The limping child
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Transcript of The limping child
Prof. Mamoun KremliAlMaarefa College
The limping child
Introduction Limping is a common presentation in children
Seen by orthopedic surgeons, pediatricians, primary care physicians
Need to take a properHistoryphysical examinationInvestigations
Some diseases related to specific age groups
HistoryDuration, when first noticed
Pain
History of trauma
Associated systemic symptomsFever, night sweating, anorexia, weight loss
LimpingPainful
Antalgic gait – short stance phase of gait cycleChild may not complain of pain
Painless
History of trauma often reported in all casesRelevantIrrelevant
Types of gaitHigh 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 gaitWide-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 gaitStiff-knee
Knee disease / arthrogryposis
Hand-knee Weak quadriceps femoris muscle
Causes of painful limpingTrauma
Major musculoskeletalSplinter into foot
InfectionAcute OM, Septic arthritis
Malignant bone tumor
Rheumatic disease
Acute slipped capital femoral epiphysis
Perthes disease (Avascula necrosis)
Causes of painless limpingBenign 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
HistorySudden onset:
Trauma
Gradual onset:Disease
PitfallsMisled by parents’ history
History 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 causesDifferent diseases occur more commonly at
specific age groups
Age 1-4 yearsCDH – DDH
History: at risk groups
Physical findings:Asymmetrical foldsLimited abductionHamstring stretch signOrtolani / BarlowShorteningTrendelenburgh
Age 3 – 6 yearsTransient synovitis
Limping, 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 yearsLegg-Calve-Perthes disease
Boy, antalgic gaitPain and muscle spasm with passive motionLimitation of rotation and abductionPositive Trendelenburgh
Legg-Calve-PerthesAge 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-PerthesStages:
1. Bone death: may still look normal on x-ray
2. Revascularization and Repair:Increased density and fragmentationon x-ray
3. Distortion and Remodelling1. Distortion, falttening (coxa plana), and
enlargement (coxa magna), with partial uncoverage
Legg-Calve-PerthesClinical 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-PerthesDifferent stages of Perthes in a patient
Sclerosis Collapse Fragmentation Remodelling
http://community.tsrhc.org/Perthes-disease-about-perthes-disease
Legg-Calve-PerthesTreatment:
RestPhysiotherapy: abductionContainment by splintSurgery:
Containment, improved coverLater: for aftermath
Age 10 – 15 yearsSlipped 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 metaphysis
www2.massgeneral.org/ortho/SCFE.htm
SCFEAround 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
SCFEExternally 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
SCFEX-rays diagnosis:
Apley’s System of Orthopedics and Fractures
SCFE
http://reference.medscape.com/
SCFETreatment
Manipulation 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 yearsAcute osteomyelitis:
Constitutional symptomsWBC, CRP, ESRX-ray may initially be normalMRI
5 – 18 yearsTrauma – place related to age
Household - 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