BYBY DR. ESSAM HOZAYEN DR. ESSAM HOZAYEN SAIFSAIF orthopedic orthopedic specialistspecialist ALDHAID ALDHAID HOSPITALHOSPITAL

DefinitionDefinition

Limp is defined as an uneven, jerky gait, usually caused by pain, weakness, or deformity .

Limp can be caused by both benign Limp can be caused by both benign and life-threatening conditions, the and life-threatening conditions, the management varies from management varies from reassurance to major surgery reassurance to major surgery depending upon the cause .depending upon the cause .

DIFFERENTIAL DIFFERENTIAL DIAGNOSIS DIAGNOSIS 

Bones.Bones. Joints.Joints. Soft tissue.Soft tissue. Neurological.Neurological.

Bone:Bone: Fractures.Fractures.

Legg-Calvé -Perth's.Legg-Calvé -Perth's.

Slipped capital femoral epiphysis.Slipped capital femoral epiphysis.

Tumors.Tumors.

Vasoocclusive crisis of sickle cell Vasoocclusive crisis of sickle cell diseasedisease

( the pain is sever, some times ( the pain is sever, some times equal to cancer pain)equal to cancer pain)

Joints:Joints: Transient synovitis Transient synovitis

Septic arthritisSeptic arthritis

Acute rheumatic feverAcute rheumatic fever

Juvenile rheumatoid arthritisJuvenile rheumatoid arthritis

Developmental dysplasia of the hipDevelopmental dysplasia of the hip

Hemarthrosis: traumatic, Hemarthrosis: traumatic, hemophiliahemophilia

Systemic lupus erythematosis.Systemic lupus erythematosis.

Soft tissue:Soft tissue: Viral myositis.( high level of serum Viral myositis.( high level of serum

creatinine kinas )creatinine kinas )

Intramuscular vaccination.Intramuscular vaccination.

Cellulitis.Cellulitis.

Neurological:Neurological: Cerebral palsyCerebral palsy

Peripheral neuropathyPeripheral neuropathy

Meningitis.Meningitis.

Epidural abscess of the spine.Epidural abscess of the spine.

Infectious:Infectious: Septic arthritisSeptic arthritis OsteomylitisOsteomylitis descitisdescitis

Non-Non-InfectiousInfectious

InflammationInflammation TraumaTrauma TumorTumor Bony deformityBony deformity Aseptic necrosisAseptic necrosis

Age – specified conditions that cause a limp

1-3 years DDH Child abuse Neuromuscular disease Leg length discrepancy Infections 4-10 years Transient synovitis Perth's disease Infections leg length discrepancy

>10 years SCFE OVERUSE SYNDROME all age groups Trauma Tumors

8.5%5.3% 2.8% 6.0%

77.4%

Transientsynovitis

SCFE

Infection

Perthes'disease

Other

The Limping Child

Physical examination should started with observation of the

gait*Gait is a repeated cycle of limb motion

controlled by muscle activity that carries the body forward

*The gait cycle is traditionally described as starting when one heel strikes the ground and ending when it strikes the ground again

*There is two phases of the gait cycle (60% stance phase and 40% swing phase)

*The progress of gait as following: initial contact---loading response---mid

stance---terminal stance---preswing —initial swing---mid swing---terminal swing.

Prior to the heel strike…relaxation of the hamstrings ms & contraction of quadriceps ms >>>>straightening of knee joint>>>>contraction of the dorsiflexors of the ankle & foot >>>>heel strike. which followed by flat foot ( loading response)>>>>motion of the body forward over the foot ( mid stance )>>>> contraction of the calf ms >>>>planter flexion( heel off)>>>>knee flexion >>>>toe off & beginning of the swing phase by contraction of the iliopsoas ms >>>> flexion of the hip>>>> knee flexion & contraction of the ankle dorsiflexors ( acceleration or preswing phase)>>>>midswing phase =midstance phase of the other limb (moving of the body with ipsilateral limb forward >>>>deceleration occur to start new heel strike ( by contraction of Q.ms & hamstring ms relaxation to make the knee straight >>>> new heel strike

Other components of the gait: 1- pelvic tilt during normal gait , the pelvis dropped at the side of swing limb by 5

degrees below the horizontal plane

2- pelvic rotation during swing phase the pelvis rotates anteriorley by 4 degrees & on

the stance side the pelvis rotates posteriorely by 4 degrees

3- lateral shift during the stance phase the pelvis & trunk shifted laterally toward

the stance limb by one inch N.B…. Pelvic tilt ,pelvic rotation , lateral shift, knee flexion,, knee -ankle –foot

motion >>>>minimize the shift of the gravity body centre in both vertical & horizontal axis's

4- width of the base by the examiner behind the pt.= distance between both foot during

double support= 2-4 inches

5- stride length the distance between the heel strike of limb & the next heel strike of

the same limb

6- step lengthThe distance between heel strike of one limb & heel strike of

the other limb

PATHOLOGICAL GAIT Child limp may be caused by pain, structural changes,

weakness or a combination of these.Most of abnormalities occur at the stance phase.

