The Limping Child David C Koronkiewicz, D.O. IU Goshen Orthopedics and Sports Medicine I0A 30 th Winter Update 12-2-11

The Limping ChildThe Limping Child

David C Koronkiewicz, D.O.IU Goshen Orthopedics and Sports Medicine

I0A 30th Winter Update

12-2-11

Definition

Limp = Asymmetry• Joint - Range of motion• Bone - Deformity• Pain• Control

The Limping Child

•Diagnosis

•Mechanism

The Limping Child

• Pitfalls• Being misled by the parents’ analysis

• Always a leg length discrepancy

• Being misled by the patient’s complaint• Hip problems can case knee pain

• Complaints of pain

The Limping Child

• Pitfalls• Being misled by the parents’ analysis

• Always a leg length discrepancy

• Being misled by the patient’s complaint• Hip problems can cause knee pain

• Complaints of pain

AGE

NEWBORNINFANT

TODDLER

CHILD

PRE-TEEN

TEENAGER

ADULT

5

COMPLAINS

LIMPS

The Limping Child

Causes of limp• Joint - Range of motion• Bone - Deformity• Pain

--Hip• Control

-Physical exam-X-ray-‘Antalgic’ gait-Abductor lurch

Differential Diagnosis of the Acutely Limping Child

Trauma• Fracture• Stress fracture• Toddler's fracture• Soft tissue contusion• Ankle sprain

Infection• Cellulitis• Osteomyelitis• Septic arthritis• Lyme disease• Tuberculosis of bone• Gonorrhea• Postinfectious reactive arthritis

Tumor•Spinal cord tumors

•Tumors of bone

•Benign: osteoid osteoma, osteoblastoma

•Malignant: osteosarcoma, Ewing's s

sarcoma

•Lymphoma

•Leukemia

Inflammatory

•Juvenile rheumatoid arthritis

•Transient synovitis

•Systemic lupus erythematosus

Differential Diagnosis of the Acutely Limping Child

Congenital• Developmental dysplasia of the hip• Sickle cell• Congenitally short femur• Clubfoot

Developmental• Legg-Calvé-Perthes disease• Slipped capital femoral epiphysis• Tarsal coalitions• Osteochondritis dissecans (knee, talus)

Neurologic• Cerebral palsy, especially

mild hemi paresis

• Hereditary sensory

motor neuropathies

Differential Diagnosis of the Acutely Limping Child by Age

All Ages• Septic arthritis• Osteomyelitis• Cellulitis• Stress fracture• Neoplasm (including

leukemia)• Neuromuscular

Toddler (ages 1-3)• Septic hip• Developmental

dysplasia of the hip• Occult fractures• Leg-length

discrepancy

Differential Diagnosis of the Acutely Limping Child by Age

Child (ages 4 to 10)• Legg-Calvé-Perthes

disease• Transient synovitis• Juvenile rheumatoid

arthritis

Adolescent (ages 11-16)• Slipped capital femoral

epiphysis• Avascular necrosis of

femoral head• Overuse syndromes• Tarsal coalitions• Gonococcal septic arthritis

Too much to cover

The Limping Child

Hip

Best Bets

Age

The Limping Child

• Age 1 – 3 years




• DDH• Developmental Dysplasia of the Hip

• CDH• Congenital Dislocation of the Hip

Best Bet

The Limping Child:Age 1 – 3

1

The Limping Child: Age 1 – 3DDH

Physical findings• Girl• Asymmetrical skin folds• Limited abduction


Physical findings• Short leg• Pistoning• Ortolani’s sign• Barlow’s sign


Feel ClunkFeel Clunk Not hear click Not hear click !

Barlow

( rollout the barrel)

Ortoloni

Barlow & Ortolani Tests

X-ray findings• Delayed appearance of ossific nucleus• Small ossific nucleus• Dysplastic acetabulum• Proximal displacement of femur


22 42


Treatment• 0 – ½: Pavlik harness• ½ – 1½: Closed reduction, cast• 1 ½ - 5 or 8: Open reduction, pelvic osteotomy• Older: Leave dislocated

Pavlik Harness

• Check at 3 weeks to confirm reduction

• Adjust position every 1-2 weeks

• Continue until the hips are clinically and radiolographically normal

• Transient synovitis

• Septic arthritis

Best Bet


s

• Flu

• Tonsillitis2


Transient synovitis• Child refuses to walk• Movement of hip is painful• May have fever• Moderately elevated WBC• Lasts a few days• Disappears without treatment

Transient Synovitis

• Benign, self-limited disorder• Associated with recent URI in 32-50% of children• 30-40% of all non-traumatic limps• Sterile inflammation causing joint effusion• Lasts 2-7 days without intervention• Male:Female is > 2:1• Ages 2-6 (average 4)

Transient Synovitis

• Sudden onset of hip pain• Don’t forget knee pain!!

