Evaluation of the Child with a Limp

DD Aronsson

University of Vermont

Hx – 2-year-old boy limps because of pain in the right

thigh (antalgic)

PE – pain and swelling just above the knee

Differential Diagnosis

• Bone infection (osteomyelitis)

• Joint infection (septic arthritis)

• Fracture

• Toxic synovitis

Bone & Joint Infections

• Hematogenous origin–Strep throat

• Implantation–Stepping on a nail

Osteomyelitis

• Metaphyseal origin

• Vessels don’t cross the growth plate

Septic Arthritis

• Infection can decompress into a joint

• Septic dislocation

Clinical Findings

• Systemically ill

• Irritable

• Refusal to bear weight

• Pseudoparalysis

• Pain & swelling @ the site

Laboratory Studies

• Elevated WBC,ESR, & CRP

• 50% Positive blood culture

• Infant–May be normal

Imaging

• Radiographs–Soft tissue

swelling

• Bone scan–Increased uptake

Treatment

• Aspiration is the “key” to the diagnosis

• Don’t wait for imaging

Subperiosteal aspiration

Treatment

• IV antibiotics–S aureus, gram-negative

enteric, & Group B Streptococcus

• Surgical decompression –Hip & shoulder

Hx – 18 month-old girl limps on the left leg (no pain)

PE – short left lower extremity is causing the

limp

Differential Diagnosis

• Developmental dysplasia of the hip

• Limb-length discrepancy

DDH

• Instability

• Subluxation

• Dislocatable

• Reducible dislocation

• Irreducible dislocation

Etiology Unknown Multifactorial

• Genetic whites

• Physiologic girls

• Mechanical breech

• Environmental swaddling

Barlow Provocative Test

• Dislocates hip (exit)

Clunk

Ortolani Maneuver

• Reduces dislocated hip (entry)

Abduction

Clunk

PE > 3 Months

57º 43º

Limited abduction is key

PE > 3 Months

• Asymmetric thigh folds–Limb-length

discrepancy

Radiographs

Ultrasound

• Alpha > 60º–Slope of osseus

acetabulum

Pavlik Harness Success

• Dysplasia 95%

• Dislocated 80%

Hx – 6-year-old boy limps on the right leg

PE – limp with painful range-of-motion of the hip

Differential Diagnosis

• Infection

• Toxic synovitis

• Slipped capital femoral epiphysis (endocrine)

• Legg-Calv-Perthes disease

Legg-Calv-Perthes

• Loss of blood supply of the epiphysis

Legg-Calv-Perthes

• History–Pain in the groin or knee

–Limp

–Aggravated by exercise

Legg-Calv-Perthes

• Physical examination–Decreased internal rotation

–Decreased abduction

–Irritable hip

Necrotic stage Fragmentation stage

Reossification stage Remodeling stage

Treatment

• Containment–Physical therapy

•ROM exercises

–Orthosis•Abduction & internal rotation

–Osteotomy

Toxic synovitis

• History – sudden onset–Pain in groin or thigh

–Painful limp

–URI 2 weeks ago

Physical Examination

• Limp

• Irritable hip with guarding

• Mimic septic hip

Treatment

• Activity modification

• Expect improvement

• Question diagnosis if not responding

Hx – 14-year-old obese boy has pain in the right knee

and limps

PE – no swelling and full ROM of the knee but decreased internal rotation of the hip

Differential Diagnosis

• Infection

• Osgood-Schlatter disease

• Anterior knee pain

• Slipped capital femoral epiphysis

Slipped Capital Femoral Epiphysis (SCFE)

• Most common hip disorder in adolescents

• Age–Boys 14 y/o

–Girls 12 y/o

Etiology

• Endocrine–Hypothyroid

–Growth hormone treatment

• Mechanical–63% > 95th percentile weight

Hip Flexion Causes Abduction & External Rotation

FABER

AP Pelvis Radiograph

• Wide & irregular physis

• Epiphysis at or below Klein’s line

Klein’s line

Frog Pelvis Radiograph

• Posterior slip

• Wide, irregular physis

Preop AP pelvis Preop frog pelvis

Postop AP pelvis Postop frog pelvis

Limp

Think hips