PEMDenver Limping Child

The Limping Childand

Hip PainPatrick J. Maloney, MD

Denver Emergency Center for ChildrenDenver Health Medical Center

Evaluation of the Limping Child or Child w/ Hip pain Clinical History

Circumstances surrounding the limpTrauma, pain, associated systemic

symptoms/illness Physical Exam

Localize source of painAbdominal and genitourinary exam

Laboratory and Radiologic StudiesTailored to findings in history and physical

exam

Evaluation of the Limping Child

Physical ExamFlexed, abducted, externally

rotated hip = fluid in hip joint capsule


Physical ExamPassive ROM of the hip


Trauma is the most common cause in all age groupsAcute or repetitiveOftentimes, parents will endorse minor trauma

as cause of limpCoincidence or Causation?

Differential Diagnosis for Non-Traumatic Limp Transient Synovitis Septic Arthritis Legg-Calve-Perthes disease (Avascular

Necrosis of the Capital Femoral Epiphysis) Slipped capital femoral epiphysis (SCFE) Other

Peripelvic Pyomyositis Osteomyelitis Tumor/Leukemia Occult Fracture (e.g. Toddler’s Fx)

Case 1 A 5-year-old boy presents with a 4-week

history of limp that has worsened progressively. There are no significant findings on the past medical history. He has not been ill recently. There is not history of trauma. Physical examination reveals a decreased range of motion of the left hip and an obvious limp with walking.

What is the MOST likely etiology of this child’s limp?

Legg-Calve-Perthes DiseaseAvascular necrosis of the capital

femoral epiphysisMost common between 4-10 years of

age.Male:Female is 4:1Child may complain of pain in hip,

thigh or knee.often insidious and can lead to

disuse of affected limbXray findings are pathopnomonic

4 distinct radiographic stagesSynovitis/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

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 Disease

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 ©

Treatment 50% recover without treatment Goal: maintain femoral head within the

acetabulumAbduction splints/casts and non-weight bearing stateSurgically with an osteotomy of the proximal femur

Prognostic factors Better Prognosis

Younger (<6y)<50% epiphyseal necrosis

Worse OutcomeObesity

Legg-Calve-Perthes Disease

Case 2 A 6 year-old boy presents with a 3-day history of a

limp. He has had a URI for 1 week. There is no history of trauma. On physical examination, his temp is 100.4 F (38C), he does not bear weight on the right leg, and there is decreased ROM at the right hip. WBC count is 8,000, and the ESR is 20 mm/hr.

What is the MOST likely etiology of this child’s

pain?

Transient SynovitisAlso called “toxic synovitis” or “irritable

hip”Most common cause of non-traumatic hip

pain in children Accounts for 30-40% of all non-traumatic limps

Occurs in children 2-6 years old typically <4 years old

Associated with recent URI in 32-50% of cases

Male:Female is > 2:1Almost always unilateral

Transient SynovitisBenign, self-limited disorder

Sterile inflammation of the synovium of the joint With or without a joint effusion Unclear etiology (? Post-viral)

Transient Synovitis Clinical History

Acute onset of pain and limited ROM of the hipLimp or refusal to bear weight

Physical ExamHip is flexed and externally rotated

mildly decreased ROMAfebrile/low-grade fever (<38.5)

LaboratoryNormal WBC (<12,000)Normal or mildly elevated CRP (<2) and ESR (<40)

Transient Synovitis X-Ray

Most commonly normalJoint space widening (joint effusion)

UltrasoundJoint effusion and/or synovial swelling

Transient Synovitis

TreatmentRest; weight bear as tolerated Ibuprofen

Decreased pain vs Placebo (2d vs. 4.5d) 80% of all patients with resolution by 7 days

Prognosis Generally good Recurrence in 4-15% have been reported

So why is it important to make the diagnosis of transient synovitis?

Annals of Emergency Medicine 2002; 40:3:297

Case 3 A 6-month-old female infant presents to

you with fever to 102°F (38.9°C), poor feeding, and decreased activity for 5 days. Her mother has noted that over the last 7 days she cries whenever her diaper is changed, and for the last 2 days she has refused to move her left leg. On physical examination, you note a febrile infant who cries with passive movement of the left leg.

What is the MOST likely etiology of this child’s leg pain?

Septic ArthritisTrue Orthopedic emergency

Single most important prognostic factor for a good outcome is early treatment!!!Results from bacterial invasion into the joint space

Most commonly hematogenous spreadContiguous spread from neighboring osteomyelitisDirect inoculation from penetrating wound

Can occur at any age but >50% of cases are in children <3 years old Hip is most commonly affected joint in children

Septic Arthritis Organisms

Staphycoccus aureus (most common) Streptococcus species

Strep pneumoniae Strep pyogenes Group B Strep (neonates)

Haemophilus Influenzae Neisseria gonorrhea (adolescents) Salmonella (sickle cell disease) Gran negative bacilli (neonates)

Acute inflammatory response (TNF-α, IL-1, proteases destroy the articular cartilage Continues after eradication of the bacteria

Septic ArthritisDiagnosis may be very difficult

Usually previously healthy children <5 years (>50% of cases occur in children <3 years)Early peak in the first months of infancy

1/3 w/ URI’s within the past month

Usually temp > 38.5Usually unable to bear weightOther symptoms include:

Malaise, fatigue, irritability, abdominal pain, etc.