For example: 1-antalgic gait (anti-pain) in which the child limits the time spent on the painful leg in stance phase2-leg length discrepancy gait the pt. can compensate by walking on tip-toe on the short side and with slight hip and knee flexion on the long side3-trendelenburg gait is a painless limp in a pt. with weakened hip abductor muscles the pt. leans over the affected side. bilateral involvement causes waddling gait4-gait in cerebral palsy

there is brain lesion with secondary muscle contracture and compensatory movements.

5- foot slap gait: due to weakness of the ankle & foot dorsiflexors=drop foot

during the swing phase

6- G. maximums gait: during midstance >>>the ipsilateral hip must be maintained

in extension or the trunk falls forward .if there is weakness of the G.M >>the pt. push his trunk posteriorly resulting in extension lurch or G.M. gait.

7- calceneal gait: weakness of calf ms or flat foot( loss of planter flexion >>>

loss of heel off)

8- hip –hike gait: pt. with stiff knee >>> may elevate the ipsilateral pelvis to

hold the foot up. = circumduction gait

9- wide based gait: the width of the base is more than 4 inches ==( cerebellar

lesion ) >>> loss of coordination >>> execive shift of the gravity centre

HISTORY HISTORY

Duration and course of the limp? Duration and course of the limp? History of trauma ? History of trauma ? Associated symptoms (e.g., fever, weight Associated symptoms (e.g., fever, weight

loss, anorexia, back pain, arthralgia, loss, anorexia, back pain, arthralgia, voiding or stooling problems) voiding or stooling problems)

If pain is present, where is it located, If pain is present, where is it located, when does it occur, and what its severity? when does it occur, and what its severity?

Does the limp improve or worsen with Does the limp improve or worsen with activity? activity?

Recent history of viral illness or streptococcal Recent history of viral illness or streptococcal infection (post infectious arthritis). infection (post infectious arthritis).

Recent history of new or increased sports activity Recent history of new or increased sports activity Recent history of intramuscular injection (can Recent history of intramuscular injection (can

cause muscle inflammation or sterile abscess) cause muscle inflammation or sterile abscess) History of endocrine dysfunction (may predispose History of endocrine dysfunction (may predispose

to slipped capital femoral epiphysis) to slipped capital femoral epiphysis) Family history of connective tissue disorder, Family history of connective tissue disorder,

inflammatory bowel disease, hemoglobinopathy, inflammatory bowel disease, hemoglobinopathy, bleeding disorder, or neuromuscular disorderbleeding disorder, or neuromuscular disorder

Physical examinationStanding: * back should be examined for scoliosis ,local tenderness,

range of motion. *if there is pelvic tilt is present , it can be measured by placing

blocks under the shorter leg until the pelvis in level (horizontal) .

*trendelenburg test *skin dimples ,hairy patches over lumbar spine

Supine: * each joint should be examined separately *look for swelling, feel for tenderness, assess the ROM *for hip flexion contracture --------Thomas test *abdomen should always examined ------may be

appendicitis *neurological examination should be performed *check for leg length discrepancy , the short leg must

be differentiated from apparent shortening that is caused by scoliosis or pelvic obliquity or joint contracture.

Prone: *hip rotation * femoral anteversion

Hip rotationHip rotation

Internal rotation of the hipsInternal rotation of the hips : is : is performed with the child in the performed with the child in the prone position with the knees flexed; prone position with the knees flexed; the ankles and feet are then rotated the ankles and feet are then rotated away from the body to compare the away from the body to compare the amount of internal rotation in the amount of internal rotation in the symptomatic versus the symptomatic versus the asymptomatic hip. asymptomatic hip.

Galeazzi test :Galeazzi test :

   The Galeazzi test is useful in diagnosing The Galeazzi test is useful in diagnosing developmental hip dysplasia or leg length developmental hip dysplasia or leg length discrepancy.discrepancy.

