THE CHILD WITH A LIMP Madesa Espana, MD, FAAP Pediatric Emergency Medicine St. Joseph’s Regional Medical Center Paterson, New Jersey

THE CHILD WITH A THE CHILD WITH A LIMPLIMP

Madesa Espana, MD, FAAPMadesa Espana, MD, FAAP

Pediatric Emergency MedicinePediatric Emergency Medicine

St. Joseph’s Regional Medical St. Joseph’s Regional Medical CenterCenter

Paterson, New JerseyPaterson, New Jersey

LIMPLIMP

An uneven, jerky or laborious gait, An uneven, jerky or laborious gait, usually caused by pain, weakness or usually caused by pain, weakness or deformity.deformity.

4/1000 visits in a pediatric ED4/1000 visits in a pediatric ED

A CHILD WITH A LIMPA CHILD WITH A LIMP

EpidemiologyEpidemiology– Median age: 4 years oldMedian age: 4 years old– Male:female ratio: 2:1Male:female ratio: 2:1– Most common diagnosis: Transient Most common diagnosis: Transient

synovitissynovitis– Pain is present in 80% of casesPain is present in 80% of cases– Localization: hip and kneeLocalization: hip and knee– Benign cause: 77%Benign cause: 77%

THE CHILD WITH A LIMPTHE CHILD WITH A LIMP

HISTORYHISTORY– DurationDuration– TraumaTrauma– FeverFever


HISTORYHISTORY– Location of the painLocation of the pain– Pain characteristicsPain characteristics

Constant severe painConstant severe pain Intermittent mild to moderate painIntermittent mild to moderate pain Bilateral painBilateral pain Modifying factorsModifying factors


HISTORYHISTORY– Other symptomsOther symptoms

Morning stiffnessMorning stiffness Incontinence, weakness or sciaticaIncontinence, weakness or sciatica Recent viral or bacterial illnessRecent viral or bacterial illness Recent medicationsRecent medications Endocrine and other systemic diseasesEndocrine and other systemic diseases


PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– General appearanceGeneral appearance

Ill or toxic appearingIll or toxic appearing FeverFever Obvious discomfort/pain at restObvious discomfort/pain at rest


PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– Gait evaluationGait evaluation

Phases of a gaitPhases of a gait– Stance: time when the foot is in contact Stance: time when the foot is in contact

with the surfacewith the surface Heel-strike to toe flat (contact)Heel-strike to toe flat (contact) Foot-flat to heel-off (mid-stance)Foot-flat to heel-off (mid-stance) Heel-lift to toe off (propulsion)Heel-lift to toe off (propulsion)

– Swing: time from toe-off to heel strikeSwing: time from toe-off to heel strike


PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– Young child (<4 years) vs. adult gaitYoung child (<4 years) vs. adult gait

Increased flexion of the hips, knees and Increased flexion of the hips, knees and anklesankles

Rotation of the feet externally, wider Rotation of the feet externally, wider base of supportbase of support

Faster cadence, slower velocity, Faster cadence, slower velocity, shorter stride lengthshorter stride length

Smaller percentage of the gait cycle is Smaller percentage of the gait cycle is spent in single limb stancespent in single limb stance


PYSICAL EXAMINATIONPYSICAL EXAMINATION– Gait examinationGait examination

Expose the legsExpose the legs Bare feet or wearing only a pair of Bare feet or wearing only a pair of

sockssocks Listening to the gaitListening to the gait

– CadenceCadence– Foot slapFoot slap– ScrapingScraping


PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– Gait examinationGait examination

Observe several gait cyclesObserve several gait cycles Includes jumping/hoppingIncludes jumping/hopping

Gait evaluationGait evaluation


PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– MusculoskeletalMusculoskeletal

Muscle strengthMuscle strength Muscular atrophyMuscular atrophy Bony tendernessBony tenderness Bony deformityBony deformity


