2THE LIMPING CHILD-JOA

8/7/2019 2THE LIMPING CHILD-JOA

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THE LIMPING CHILDTHE LIMPING CHILD

MahmoudMahmoud M.M. OdatOdat MDMD



Late diagnosis of septic arthritis will causepermanent disability



Role of the OrthopedistRole of the Orthopedist

Recognize the gait abnormalityRecognize the gait abnormality

Determine the site of originDetermine the site of originDevelop a good working diagnosisDevelop a good working diagnosis

Develop a treatment planDevelop a treatment plan



Making the diagnosisMaking the diagnosis

Some cases require urgent treatmentSome cases require urgent treatment

Some conditions affect all age groupsSome conditions affect all age groupsSome presentations are not straightforwardSome presentations are not straightforward

Many conditions have a peak age of onsetMany conditions have a peak age of onset

No single algorithm will be reliable for all presentationsNo single algorithm will be reliable for all presentations



THE LIMPING CHILDTHE LIMPING CHILD

Common reason for consultationCommon reason for consultation

Parents are keen observersParents are keen observers



Events

Normal Gait Normal Gait



Gait change with ageGait change with age



Primary causesPrimary causes

PainPain Antalgic Antalgic

WeaknessWeakness NonNon--Antalgic Antalgic

Mechanical factorsMechanical factors

Tight shoe Tight PersonWide DD



DD: Antalgic gait (All ages)DD: Antalgic gait (All ages)

Fractures, TraumaFractures, Trauma

Infection (OM, septic arthritis, diskitis)Infection (OM, septic arthritis, diskitis)

Arthritis (JR A) Arthritis (JR A)

Discoid meniscusDiscoid meniscus

Foreign body in the footForeign body in the foot

tumorstumors



Bone tumors and leukemia are rare causes of limp

but life threatening



DD: nonantalgic limpDD: nonantalgic limp

EquinusEquinus gait (toegait (toe--Walking)Walking)Idiopathic tight TAIdiopathic tight TA

Club footClub foot

CPCPLLDLLD




Circumduction gaitCircumduction gait

LLDLLD

CPCP

Ankle & Knee stiffness Ankle & Knee stiffness




Steppage gaitSteppage gait

CPCP

MyelodysplasiaMyelodysplasia

CharcotCharcot--MarieMarie-- Tooth diseaseTooth disease

Friedriech¶s ataxiaFriedriech¶s ataxia




TrendelenburgTrendelenburg gaitgait




TrendelenburgTrendelenburg gaitgait

LCP diseaseLCP disease

DDHDDH

SCFESCFE

Muscular dystrophyMuscular dystrophy

Hemiplegic CPHemiplegic CP



Waddling gaitWaddling gait



DD: according to ageDD: according to age

Toddler Toddler 11--33 yrsyrs

Transient synovitisTransient synovitis

Septic arthritisSeptic arthritis

DiskitisDiskitis

#s#sPauciarticular JAPauciarticular JA

CPCP

Muscular dystrophyMuscular dystrophy

DDHDDH

Coxa varaCoxa vara

RaritiesRarities

LeukemiaLeukemia

OOOO




ChildChild 44--1010 yearsyearsLeggLegg--CalveCalve--Perthes diseasePerthes disease

Transient synovitisTransient synovitis

Septic arthritisSeptic arthritisDiscoid meniscusDiscoid meniscus

Osteochondritis dissecans (knee, ankle)Osteochondritis dissecans (knee, ankle)

Sever¶s apophysitisSever¶s apophysitis

Accessory tarsal navicular Accessory tarsal navicular LLDLLD




Adolescent > Adolescent > 1010 yearsyearsSCFESCFE

Hip dysplasiaHip dysplasia

Overuse syndromeOveruse syndrome

ChondrolysisChondrolysis

OsgoodOsgood--Schlatter diseaseSchlatter disease

SindigSindig--LarsenLarsen--Johanssen syndromeJohanssen syndrome

Osteochondritis dissecans (knee, ankle)Osteochondritis dissecans (knee, ankle)