Septic Arthritis Physical Exam

DOES NOT present with erythema, warmth or swelling (hip)

Hip is usually held in flexion, external rotation, abduction Usually very painful ROM

Septic Arthritis

Joint Aspiration is definitive diagnosis Cloudy, turbid WBC count >50,000; predominantly PMNs Glucose levels < ½ of serum 50% positive gram stain 50-70% with positive culture

Septic Arthritis Joint Aspiration

Performed under ultrasound guidanceUsually needs procedural sedationComplications

iatrogenic infectionBleedingneurovascular injury

Septic ArthritisOther Diagnostic Tests

WBC: elevated with left shift (>12,000)ESR: elevated (>40)CRP: elevated (>2)Xray: may show wide joint space (effusion)

late findings (10 days): osteopenia, joint narrowing, soft tissue swelling

Ultrasound: may demonstrate joint effusion early in disease

MRI: helps evaluate for abscess and/or osteomyelitis

Septic Arthritis vs Transient Synovitis Kocher et al. Journal of

Bone and Joint Surgery. 1999 Boston Children’s Retrospective study Risk Factors

WBC >12,000/mm3

ESR >40 mm/hr Temp >38.5 OralRefusal to bear weight

Caird et al. Journal of Bone and Joint Surgery. 2006 CHOP Prospective study 53 patients who all had hip

aspiration Risk Factors

WBC >12,000/mm3

ESR >40 mm/hrCRP >2 mg/dLTemp >38.5 OralRefusal to bear weight

# of factors

Caird et al Kocher et al

0 16.9 0.2

1 36.7 3

2 62.4 40

3 82.6 93.1

4 93.1 99.6

5 97.5 N/A

PPV of Septic Arthritis

Septic Arthritis vs Transient Synovitis

Fever (>38.5 C) was best predictive factor

CRP >2mg/dL was only other independent risk factor

Caveat: studies evaluated children

with high clinical suspicion for septic arthritis

Septic Arthritis Treatment

Joint drainage (“wash-out”) IV antibiotics for 2-4 weeks

<2 months: Nafcillin + Gentamicin>2 months: Ceftriaxone +/- Vancomycin

• Prognosis: risk of avascular necrosis• 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

Case 4

• A 14 year-old boy presents to your office for evaluation of low-grade, diffuse knee pain on the right. On exam you have the child stand on the right leg and notice that he has a mild downward tilt of the pelvis to the left.What is the most likely etiology of his knee pain?

Slipped Capital Femoral Epiphysis (SCFE)

An acquired growth plate injury (Salter-Harris I) Separation of the proximal femoral epiphysis from the metaphysis

Most commonly occurs in adolescents and preadolescents 81% BMI >95th Percentile Peak age is 10-13y in females and 12-16y in males

Overweight boysRare after menarche

African Americans and Pacific Islanders >> Caucasian and Hispanics Associated with endocrinopathies (growth hormone deficiency) in 8%

Slipped Capital Femoral EpiphysisClinical History

Preceding history of trauma with acute pain/limp common

Subacute or chronic pain with insidious onset that can be referred to the hip or knee

Pain increased with physical activity May be able to bear weight if stable

Examination Hips is 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%

Slipped Capital Femoral EpiphysisRadiography

X-ray of both hips AP, Lateral, and Frog-Leg Views“Ice Cream falling off Cone”

Slipped Capital Femoral Epiphysis

Slipped Capital Femoral EpiphysisKlein’s Line

Line drawn along the posterior aspect of the femoral neck

Normal Abnormal


Treatment Strict non-weight bearing to prevent further slip

Occasionally may discharge on crutches Surgical fixation

Screw fixation under flouroscopy Some prophylactically fix contralateral hip as well

Osteotomy may be necessary for advanced slippage


25-40% have bilateral SCFEsContralateral slip usually occurs within 6-12

months of index side Prognosis

Usually good prognosis (stable and chronic slips) Increased risk of subsequent acute chondrolysis,

avascular necrosis, and premature hip arthritis

Other Etiologies of LimpPeripelvic PyomyositisOsteomyelitisOccult Fractures (Toddler’s Fx)TumorsLeukemiaDeep Muscle Hematomas/AbscessesAbdominal and Genitourinary Dx

Disease Age Onset Systemic Symptoms Labs Radiology Treatment

Transient Synovitis

2-6y (typically

<4y)acute

Preceding URI common; afebrile of low-grade

fever (<38.5)

WBC <12ESR <40CRP <2

none NSAIDssupportive

Septic Arthritis

<5y(50% <3y) acute

Fever (>38.5) malaise

irritability

WBC >12ESR >40CRP <2

Joint Asp:>50k WBC

U/S: joint effusion

Xray: joint widening

Abx“wash-out”

Leg-Calves-Perthes (AVN)

4-6yAcute

or insidious

none none

Xray: various

stages of epiphyseal

necrosis

NWBOsteotomy

SCFE M: 12-16F: 10-13

Acute or

insidiousnone none

Xray: “ice cream

scoop off cone,”

Klein’s line

Screw fixation,

Osteotomy

Non-Traumatic Limp/Hip Pain

Thank you

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PEMDenver Limping Child