• Afebrile/low-grade fever (<38.5)• Usually able to ambulate with a limp

• Antalgic gait

• Hip is flexed and externally rotated with mildly decreased ROM• 5% bilateral presentation• 25% with unilateral presentation with effusion on contralateral

hip by ultrasound

Transient Synovitis

Laboratory Evaluation• WBC count <12,000• Mildly elevated ESR (<40); CRP (<2)

• X-Ray• Joint space widening • Discrepancies >2mm between sides

• Ultrasound:• Joint effusion and/or synovial swelling giving an increase in the synovial capsular

complex distance– Distance btwn the posterior surface of the anterior fibrous joint capsule and the anterior

bony surface of the femoral neck

• Bilateral joint effusions in up to 25% of cases of asymtpmatic contralateral hip

J Bone Joint Surg 1999; 81:1662; J Bone Joint Surg 2006; 88A:1253


Septic arthritis• Child refuses to walk• Movement of hip is painful• May have fever• Elevated WBC• Progressively sicker• Progressive joint destruction

WIDENED JOINT SPACE

Transient Synovitis

www.emedicine.com/ped/images/1686.JPG

Transient Synovitis

Treatment• Self-limited after 2-7 days• Bed rest• Ibuprofen

• Decreased pain by 2.5 days Vs Placebo• Mean duration of pain

– ibuprofen: 2 days – placebo: 4.5 days

• 80% of all patients with resolution by 7 days

Annals of Emergency Medicine 2002; 40:3:297

Transient Synovitis

• Prognosis• Generally good• Questionable association with long term

increased risk for developing Legg-Calve-Perthes disease (1-2%)

• Recurrance in 4-15% have been reported

Septic Arthritis

Medical Emergency• Single most important prognostic factor for a good outcome is early

treatment!!!

• Direct entry of bacteria into the joint• S/p puncture injury; hematogenous; contiguous

• Hematogenous osteomyelitis spread is most common in neonates/infants• Blood vessels traverse from the metaphysis to the epiphysis in infants. Physis

formation disrupts this connection

• >50% of neonates with osteomyelitis have associated septic arthritis

Septic Arthritis

• Most common organism: Staph aureus• Neonates: group B strep; gram (-) bacilli• Adolescent: Neisseria gonorrhoeae• Sickle Cell Disease: Salmonella

• Acute inflammatory response• TNF-alpha, IL-1, proteases: destroy the articular cartilage• Continues after eradication of the bacteria

• Associated with high risk of avascular necrosis of the hip• Joint pressure compressing the blood vessels supplying the cartilage and

femoral head

Septic Arthritis

• Fetal breech presentation predisposes to sebsequent development of septic arthritis of the hip. The Pediatric Infectious Disease Journal 2005; 24:650-652

• Propensity for group B strep osteomyelitis to involve the right proximal humerus in infants

• J Pediatrics 1978; 93:578-583

Septic Arthritis

• Usually in previously healthy children < 5 years • Early peak in the first months of infancy • 1/3 of pts with URI’s within the past month

• Acute painful joint with erythema, warmth, swelling and pain on passive movement (knee)• Up to 8% is multifocal• Fever > 38.5• Usually unable to bear weight

• Antalgic gait present if able to bear weight

• Knee is most common joint• Hip, ankle, wrist, elbow, shoulder

Septic Arthritis

• Septic arthritis of the hip DOES NOT present with erythema, warmth or swelling

• Hip is flexed in external rotation and abduction• Relieves intracapsular pressure

• Infants often present with paradoxical irritability, malaise and/or pseudoparalysis of the affected limb• Gentle motion aggravates Vs soothes• Do not necessarily have fevers

Septic Arthritis

• Elevated WBC, ESR, CRP• CRP accurate negative predictor of disease

• Inc. dramatically within 6 hrs after a trigger

• Peaks on D#2 and resolves by D# 7-10• Blood Culture positive in 40-50%+

Septic Arthritis

Aspiration of the hip: definitive diagnosis• Cloudy, turbid• WBC count >50,000; predominately neutrophils• Glucose levels < ½ of serum levels• 50% with positive gram stain• 50-70% with positive culture

• Specific media needed to isolate N. gonorrhoeae

The Limping Child: Age 3 – 6Septic Arthritis

Bacteria

Enzymes

Destroy cartilage

Irreversable joint damage

White cells

Enzymes

Septic Arthritis

Radiographic Findings• Xray findings seen 10 days into disease

• Osteopenia, marked joint space loss, soft-tissue swelling• Ultrasound (both hips)

• Visualize joint effusions at onset• CT/MRI

• Good to r/o abscesses and assess for concurrent osteomyelitis

Septic Arthritis Antibiotic Treatment

Age Organism Antibiotics

<12 mos

staphylococcus, group B streptococcus, and gram-negative bacilli

1st generation cephalosporin

6 mos. to 5 yrs

S. aureus,S. pneumonae, Group A streptococcus, H influenzae

2nd or 3rd generation cepahlosporin

5-12 yrs S. aureus1st generatin cephalosporin

12-18 yrs.