This test is performed by putting the This test is performed by putting the child in a supine position and then flexing child in a supine position and then flexing the hips and knees by bringing the ankles the hips and knees by bringing the ankles to the buttocks . to the buttocks .

The test is positive when the knees are of The test is positive when the knees are of different heights. Abnormal shortening of different heights. Abnormal shortening of the leg can be caused by the leg can be caused by DDH, Perth's DDH, Perth's disease. disease.

Trendelenburg testTrendelenburg test : :

Asking the child to stand on the Asking the child to stand on the affected leg, causes a affected leg, causes a pelvic tiltpelvic tilt (the (the unaffected hip is lower). unaffected hip is lower).

RADIOLOGIC RADIOLOGIC EVALUATIONEVALUATION

Plain radiographsPlain radiographs : Most children  : Most children who limp require radiographic who limp require radiographic evaluation.evaluation.

Both anteroposterior and lateral Both anteroposterior and lateral views should be obtained. The frog-views should be obtained. The frog-leg view of the pelvis provides the leg view of the pelvis provides the lateral view of the femoral heads.lateral view of the femoral heads.

UltrasonographyUltrasonography :  : Ultrasonography is Ultrasonography is an excellent technique for identifying an excellent technique for identifying small joint effusions of the hip and small joint effusions of the hip and should be used when plain radiographs should be used when plain radiographs are normal but the suspicion of are normal but the suspicion of septic septic arthritisarthritis remains high. remains high.

A difference of more than A difference of more than 2 mm2 mm between the anterior joint capsule and between the anterior joint capsule and the femoral neck is considered the femoral neck is considered significant. significant.

Ultrasonography also may be used to Ultrasonography also may be used to guide aspiration of the hip (e.g., guide aspiration of the hip (e.g., isolated unilateral hip effusion in a isolated unilateral hip effusion in a febrile child).febrile child).

Bilateral effusions suggest a systemic Bilateral effusions suggest a systemic arthritic disorder or transient synovitis arthritic disorder or transient synovitis because as many as one-quarter of because as many as one-quarter of patients with symptomatically unilateral patients with symptomatically unilateral transient synovitis have bilateral transient synovitis have bilateral effusions.effusions.

Radionuclide scansRadionuclide scans : :

Bone scintigraphy is a sensitive means of Bone scintigraphy is a sensitive means of detecting alterations in the detecting alterations in the metabolic ratemetabolic rate of bone and thus a sensitive means of of bone and thus a sensitive means of localizing pathology. localizing pathology.

However, bone scintigraphy lacks However, bone scintigraphy lacks specificity because such alterations in specificity because such alterations in bone metabolism can occur in Legg-Calvé-bone metabolism can occur in Legg-Calvé-Perthes disease, osteomyelitis, osteoid Perthes disease, osteomyelitis, osteoid osteoma, and malignant bone tumors.osteoma, and malignant bone tumors.

CT and MRICT and MRI

CT scanningCT scanning is useful in the diagnosis is useful in the diagnosis of deep soft tissue infections of the Para of deep soft tissue infections of the Para spinal and retroperitoneal regions.spinal and retroperitoneal regions.

MRIMRI is useful in the evaluation of the is useful in the evaluation of the spine (for discitis or spinal tumors), soft spine (for discitis or spinal tumors), soft tissue tumors and abscesses in the Para tissue tumors and abscesses in the Para spinal and retroperitoneal regions, spinal and retroperitoneal regions, osteomyelitis of the pelvis and long osteomyelitis of the pelvis and long bones, and in Legg-Calvé-Perthes bones, and in Legg-Calvé-Perthes disease disease

LABORATORY LABORATORY EVALUATIONEVALUATION   

Complete blood count (CBC), ESR or Complete blood count (CBC), ESR or CRP,CRP, and blood cultureand blood culture are useful in the are useful in the evaluation of evaluation of febrilefebrile patients and those patients and those in whom infection is being consideredin whom infection is being considered

. CBC and ESR or CRP also should be . CBC and ESR or CRP also should be considered in the evaluation of theconsidered in the evaluation of the afebrileafebrile child with a several day history child with a several day history of limp and no abnormalities on plain of limp and no abnormalities on plain radiography. radiography.