PHYSCIAL EXAMINATONPHYSCIAL EXAMINATON– MusculoskeletalMusculoskeletal

Active and passive ROMActive and passive ROM Joint swelling/tendernessJoint swelling/tenderness Muscle tendernessMuscle tenderness Tenderness on the tendons, insertions Tenderness on the tendons, insertions

sitessites



Back and spineBack and spine HipHip ThighThigh KneeKnee LegLeg AnkleAnkle FootFoot



Limb length discrepancyLimb length discrepancy Hip rotationHip rotation Galeazzi testGaleazzi test Trendelenburg testTrendelenburg test FABERE testFABERE test


PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– SkinSkin

BruisesBruises Rashes and other lesionsRashes and other lesions SwellingSwelling RednessRedness TendernessTenderness


PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– LymphaticLymphatic

LymphadenopathyLymphadenopathy– Localized vs. systemicLocalized vs. systemic

LymphadenitisLymphadenitis LymphangitisLymphangitis


PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– NeurologicNeurologic

Muscle strengthMuscle strength Muscle toneMuscle tone DTR’sDTR’s


PHYSICAL EXAMINATIONPHYSICAL EXAMINATION– GastroentestinalGastroentestinal

Abdominal tendernessAbdominal tenderness Abdominal swellingAbdominal swelling

– GenitourinaryGenitourinary Testicular or scrotal pain/swellingTesticular or scrotal pain/swelling Inguinal swellingInguinal swelling


DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– Age of the childAge of the child– Location of abnormal findingsLocation of abnormal findings– Duration of symptomsDuration of symptoms– Type of gait abnormalityType of gait abnormality


DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– OSSEOUSOSSEOUS

FracturesFractures– Salter-Harris or growth plate injuriesSalter-Harris or growth plate injuries– Toddler’s: tibia, calcaneous and cuboidToddler’s: tibia, calcaneous and cuboid– StressStress– Incomplete: buckle, greenstickIncomplete: buckle, greenstick– Complete Complete – Plastic or bowing deformityPlastic or bowing deformity– AvulsionAvulsion– Child abuse: bucket-handle fracturesChild abuse: bucket-handle fractures



ApophysitisApophysitis– Sinding-Larsen-Johnson diseaseSinding-Larsen-Johnson disease– Kohler diseaseKohler disease– Sever diseaseSever disease– Freiberg diseaseFreiberg disease– Osgood-schlater diseaseOsgood-schlater disease



Vasoocclussive crisis of SCDVasoocclussive crisis of SCD Slipped capital femoral epiphysisSlipped capital femoral epiphysis Legg-Calve-Perthes diseaseLegg-Calve-Perthes disease


DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– TUMORSTUMORS

LeukemiaLeukemia LymphomaLymphoma Spinal cord tumorSpinal cord tumor Osteogenic sarcomaOsteogenic sarcoma Ewing’s sarcomaEwing’s sarcoma Osteoid sarcomaOsteoid sarcoma Metastatic neuroblastomaMetastatic neuroblastoma


DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– ARTICULARARTICULAR

Transient synovitis of the hipTransient synovitis of the hip Septic arthritisSeptic arthritis Osteochondritis dessicansOsteochondritis dessicans Acute rheumatic feverAcute rheumatic fever Juvenile rheumatoid arthritisJuvenile rheumatoid arthritis



Serum sicknessSerum sickness DiscitisDiscitis Developmental dysplasia of the hipDevelopmental dysplasia of the hip Chondromalacia of the patellaChondromalacia of the patella Hemarthrosis: traumatic, hemophiliaHemarthrosis: traumatic, hemophilia



Henoch-Schonlein purpuraHenoch-Schonlein purpura Lyme diseaseLyme disease SLESLE Patellar dislocationPatellar dislocation


DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– SOFT TISSUESOFT TISSUE

ContusionContusion Muscle strainMuscle strain SprainSprain TendonitisTendonitis Viral myositisViral myositis Foreign bodyForeign body