N. gonorrhoeae, S. aureus

oxacillin/cephalosporin

Septic Arthritis

Septic Arthritis

Treatment• IV antibiotics times 2-4 weeks

• Can change to PO if clinically imp with normalizing ESR/CRP on IV therapy, but NOT with septic arthritis of the hip

• Joint drainage• Low-dose dexamethasone for 4 days

• Pediatric Infectious Disease Journal 2003;22:883-888

Treatment1. Kill the bacteria

• Antibiotics

2. Eliminate the white cells• Incision and drainage

3. Don’t delay• 48 hour window


Septic Arthritis

• Prognosis• Good outcome

• Initiation of treatment within 4 days of symptom onset

• Poor outcome• Initiation of treatment after 5 or more days • Severe joint destruction: osteonecrosis

• Lifelong joint pain increased after activities

• Decreased ROM• Leg length discrepancies

• Lifelong limp

Septic Arthritis Vs Transient Synovitis

• Kocher et al. Journal of Bone and Joint Surgery. 1999

• Boston Children’s• Retrospective study

• WBC> 12,000/mm3

• ESR> 40 mm/hr

• Temp > 38.5 Oral

• Refusal to bear weight

• Caird et al. Journal of Bone and Joint Surgery. 2006

• CHOP• Prospective study

• WBC> 12,000/mm3

• ESR> 40 mm/hr• CRP> 2 mg/dL• Temp> 38.5 Oral• Refusal to bear weight

Septic Arthritis Vs Transient Synovitis

Individual Factor results:• No child with a temperature >38.5 was found to have transient

synovitis• CRP > 2mg/dL was the only independent risk factor strongly

associated with septic arthritis after backward elimination• 86% of patients with ESR < 40 mm/hr had transient synovitis• 71% of patients with CRP < 2mg/dL or WBC < 12,000/mm3

had transient synovitis

• How to tell the difference?• Four predictors

• History of fever• Refusal to weight-bear• ESR > 40 mm/hr• WBC > 12,000

• If in doubt• Review in 12 hours• Do incision and drainage!

The Limping Child: Age 3 – 6Transient Synovitis vs. Septic Arthritis

Kocher, Kasser, et al.JBJS 86-A: 1629, 2004

The Worst Scenario

• Destruction of articular cartilage

• Destruction of femoral head

• Destruction of femoral neck



Legg-Calvé-Perthes Disease

Best Bet

The Limping Child:Age 6 - 10

3

Legg-Calve-Perthes Disease

• Avascular necrosis of the capital femoral epiphysis.• Hypothesized to arise from repeated interruptions of

the vascular supply to the femoral head.• Male:Female is 4:1.• Most common between 4-10 years of age.• 10% of cases are familial• Present with limp (most common presentation) with

decreased internal rotation of the hip.

Legg-Calve-Perthes Disease

• Positive Trendelenburg test.• Pelvic tilt (affected side is lower) when

standing on the affected leg.• Pain can radiate to hip, thigh or knee.

• often insidious and can lead to disuse of affected limb

Physical findings• Boy• Limp• Antalgic gait• Pain with passive motion• Limited abduction• Positive Trendelenburg sign

The Limping Child: Age 6 – 10Perthes Disease


• X-ray findings• Perhaps nothing

• MRI

• Irregular consistency• Flattening• Lateral bump/ridge• Lateral hinging

Legg-Calve-Perthes

4 Distinct Radiographic Stages• Synovitis/Necrosis: Initial joint space widening

and irregularity of the physis. Ischemia of the epiphysis resulting in dead bone. Ave age 5.6 years

• Fragmentation. Fracturing of the weakened demineralized epiphysis. Epiphysis may collapse resulting in a shortened limb. Ave age 6.1 years

Legg-Calve-Perthes

4 Distinct Radiographic Stages (cont.)• Re-ossification. Begins at the margins of the

epiphysis. Ave age 7 years• Remodeling. Newly formed head is soft. At

risk for poor prognosis if not allowed to heal. Ave age 9.1 years

• MRI better at detecting early disease

Legg-Calve-Perthes

radiology.creighton.edu/.../case19/index.htm

Legg-Calve-Perthes

Legg-Calve-Perthes

Revascularization phase

Avascular phase

Legg-Calve-Perthes

Bilateral disease in up to 24% of cases• Contralateral hip usually involved within 3 years of disease onset, but can present

after 5 years• 1/3 of cases present with BIL hip involvement in the same stage

• Questions the previously held belief that the disease in one hip puts the contralateral hip at risk