Chondromalacia patellaeChondromalacia patellae

Tarsal coalitionTarsal coalition



HistoryHistory

Limp character Limp character

± ± Injury (mechanism)Injury (mechanism)

± ± Pain or other localizing symptomsPain or other localizing symptoms ± ± Frequency & duration of symptomsFrequency & duration of symptoms

± ± Absence of pain Absence of pain



PatternPatternOnsetOnset

± ± Acute (trauma, infection, malignancy) Acute (trauma, infection, malignancy)

± ± Gradual (inflammatory, mechanical)Gradual (inflammatory, mechanical)

DurationDurationQualityQuality

± ± Constant, intermittent or mechanicalConstant, intermittent or mechanical

TimingTiming

± ± Morning, after activity, nightMorning, after activity, nightRelief Relief

ReferredReferred

Multiple jointsMultiple joints

PainPain



Past medical historyPast medical history

Recent traumaRecent trauma

Exposure to infectious diseaseExposure to infectious disease

Recent fever, weight loss, malaiseRecent fever, weight loss, malaise

Developmental milestoneDevelopmental milestone

Motor abilityMotor ability

Family history of Family history of

Neuromuscular diseaseNeuromuscular diseaseMetabolic diseaseMetabolic disease

Inflammatory arthritisInflammatory arthritis

Infectious diseaseInfectious disease



Physical examination:Physical examination:

Gait examGait exam

Standing examStanding exam

TableTable--tope examtope exam




SpineSpine

Balance in coronal and saggitalBalance in coronal and saggital

Scoliosis,Scoliosis,LS stepLS step--off off

pelvic obliquitypelvic obliquity

cutaneous findingscutaneous findings

(café(café--auau--lait, hairy patches)lait, hairy patches)Bend Forward, backward, sidewayBend Forward, backward, sideway




PelvisPelvis

ObliquityObliquity

Trendelenburg testTrendelenburg test(flexed knee, extended hip)(flexed knee, extended hip)

waitwait 2020 secondsseconds




LLLL

Gower test (Muscular dystrophy)Gower test (Muscular dystrophy)

R

epetitive heel raises, toe raisesR

epetitive heel raises, toe raisesClawing or CavusClawing or Cavus

Deep tendon reflexes and ClonusDeep tendon reflexes and Clonus




InspectionInspection

Asymmetry, Deformity, Erythema, Rashes, Asymmetry, Deformity, Erythema, Rashes,

SwellingSwelling

Wounds or FBs (Foot, knee)Wounds or FBs (Foot, knee)

Position, muscle (atrophy, hypertrophy)Position, muscle (atrophy, hypertrophy)

PalpationPalpation

Max. tenderness (most valuable part)Max. tenderness (most valuable part)




JointsJointsROM, pain, contracture, spasticity.ROM, pain, contracture, spasticity.

PF joint, SI jointPF joint, SI joint

Rotational profile

Rotational profile




Neurological examNeurological exam

LLD (measure, Galeazzi test)LLD (measure, Galeazzi test)



When the cause of limp cannot be localizedWhen the cause of limp cannot be localizedby history and pysical examinationby history and pysical examination



Radiographic evaluation:Radiographic evaluation:

Plain radiographyPlain radiography

Isotope bone scan (techIsotope bone scan (tech--9999m)m)

UltrasonographyUltrasonographyCT scanCT scan

MRIMRI



Laboratory testing:Laboratory testing:

TestsTests

CBC diff CBC diff

ESRESR

CRPCRP

Aspiration Aspiration

ANA ANA

Rh F

Rh F

HLA TYPINGHLA TYPING





Isotope bone scan (techIsotope bone scan (tech--9999m)m)

UltrasonographyUltrasonographyCT scanCT scan

MRIMRI





Inexpensive, any time, sensitive, specificInexpensive, any time, sensitive, specific