CellulitisCellulitis AbscessAbscess PyomyositisPyomyositis IM vaccinationIM vaccination Insect envenomationInsect envenomation Plantar wartsPlantar warts



BunionBunion Ingrown toenailIngrown toenail Baker’s cyst ruptureBaker’s cyst rupture Myositis ossificansMyositis ossificans BursitisBursitis Benign hypermobility syndromeBenign hypermobility syndrome


DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– NEUROLOGICALNEUROLOGICAL

Meningitis/Intracranial abscessMeningitis/Intracranial abscess Cerebral palsyCerebral palsy Peripheral neuropathyPeripheral neuropathy Epidural abscessEpidural abscess Spinal cord tumorSpinal cord tumor Complex regional pain syndrome (reflex Complex regional pain syndrome (reflex

sympathetic dystrophy)sympathetic dystrophy)


DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– INTRA-ABDOMINALINTRA-ABDOMINAL

AppendicitisAppendicitis PIDPID Pelvic abscessPelvic abscess Psoas abscessPsoas abscess Perirectal abscessPerirectal abscess Iliac adenitisIliac adenitis


DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– GENITO-URINARYGENITO-URINARY

Incarcerated inguinal herniaIncarcerated inguinal hernia Testicular torsionTesticular torsion STD’sSTD’s


DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– PSYCHIATRICPSYCHIATRIC

Conversion disorderConversion disorder MalingeringMalingering


DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES– DERMATOLOGICDERMATOLOGIC

Erythema multiformeErythema multiforme

– VASCULARVASCULAR Henoch-schonlein purpuraHenoch-schonlein purpura

THE CHILD WITH A LIMPTHE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES

LIFE OR LIMB-THREATENING CAUSES OFLIFE OR LIMB-THREATENING CAUSES OFLIMP IN CHILDRENLIMP IN CHILDREN

Septic arthritisSeptic arthritis SCFESCFE OsteomyelitisOsteomyelitis FractureFracture

TumorsTumors AppendicitisAppendicitisTesticular torsionTesticular torsion DiscitisDiscitisMeningitisMeningitis Epidural abscessEpidural abscessDevelopmental dysplasia of the hipDevelopmental dysplasia of the hip

CAUSES OF LIMP IN CAUSES OF LIMP IN CHILDREN OF ALL AGESCHILDREN OF ALL AGES

ACUTEACUTE– ContusionContusion– Foreign bodyForeign body– FractureFracture– OsteomyelitisOsteomyelitis– Reactive arthritisReactive arthritis– Septic arthritisSeptic arthritis– Transient Transient

synovitissynovitis– Lyme arthritisLyme arthritis– Poor shoe fitPoor shoe fit

CHRONICCHRONIC– Rheumatic Rheumatic

diseasedisease JRAJRA Acute rheumatic Acute rheumatic

feverfever SLESLE Inflammatory Inflammatory

bowel diseasebowel disease


SEPTIC ATHRITISSEPTIC ATHRITIS– Clinical signs/symptomsClinical signs/symptoms

FeverFever PainPain Decreased ROMDecreased ROM Minor traumaMinor trauma


SEPTIC ARTHRITISSEPTIC ARTHRITIS– Clinical signs/symptomsClinical signs/symptoms

Toxic or ill appearanceToxic or ill appearance Painful ROMPainful ROM Joint effusionJoint effusion Warmth/erythemaWarmth/erythema


SEPTIC ARTHRITISSEPTIC ARTHRITIS– Laboratory findingsLaboratory findings

Elevated WBC count with left shiftElevated WBC count with left shift Elevated ESRElevated ESR Elevated CRPElevated CRP Positive blood culture Positive blood culture