• Retrospective review – J Pediatric Orthopaedics 2002; 22:458-463

• Girls more likely to have bilateral disease

Legg-Calve-Perthes

Treatment• 50% recover without treatment• Maintaining containment of the femoral head

within the acetabulum• Abduction splints/casts and non-weight

bearing state• Surgically with an osteotomy of the proximal

femur

Legg-Calve-Perthes

Prognostic factors• Better prognosis if child presents before 6 years of

age: extended period of time allowed for remodeling• Obesity is associated with a poor prognosis• Extent of epiphyseal necrosis present: <50% necrosis

with better outcome• Bilateral disease not associated with a worse

prognosis



50% need a Total Hip by age 50

Legg-Calve-Perthes

Natural history of early onset LCP disease. These radiographs were taken at age 2, 3, 5, 8 and 15 years. Courtesy of "Fundamentals of Pediatric Orthopedics", 2003, Lippincott Williams & Wilkins ©

Slipped Capital Femoral Epiphysis(SCFE – sciffey)

Best Bet


4

Slipped Capital Femoral Epiphysis

• Non-inflammatory condition• Femoral head displaced posteriorly

from the femoral neck• Age of onset: 10-17 years• Overweight boys (1.5M:1F) • African Americans>whites, hispanics


• Associated with endocrinopathies (growth hormone deficiency) in 8%• If presenting under 10 years of

age, hx of short stature or hypogonadism: endocrine evaluation


• Preceding history of trauma with acute pain/limp

• Subacute or chronic pain with insidious onset that can be referred to the hip or knee• Pain increased with physical activity


Examination• Limb is held slightly flexed and externally rotated• Often unable to fully flex hip• Limited internal rotation and abduction of the hip• Limited passive ROM secondary to pain• Bilateral in up to 30%• Positive Trendelenburg test


Radiography• X-ray of both hips

• Mild, moderate or severe depending on degree of femoral head slip compared to the femoral head diameter (<1/

3=mild; 1/3-2/3=moderate; >2/3=severe)

Xray FindingsXray Findings

• Displacement of neck on headDisplacement of neck on head• Mainly anteriorMainly anterior• Somewhat superiorSomewhat superior

• Decreased projected femoral head heightDecreased projected femoral head height• ChronicityChronicity

• Inferior new boneInferior new bone• Superior rounding off of metaphysisSuperior rounding off of metaphysis• Curved neckCurved neck


Klein’s line




www.pedsortho.ca/images/scfe.JPG

The Limping Child: Age 10 – 14SCFE

Always get a frog lateral view

Always check the other side

CastroAPCastroAP

• Pediatric orthopaedic surgeons• See 6 per year

• General orthopaedic surgeons• See 1 every 6 years• Same as fixing a fracture


ClassificationClassification• Acute or chronicAcute or chronic• Acute on chronicAcute on chronic• Stable or unstableStable or unstable• Severity of displacementSeverity of displacement• Slip angleSlip angle

• BilateralityBilaterality• 10 – 15% at presentation10 – 15% at presentation


Useful ClassificationUseful Classification

StableStable Walks inWalks in

UnstableUnstable Wheels inWheels in

• Bone in one pieceBone in one piece • Slow plastic deformationSlow plastic deformation of the growth plate of the growth plate

•Bone in two piecesBone in two pieces• Physeal fracturePhyseal fracture

No reductionNo reductionOne screwOne screw

Closed reductionClosed reductionTwo screwsTwo screws


• Treatment• Non-weight bearing with crutches to prevent further slip• Surgical fixation

• Prognosis• Usually good prognosis• Increased risk of subsequent acute chondrolysis or

avascular necrosis of the hip

Fixation SCFEFixation SCFE

Fixation SCFEFixation SCFE

The Contralateral HipThe Contralateral Hip

Out of 100 patients:

• 10 are bilateral at presentation• 10 will slip on the other side later• 5 will have painless slips on the other

side

Follow-up for BilateralityFollow-up for Bilaterality

• Follow radiolographicallyFollow radiolographically

• Every three monthsEvery three months

• For 18 monthsFor 18 months

• Screw removal- controversialScrew removal- controversial

The Limping Child

• Age 1 – 3 years - DDH• Age 3 – 6 years - Septic arthritis• Age 6 – 10 years - Perthes Disease• Age 10 – 14 years - SCFE

Best Bets

THANK YOU

Documents

The Limping Child David C Koronkiewicz, D.O. IU Goshen Orthopedics and Sports Medicine I0A 30 th Winter Update 12-2-11