95%• Echogenicity?
Transient synovitis 28%
Septic hip arthritis 79%
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Clinical Variables Suggestive of Septic Arthritis
• CRP > 20mg/l• Temp> 38.5C
• ESR >20mm/hr• Temp >37.5C
• Hx of Fever• Non-weight bearing• WBC >12,000• ESR >40mm/hr/Or CRP> 2.0
• 100% sensitivity
• 87% specificity
• 97% for SA
• 3% if ¼
• 40% if 2/4
• 93% if ¾• 99.6% if 4/4
• 4 of 34 children who met one or none of these criteria had +hip aspiration
Kunnamo
Del Beccaro
Kocher
Rx & F/U: Transient synovitis of the hip
• Symptomatic• Duration: 2 weeks• Ultrasound not
diagnostic• 2/3 resolve < 1 week• Pain > 1 month?
• 12%• Recurrence rate
• 4-15%• LCP (4/192)
• Royle SG, Galasko CS. The irritable hip. Scintigraphy in 192 children. Acta Orthop Scand 1992; 63:25.
• Gough‐Palmer A, McHugh K. Investigating hip pain in a well child. BMJ 2007; 334:1216.
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Septic Arthritis
Historically difficult to treat
Etiology and Incidence?
Peak age <2y/o
M>F 2:1
75% LE: Knee>hip
How much time do we have?
• Prognosis/Time to Rx?• 9 children treated < 5d
• no morbidity1
• 11 children treated >1 week• 9/11 had
complications ->AVN, growth arrest ->chronic pain, limited ROM1
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10y6m African-American F
• ~ two months ago while swimming
• “Hurts while walking”• Ibuprofen +/‐
“pop in my hip”
• Obese
• Antalgic gait
• ROM‐<IR and painExam:
Case 3 - AP Pelvis and “Frog Leg” lateral
• “Klein line” • lateral displacement of femoral neck
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Slipped Capital Femoral Epiphysis
• Most common cause of adolescent limp
• Incidence• 2/100,000M/F=2.5:1L>R?
• Peak incidence• early adolescent growth spurt.
http://commons.wikimedia.org/wiki/File:Epilys.jpg
Etiology of SCFE
• Multifactorial
• Obesity ‐>Excessive mechanical shear
• Metabolic syndrome
• Biologic susceptibility of adolescent physis
• Genetic predisposition
• 4 cases in 1 family!1
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Dx of SCFE
• Dull hip pain radiate to knee?
• Pain during activity
• Acute/chronic
History
• Antalgic gait
PE
• Obligate external rotation with flexion
<ROM on IR & ER
Slipped Capital Femoral Epiphysis
• Treatment:• No weight bearing!• Surgical Fixation-ASAP
• Reduce???
• RTP?
• Bilateral SCFE ~35%. • 1/3 at presentation• 2/3 ~18m
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PT can’t hurt? 11/2712/18/12
8y5m F 1year c/o
LBP
• 2 m hx of limp, favoring L
• No constitutional symptoms
• No PMH
• Birth & Development• NSVD• Walked at 10 m
• Dx: Growing pains
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PE
• 75lbs, AVSS
• Nl spine?
• Pelvis is non tender
• Mild TTP L ant groin
• ROM• ® F-120, Abd-70, ER-60, IR-30
• (L) F-120, Adb-45, ER & IR-20
Initial dx (peds chief) “Growing pains”
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Case 3: LCPRx
• Initial RX• Adductor tenotomy• Petri Cast-5m• Non weight bearing in a wheelchair
• Second Rx• Varus derotation osteotomy L proximal femur –
1y6m post dx
• Complete resolution of symptoms 2y• Painfree ROM• F-130, Abd-50, ER-45, IR-10
Legg-Calve-Perthes Disease
• HX:• Described early in 20th century• Dr. Legg from Boston/ Dr.
Perthes from Germany
• DefinitionIschemic necrosis, collapse,
and subsequent repair of the femoral head
AP Pelvis-L LCPL-fragmentation stage
http://commons.wikimedia.org/wiki/File:LeggCalvePerthes2.jpg
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Etiology???Unknown!
Calve –Ricketts?
Perthes:
infection possibly causing degenerative arthritis leads
to LCP disease.
Genetics? (hypercoagulable state?)
Idiopathic, SCFE, Trauma, steroids, sickle cell,
transient synovitis, DDH
AES Question #7What is consistent with LCP
Overweight children higher risk
1
Delay in skeletal maturation is common
2
Girls>boys
3
Limping is often symptomatic
4
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Legg-Calve-Perthes Disease
• Incidence• Peak 4-9y, • (18m -12 years)
• Risk FactorsMale 4-1Low birth weightDelay in skeletal
maturation?
• History• Limping: often
asymptomatic
• PE• Antalgic gait• < IR• + Roll test
• Dx: • X-ray (+ high index of suspicion because initial radiographs often are normal!)
• MRI & bone scan?
Legg-Calve-Perthes Disease
• Always heals and blood supply always returns 1‐2y
• Relatively benign in 60‐70%
• Outcome worse if >6y/o
Natural Hx
• Observation: Young children with minimal involvement
• Surgery: reposition femoral head in acetabulum to prevent OA
Even though the disease is self‐limiting,
orthopedic referral is necessary to optimize the
outcome
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Legg-Calve-Perthes Disease
• Treatment• All Rx is
controversial!• Crutches: do not
change collapse and are useful only for symptom control
• Bone scans & MRI: add little to clinical management
• Pain control:• Restriction of
activity• Avoidance of
running• NSAIDS
• Bracing +/- surgery
• Motion is lotion?• Swimming and
cycling!
Practice Recommendations
• Physeal and apophyseal injuries are almost universal
• Take care before calling CPS
• Up to 5 days to figure out transient synovitis of the hip
• X-ray all adolescents with hip pain to make sure not to miss SCFE
• Review all films and/or reports for periosteal changes that could be consistent with infection or malignancy
• Consult for any questions or concerns!
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Questions
Contact Information
Suraj Achar MD
Professor UCSD school of medicine
Editor in chief: 5 minute sports medicine consult