SEPTIC ARTHRITISSEPTIC ARTHRITIS– Laboratory findingsLaboratory findings

Synovial fluid analysisSynovial fluid analysis– Volume > 3.5 mlVolume > 3.5 ml– Clarity: opaqueClarity: opaque– Color: yellow to greenColor: yellow to green– WBC: > 100,000/mm3, >75% PMN’sWBC: > 100,000/mm3, >75% PMN’s– Gram stain/Culture: positiveGram stain/Culture: positive– Total protein: 3 – 5 g/dlTotal protein: 3 – 5 g/dl– Glucose: <25 mg/dlGlucose: <25 mg/dl– LDH: variable compared to blood levelLDH: variable compared to blood level


SEPTIC ARTHRITISSEPTIC ARTHRITIS– Common organismsCommon organisms

Staphylococcus aureusStaphylococcus aureus Beta hemolytic streptococcusBeta hemolytic streptococcus Group A strepGroup A strep Hemophilus influenzaeHemophilus influenzae Neisseria gonorrheaNeisseria gonorrhea


SEPTIC ARTHRITISSEPTIC ARTHRITIS– Radiologic findingsRadiologic findings

Plain films:Plain films:– Soft tissue swellingSoft tissue swelling– Widened joint spaceWidened joint space– Periosteal reaction of the adjacent bone, Periosteal reaction of the adjacent bone,

suggestive of osteomyelitissuggestive of osteomyelitis



UltrasonographyUltrasonography– Increased joint space and amount of joint Increased joint space and amount of joint

fluidfluid– Increased vascularityIncreased vascularity

CT scanCT scan– Joint effusionJoint effusion– Increased vascularityIncreased vascularity– Erosion of the cartillageErosion of the cartillage– Periosteal reaction or osteomyelitisPeriosteal reaction or osteomyelitis



MRIMRI Radionuclide studiesRadionuclide studies

CAUSES OF LIMP IN PRE-CAUSES OF LIMP IN PRE-SCHOOL CHILDREN SCHOOL CHILDREN

ACUTEACUTE– FracturesFractures

Abusive injuriesAbusive injuries Toddler’s fractureToddler’s fracture Salter I fracturesSalter I fractures

– HemarthrosisHemarthrosis– HSPHSP– Septic hipSeptic hip– IM shotsIM shots– Toxic synovitisToxic synovitis

CHRONICCHRONIC– Blount diseaseBlount disease– Cerebral palsyCerebral palsy– Developmental Developmental

dysplasia of the dysplasia of the hiphip

– DiscitisDiscitis– Kohler diseaseKohler disease– Leg length Leg length

discrepancydiscrepancy– Vertical talusVertical talus

CAUSES OF LIMP IN CAUSES OF LIMP IN SCHOOL-AGE CHILDREN SCHOOL-AGE CHILDREN

ACUTEACUTE– FracturesFractures– MyositisMyositis

CHRONICCHRONIC– Legg-calve-Legg-calve-

Perthes diseasePerthes disease– Baker cystBaker cyst– Kohler diseaseKohler disease– LeukemiaLeukemia– Spinal Spinal

dysraphism dysraphism (tethered cord)(tethered cord)

– Tarsal coalitionTarsal coalition


LEGG-CALVE-PERTHES DISEASELEGG-CALVE-PERTHES DISEASE– Idiopathic vascular necrosis of the Idiopathic vascular necrosis of the

femoral headfemoral head– More common in boysMore common in boys– Common in 5 – 9 years old, may affect 2 Common in 5 – 9 years old, may affect 2

– 11 years old– 11 years old– Transitional stage of development of the Transitional stage of development of the

vascular anatomy of the femur vascular anatomy of the femur


LEGG-CALVE-PERTHES DISEASELEGG-CALVE-PERTHES DISEASE– Preceding history of minor traumaPreceding history of minor trauma– Predisposing factorsPredisposing factors

SCDSCD Steroid useSteroid use Hip dysplasiaHip dysplasia


LEGG-CALVE-PERTHES DISEASELEGG-CALVE-PERTHES DISEASE– Radiologic studiesRadiologic studies

