Prof. Mamoun KremliAlMaarefa College

The limping child

Introduction

Limping is a common presentation in childrenSeen by orthopedic surgeons, pediatricians, primary

care physicians

Need to take a properHistoryphysical examinationInvestigations

Some diseases related to specific age groups

History

Duration, when first noticed

Pain

History of trauma

Associated systemic symptomsFever, night sweating, anorexia, weight loss

Limping

PainfulAntalgic gait – short stance phase of gait cycle

Child may not complain of pain

Painless

History of trauma often reported in all casesRelevantIrrelevant

Types of gait

High steppage:Foot drop – neurologic disease

Trendelenburgh:DDH, weak hip abductors, could not abduct

Circumduction:Stiff hip, neurologic disaese

Tip-toeTight achilles tendon, CTEV, Cerebral Palsy, habitual,

compensating length discrepency

Lurching:Short length

Types of gait

Wide-base:To gain balance – neurologic disease

ScissoringTight hip adductors – Cerebral Palsy

Hemiplegic gaitCerebral palsy - neurologic

AtaxicNeurologic disease

Foot inversion / eversionFoot deformity / avoiding pain

Types of gait

Stiff-kneeKnee disease / arthrogryposis

Hand-knee Weak quadriceps femoris muscle

Causes of painful limping

TraumaMajor musculoskeletalSplinter into foot

InfectionAcute OM, Septic arthritis

Malignant bone tumor

Rheumatic disease

Acute slipped capital femoral epiphysis

Perthes disease (Avascula necrosis)

Causes of painless limping

Benign bone tumors

CongenitalDDH, club foot, congenitally short femur, short tibia

Post injury deformity / length discrepancy

AVN – Perthe’s disease

Slipped capital femoral epiphysis (chronic)

Deformity and leg length discrepancy

History

Sudden onset:Trauma

Gradual onset:Disease

Pitfalls

Misled by parents’ historyHistory of traumaAlways a leg length inequality

Misled by patients’ complaintHip problems may present with knee pain

Children below 5 years do not complain of pain

Many causes

Different diseases occur more commonly at specific age groups

Age 1-4 years

CDH – DDH

History: at risk groups

Physical findings:Asymmetrical foldsLimited abductionHamstring stretch signOrtolani / BarlowShorteningTrendelenburgh

Age 3 – 6 years

Transient synovitisLimping, painful to move, ?WBC, ? Fever, ? ESRResolves in daysDisappears without treatment

Septic arthritisLimping-refuses to walkFever >38.5WBC >12,000ESR >40 mm

If in doubt: Aspiration

Age 5 – 10 years

Legg-Calve-Perthes diseaseBoy, antalgic gaitPain and muscle spasm with passive motionLimitation of rotation and abductionPositive Trendelenburgh

Legg-Calve-Perthes

Age usually: 4-8 years, Boys= 4X girls

Idiopathic avascular necrosis of femoral head

Blood supply of femoral head:Neonates: metaphyseal,lateral epiphyseal, and scanty

ligamentum teres vessels4 years: no epiphyseal vessels7 years: ligamentum teres vessels developed well

4 – 7 years: dependent on lateral epiphyseal vesselsIf trauma or synovitis, pressure occludes blood

supply

Legg-Calve-Perthes

Stages:1. Bone death:

may still look normal on x-ray

2. Revascularization and Repair:Increased density and fragmentationon x-ray

3. Distortion and Remodelling

1. Distortion, falttening (coxa plana), and enlargement (coxa magna), with partial uncoverage

Legg-Calve-Perthes

Clinical picture:Limping (painful / painless)May present with knee/thigh painEarly: limitation of all movementsLater: limitation of abduction and internal rotation

Legg-Calve-Perthes

Apley’s System of Orthopedics and Fractures

Legg-Calve-Perthes

Apley’s System of Orthopedics and Fractures

Legg-Calve-Perthes

Different stages of Perthes in a patient

Sclerosis Collapse Fragmentation Remodelling

http://community.tsrhc.org/Perthes-disease-about-perthes-disease

Legg-Calve-Perthes

Treatment:RestPhysiotherapy: abductionContainment by splintSurgery:

Containment, improved coverLater: for aftermath

Age 10 – 15 years

Slipped Capital Femoral Epiphysis (SCFE)Acute Vs. chronicBoys, overweight, ?hypogonadismLimited internal rotationHip externally rotates when flexedX-ray: AP and Frog lateral

Really is an antero-lateral slippage of the metaphysiswww2.massgeneral.org/ortho/SCFE.htm

SCFE

Around puberty

? Hormonal imbalance between gonadal and growth hormones

Tall, or obese, gonads underdevelopment

Presents with limping

May present with thigh/knee pain

Acute slip Vs. chronic slip

Apley’s System of Orthopedics and Fractures

SCFE

Externally rotated hip

Loss of internal rotation

External rotation on flexion

Slippage of other hip in one third of patients

Apley’s System of Orthopedics and Fractures

SCFE

X-rays diagnosis:

Apley’s System of Orthopedics and Fractures

SCFE

http://reference.medscape.com/

SCFE

TreatmentManipulation to try to reduce the slip may cause AVNFixation in situ? Fix the other hip

Complications:Avascular NecrosisCoxa varaSlippage of opposite hipSecondary osteoarthritis

http://bestpractice.bmj.com/

3 – 12 years

Acute osteomyelitis:Constitutional symptomsWBC, CRP, ESRX-ray may initially be normalMRI

5 – 18 years

Trauma – place related to ageHousehold - earlyPlayground - childhoodSchool and Sports 0 older child - teenagerRTA – teenager

A prick or a splinter in sole of foot

Time algorithm

years1 2 43 5 6 7 8 9 10 1211 13 14 15

DDHPerthes

SCFE

Trauma

Infection