CulturesCultures Blood culturesBlood cultures

yield organisms 30-50% of casesyield organisms 30-50% of cases Decreases w/ previous antibiotic Decreases w/ previous antibiotic

therapytherapy Aspiration of joint fluidAspiration of joint fluid

Gram stain, leukocyte cell countGram stain, leukocyte cell count Cell counts 50,000 – 100,000/ml Cell counts 50,000 – 100,000/ml

likely septic arthritislikely septic arthritis Gram stain can give you early Gram stain can give you early

diagnosisdiagnosis 1/3 are positive1/3 are positive

THE BLOOD SUPPLY OF FEMORAL HEAD:

The main sources of blood supply to the proximal femur from

medial and lateral circumflex vs.each of which arise from the profunda femoris artery.

Additional supply from: superior gluteal artery artery of ligamentum teres

DDHDDHDevelopmental Dysplasia of the Developmental Dysplasia of the HipHip

The Limping Child:The Limping Child:Age 1 – 3Age 1 – 3

Pathological changes in DDH :

* Acetabulum shallow—the roof sloops too steeply * Femoral head dislocated superiorly and posterior—delayed ossific centre * femoral neck anteverted * capsule stretched hourglass appearance by iliopsoas tendon * limbus superiorly the acetabular labrum and its capsular edge may be pushed into the socket by the dislocated head , this fibrocartilage structure may obstruct closed reduction

* ligamentum teres elongated and hypertrophied which may obstruct the reduction

Clinical findings

Imaging studies

* before age of 6 months diagnosis can be done by U/S

* plain x-ray is more helpful after age of 6 months ( appearance of the ossific nucleus of the head

*Hilgenreiner’s line *Perkins’s line Position of the femoral head in relation to this two

lines *Acetabular indexIs the angle between hilgenreiner line & the roof of

the acetabulum, it should be below 30 degree by the age of one year & below 25 degree by 2 years age

*Center edge angle is the angle between the Perkins line & line pass

through the edge of the acetabulum & the center of the head . It becomes smaller as the hip subluxated.

normally is 20 degree or greater.

Imaging findings

Treatment of DDH At age of 0---6 ms: pavlik harness Age of 6---15 ms: gentle closed reduction under G.A. & maintenance of a located position for 2—3 ms in a spica cast usually stabilize the joint , any residual dysplasia must

treated by bracing or surgery. Age of 15---2yrs: *open reduction *femoral shortening osteotomy ; may be needed at time of open reduction to reduce tension on the soft

tissue & reduce the risk of AVN of the femoral head . *Capsulorrhaphy * cast spica Age above 2 yrs Significant residual dysplasia is present so the surgical correction is needed to

creates a stable mechanical environment that permits remodeling to normal joint during growth

* femoral osteotomy to correct the ant version and valgus deformity to be done before age of 4 yrs to stimulate normal growth of the

acetabulum * pelvic osteotomy to increase the femoral head covering needed by the acetabulum examples innominate osteotomy—pemberton acetabuloplasty—Dega

osteotomy– chiari osteotomy (medial displacement osteotomy)

The Limping Child:The Limping Child:Age 3 – 6Age 3 – 6

Transient synovitisTransient synovitis Child refuses to walkChild refuses to walk Movement of hip is painfulMovement of hip is painful May have feverMay have fever Moderately elevated WBCModerately elevated WBC Lasts a few daysLasts a few days Disappears without Disappears without

treatmenttreatment

Transient synovitisTransient synovitis Commonly occurs after a respiratory Commonly occurs after a respiratory

illness. illness. X ray image may be normal X ray image may be normal Ultrasound may show effusion Ultrasound may show effusion Main treatment is bed rest and Main treatment is bed rest and

physiotherapy. physiotherapy. Non-steroidal anti-inflammatory drugs are Non-steroidal anti-inflammatory drugs are

useful for treatment and can shorten the useful for treatment and can shorten the duration of symptoms in children duration of symptoms in children

D.D. : the most difficult and important differential

diagnosis is septic arthritis of the hip:The clinical finding are similar but there is high

temperature in septic arthritis.In a recent study , four independent parameters

were used to distinguish the two entities: fever (more than 38.5). CRP more than 20 mg\L. ESR greater than 40 mm/h. serum white blood count more than 12000

cells. non wt bearing.

Septic arthritis or Septic arthritis or osteomyelitisosteomyelitis

Blood cultures are commonly Blood cultures are commonly positivepositive Raised white cell count and C reactive protein, Raised white cell count and C reactive protein,

which normalizes more rapidly than erythrocyte which normalizes more rapidly than erythrocyte sedimentation rate once infection is brought under sedimentation rate once infection is brought under control control

X ray images show delayed changes. Radiographic X ray images show delayed changes. Radiographic evidence of acute osteomyelitis first is suggested by evidence of acute osteomyelitis first is suggested by overlying soft tissue oedema at 3-5 days after overlying soft tissue oedema at 3-5 days after infection. Bony changes are not evident for 14-21 infection. Bony changes are not evident for 14-21 days and initially manifest as periosteal elevation days and initially manifest as periosteal elevation followed by cortical or medullary lucencies.followed by cortical or medullary lucencies.