Plain filmsPlain films Radioisotope studiesRadioisotope studies MRIMRI


KOHLER DISEASEKOHLER DISEASE– Affects more boys than girlsAffects more boys than girls– Most common in 5 – 10 years old, as Most common in 5 – 10 years old, as

early as 2 years oldearly as 2 years old– Impaired perfusion to the navicular bone Impaired perfusion to the navicular bone

of the talusof the talus– Inflammatory changes over the Inflammatory changes over the

navicular bonenavicular bone


KOHLER DISEASEKOHLER DISEASE– TreatmentTreatment

Weight bearing with below the knee Weight bearing with below the knee cast followed by arch supportcast followed by arch support

CAUSES OF LIMP IN CAUSES OF LIMP IN ADOLESCENTSADOLESCENTS

ACUTEACUTE– SprainSprain– StrainStrain– TendonitisTendonitis

CHRONICCHRONIC– ArthritisArthritis– Herniated discHerniated disc– SCFESCFE– ScoliosisScoliosis– Spinal Spinal

dysraphismdysraphism– SpondylolisthesisSpondylolisthesis– Chondromalacia Chondromalacia – RSDRSD– Osgood-SchlatterOsgood-Schlatter


OSGOOD-SCHLATTER DISEASEOSGOOD-SCHLATTER DISEASE– Over use injury affecting the insertion Over use injury affecting the insertion

site of the patellar tendon on the anterior site of the patellar tendon on the anterior tibial tubercletibial tubercle

– Inflammatory changes over the tubercleInflammatory changes over the tubercle– Treatment goal: decrease the stress on Treatment goal: decrease the stress on

the tuberclethe tubercle RestRest CastCast Excision of an ossicle Excision of an ossicle

Surface Anatomy of the Surface Anatomy of the KneeKnee

Saggital view of the kneeSaggital view of the knee

Osgood-Schlatter Disease Osgood-Schlatter Disease radiographsradiographs


SINDING-JOHANSSON-LARSEN SINDING-JOHANSSON-LARSEN DISEASEDISEASE– Traction tendinitis of the proximal Traction tendinitis of the proximal

attachment of the patellar tendon attachment of the patellar tendon (inferior pole of the patella)(inferior pole of the patella)

– Boys more than girlsBoys more than girls– Age of presentation: 10 –16 years old Age of presentation: 10 –16 years old – Overuse injury, athletesOveruse injury, athletes


SINDING-JOHANSSON-LARSEN SINDING-JOHANSSON-LARSEN DISEASEDISEASE– Radiologic findingsRadiologic findings

Irregular calcification of the inferior Irregular calcification of the inferior pole of the patellapole of the patella

– TreatmentTreatment RestRest CastCast


SLIPPED CAPITAL FEMORAL EPIPYSIS SLIPPED CAPITAL FEMORAL EPIPYSIS (SCFE)(SCFE)– Epiphyseal dislocation in superolateral Epiphyseal dislocation in superolateral

displacement and external rotation of displacement and external rotation of the femoral metaphysis, Salter I injurythe femoral metaphysis, Salter I injury

– Causes kinking of the epiphyseal vessels Causes kinking of the epiphyseal vessels that leads to compromised blood to the that leads to compromised blood to the epiphysisepiphysis


SCFESCFE– IncidenceIncidence

10/10000010/100000– Boys: 13.5, Girls 8.5/100000Boys: 13.5, Girls 8.5/100000

Regional and seasonal variationRegional and seasonal variation Initial presentation 20% bilateral hipInitial presentation 20% bilateral hip

– 20 – 40% eventually develop bilateral 20 – 40% eventually develop bilateral involvement within 18 months of initial involvement within 18 months of initial presentationpresentation