Entire LL in nonverbalEntire LL in nonverbal

? early bone and joint infection? early bone and joint infection




Isotope bone scan (techIsotope bone scan (tech--9999m)m)SensitivitySensitivity 8484%% --100100%, specificity%, specificity 7070%% -- 9696%%

Accumulate at the sites of increased blood flow Accumulate at the sites of increased blood flow

Osteoblastic activityOsteoblastic activityOMOM

Stress #sStress #s

Occult #sOccult #s

NeoplasmNeoplasm

MetastasisMetastasis

Superior to {temp, WBC, ESR, plain XSuperior to {temp, WBC, ESR, plain X--ray}ray}

Localization in difficult areas (pelvis, spine)Localization in difficult areas (pelvis, spine)

Ability to image the whole body Ability to image the whole body




UltrasonographyUltrasonographyIrritable hip VS septic arthritisIrritable hip VS septic arthritis

Cannot differentiateCannot differentiate

{sterile, purulent, hemorrhage}{sterile, purulent, hemorrhage}Guided aspirationGuided aspiration




UltrasonographyUltrasonography

Helpful in Diagnosing OMHelpful in Diagnosing OMdeep soft tissue swellingdeep soft tissue swelling

periosteal thickeningperiosteal thickening

subperiosteal collectionsubperiosteal collection




CT scanCT scan

Rarely necessary as an initial studyRarely necessary as an initial study

Localized cortical abnormalitiesLocalized cortical abnormalities

Central nidus (OO)Central nidus (OO)

Tarsal coalitionTarsal coalition




RIRI

Bone arroBone arro

ointointartilageartilage

oft ti ueoft ti ue

u or and treu or and tre




Rapid diagnosis and treatmentRapid diagnosis and treatmentInfectionInfection

InflammatoryInflammatory

MalignancyMalignancy

Assist in Assist in

Making a diagnosisMaking a diagnosis

Monitoring the efficacy of treatmentMonitoring the efficacy of treatment




TestsTests

CBC diff CBC diff

ESRESR

CRPCRP

Aspiration Aspiration

ANA ANA

Rh F

Rh FHLA TYPINGHLA TYPING




ESR :ESR :

Reflects the changes in the concentration of Reflects the changes in the concentration of

fibrinogen synthesized by the liver fibrinogen synthesized by the liver

Sensitive indicator of inflammationSensitive indicator of inflammation

Sensitive indicator of infection (Sensitive indicator of infection (9090% in OM)% in OM)

Increase after Increase after 2424--4848 hh

Return to normal inReturn to normal in 33 weeksweeks

Helpful in diagnosis and follow upHelpful in diagnosis and follow up

Extreme elevation ? Associated septic arthritisExtreme elevation ? Associated septic arthritis




CRP:CRP:

An acute An acute--phase protein synthesized by thephase protein synthesized by the

liver in response to inflammationliver in response to inflammation

Rises withinRises within 66hh

Returns to normal withinReturns to normal within 66--1010 daysdays

More sensitive (WBC, ESR) inMore sensitive (WBC, ESR) in

assessing the ttt effectivenessassessing the ttt effectiveness

predicting recoverypredicting recovery

22ry rise suggests relapsery rise suggests relapse




Aspiration AspirationCell countCell count

WBC >WBC >8080,,000000

7575% Polymorphonuclear % Polymorphonuclear Gram stainGram stain

Protein, glucose analysisProtein, glucose analysis

CultureCulture

HipHipTechnically difficultTechnically difficult

Sedation, LA, fluoroscopic guidance with arthrogramSedation, LA, fluoroscopic guidance with arthrogram

US guided aspirationUS guided aspiration



SUMMARYSUMMARY

Understand the normal & abnormal gaitUnderstand the normal & abnormal gait

Appropriate history, physical exam and the Appropriate history, physical exam and the

use the child¶s age will narrow the DDuse the child¶s age will narrow the DDPlan a selective approach to diagnosticPlan a selective approach to diagnostic

testingtesting

Plan the treatment scenarioPlan the treatment scenario

2THE LIMPING CHILD-JOA

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