By 28 days, 90% of patients show some abnormality.By 28 days, 90% of patients show some abnormality.

Septic arthritisSeptic arthritis

WIDENED JOINT SPACE

Joint aspiration is the definitive Joint aspiration is the definitive diagnostic procedure and the most diagnostic procedure and the most common pathogen isolated is common pathogen isolated is Staphylococcus aureusStaphylococcus aureus

Perth's disease: Is a serious but – limited pediatric hip disorder , more common in boys, It affects age 4—10 years old.Is generally unilateral.Pathological changes: initially , the AVN episodes are silent and asymptomatic ,as the

bone of the proximal femoral epiphysis dies, it is revascularized---osteoclast remove dead bone while osteoblast simultaneously lay down new bone on a dead trabeculas ( during this phase the femoral head is mechanically weak) which lead to fragmentation and collapse of the bony structure causing flattening and deformity of the ossific nucleus and femoral head . The newly formed bone has the shape of the collapsed head.

The symptomatic collapse phase rarely exceeds 1-1 ½ years but full revascularization and remodeling may continue silently for several years.

C/P : painless limp ,if pain is presents , it may be mild and referred to the

thigh or knee. atrophy of the thigh ms limited ROM –typically pt has a flexion contracture of 0-30 degree,

loss of abduction and loss of internal rotation of the hip.

Radiological study: early by plain x-ray ------NAD but can be diagnosed early by MRI late by plain x-ray-----deformed head ( flattened –

fragmented )

Treatment : no treatment for children less than 5 yrs old----with less

than ½ of the head involvement (why ?) most of the head is cartilaginous------and there is good time

for remodeling.

Non-operative: most experts agree that children who maintain excellent

motion ( particularly abduction greater than 30 degree in absence of flexion contracture ) may not require intervention. (abduction bracing )

Operative : varus femoral osteotomy Salter osteotomy

The Limping Child: Age 10 The Limping Child: Age 10 – 14– 14

SCFESCFE Risk factors: Obesity, inflammatory (neglected septic arthritis), hypothyroidism, hypopituitarism.Clinical presentation: Pain-limping – discomfort in the hip , groin, medial thigh, is accentuated by running , jumping . Antalgic gait , out toeing . Preslipage: slight discomfortAcute slip : sever pain—deformity (external rotation, adduction)—limited ROM (internal rotation and abduction)Acute on chronic: pain ,limp over several months which is suddenly becomes very painful Chronic : mild symptoms ,pain , limp, external rotation during walking, mild to moderate shortening of the affected leg, atrophy of the thigh muscles

The Limping Child: Age 10 The Limping Child: Age 10 – 14– 14

SCFESCFE

Always get a frog lateral view

Always check the other side

RADIOLOGICAL CLASSIFICATION:

Treatment :

*avoid moving or rotating the leg, the patient should not allow to walk .

*analgesia *determine if it is acute (less than 3 weeks) or chronic (+

3weeks) *determine whether stable( able to weight bearing) or

unstable (non-weight bearing) *determine the radiological type of the SCFE ***Surgical intervention by immediate internal fixation using a single cannulated

screw is the treatment of choice . ***Femoral osteotomy is a secondary procedure to relocate the

head within the acetabulum to improve the ROM

***Bone graft epiphysiodesis

follow up : non-weight bearing for at least 6-8 weeks then start

physiotherapy

Child abuseAn important cause of limping or fracture in a

child,particulary in those younger than 2 years . It is important to look for skin manifestations such as

bruises , burns . Metaphyseal corner fracture are typical of child abuse, as

pull and twist that create these fracture are rarely accidental.

Overuse syndrome Children who have very recently undergone a significant

growth spurt have less joint flexibility and are more prone to injury :

Spondylolysis (common in female gymnasts) Iliac apophysitis ( seen in adolescent runner)Osgood- Sclutters disease ( the most common condition

around the knee)Severs disease ( it is characterized by pain at the

calcaneal apophysis )

THANKS FORTHANKS FOR YOUR ATTENSION YOUR ATTENSION

The Limping Child