SCFESCFE– Radiologic classificationRadiologic classification

I: < 33%I: < 33% II: 33 – 50%II: 33 – 50% III: > 50%III: > 50% Displacement in relation to the femoral Displacement in relation to the femoral

neckneck


TreatmentTreatment– Depends on the onset of symptoms and Depends on the onset of symptoms and

gradegrade– Internal fixation with single cannulated Internal fixation with single cannulated

screwscrew– Prophylactic fixation of the unaffected Prophylactic fixation of the unaffected

hiphip– Osteomy of the proximal femurOsteomy of the proximal femur

SCFE radiographsSCFE radiographs


LABORATORY STUDIESLABORATORY STUDIES– Blood testsBlood tests

CBC, differential CBC, differential ESRESR CRProteinCRProtein Blood cultureBlood culture Lyme studiesLyme studies ANAANA ASOASO


LABORATORY STUDIESLABORATORY STUDIES– Normal synovial fluid characteristicsNormal synovial fluid characteristics

Highly viscousHighly viscous ClearClear Essentially acellularEssentially acellular Protein concentration is 1/3 of plasma Protein concentration is 1/3 of plasma

proteinprotein Glucose concentration is similar to Glucose concentration is similar to

plasma plasma


LABORATORY STUDIESLABORATORY STUDIES– Components of synovial fluid analysisComponents of synovial fluid analysis

ClarityClarity ColorColor ViscosityViscosity Glucose contentGlucose content Protein contentProtein content


LABORATORY STUDIESLABORATORY STUDIES– Components of synovial fluid analysisComponents of synovial fluid analysis

Microscopic examinationMicroscopic examination– WBC countWBC count– Crystal searchCrystal search– Gram satinGram satin

CultureCulture– Routine bacterial cultureRoutine bacterial culture– GC cultureGC culture– Unusual organismsUnusual organisms


RADIOLOGIC TESTSRADIOLOGIC TESTS– Plain radiographsPlain radiographs

Affected siteAffected site Comparison viewsComparison views Skeletal surveySkeletal survey


RADIOLOGIC TESTSRADIOLOGIC TESTS– MRIMRI– Radionuclide studiesRadionuclide studies– UltrasonographyUltrasonography– CT scanCT scan


DISPOSITIONDISPOSITION– In-patientIn-patient

IV antibioticsIV antibiotics Diagnostic work-upDiagnostic work-up Surgical interventionSurgical intervention

– Out-patientOut-patient Observation with close follow upObservation with close follow up NSAID’sNSAID’s Sub-specialty referralsSub-specialty referrals


DISPOSITIONDISPOSITION– ConsultationConsultation

OrthopedicOrthopedic– Joint aspirationJoint aspiration– Surgical interventionSurgical intervention

Hematology-OncologyHematology-Oncology– Bone marrow aspirationBone marrow aspiration– ChemotherapyChemotherapy



Gynecologic Gynecologic – Pelvic examinationPelvic examination– Surgical interventionSurgical intervention

UrologyUrology– Surgical interventionSurgical intervention



NeurosurgeryNeurosurgery Pediatric or general surgeryPediatric or general surgery

– Surgical interventionSurgical intervention

Infectious diseaseInfectious disease– Choice of antibioticsChoice of antibiotics– Length of treatmentLength of treatment



RheumatologyRheumatology Pain specialistPain specialist PsychiatryPsychiatry PhysiatryPhysiatry

– Physical/occupational therapyPhysical/occupational therapy– OrthoticsOrthotics


DISPOSITIONDISPOSITION– Diagnoses that require immediate Diagnoses that require immediate

interventionintervention Septic arthritisSeptic arthritis OsteomyelitisOsteomyelitis MeningitisMeningitis Epidural abscessEpidural abscess



interventionintervention FracturesFractures Dislocated patellaDislocated patella SCFESCFE Developmental dysplasia of the hipDevelopmental dysplasia of the hip



interventionintervention Neoplasms/tumorsNeoplasms/tumors Testicular torsionTesticular torsion AppendicitisAppendicitis PID with tuboovarian abscessPID with tuboovarian abscess DiscitisDiscitis

Documents

THE CHILD WITH A LIMP Madesa Espana, MD, FAAP Pediatric Emergency Medicine St. Joseph’s Regional Medical Center Paterson, New Jersey