the limping child david c koronkiewicz, d.o. iu goshen orthopedics and sports medicine i0a 30 th...
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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
• Age 3 – 6 years
• Age 6 – 10 years
• Age 10 – 14 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
The Limping Child: Age 1 – 3DDH
Physical findings• Short leg• Pistoning• Ortolani’s sign• Barlow’s sign
The Limping Child: Age 1 – 3DDH
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
The Limping Child: Age 1 – 3DDH
22 42
The Limping Child: Age 1 – 3DDH
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
The Limping Child:Age 3 – 6
s
• Flu
• Tonsillitis2
The Limping Child:Age 3 – 6
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
The Limping Child:Age 3 – 6
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
The Limping Child: Age 3 – 6Septic Arthritis
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
The Limping Child: Age 3 – 6Septic Arthritis
The Limping Child: Age 3 – 6Septic Arthritis
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
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
The Limping Child: Age 6 – 10Perthes Disease
The Limping Child: Age 6 – 10Perthes Disease
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
The Limping Child:Age 10 – 14
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
Slipped Capital Femoral Epiphysis
• Associated with endocrinopathies (growth hormone deficiency) in 8%• If presenting under 10 years of
age, hx of short stature or hypogonadism: endocrine evaluation
Slipped Capital Femoral Epiphysis
• 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
Slipped Capital Femoral Epiphysis
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
Slipped Capital Femoral Epiphysis
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
Slipped Capital Femoral Epiphysis
Klein’s line
Slipped Capital Femoral Epiphysis
Slipped Capital Femoral Epiphysis
Slipped Capital Femoral Epiphysis
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
The Limping Child: Age 10 – 14SCFE
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
The Limping Child: Age 10 – 14SCFE
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
Slipped Capital Femoral Epiphysis
• 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