pemdenver limping child
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The Limping Childand
Hip PainPatrick J. Maloney, MD
Denver Emergency Center for ChildrenDenver Health Medical Center
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Evaluation of the Limping Child or Child w/ Hip pain Clinical History
Circumstances surrounding the limpTrauma, pain, associated systemic
symptoms/illness Physical Exam
Localize source of painAbdominal and genitourinary exam
Laboratory and Radiologic StudiesTailored to findings in history and physical
exam
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Evaluation of the Limping Child
Physical ExamFlexed, abducted, externally
rotated hip = fluid in hip joint capsule
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Evaluation of the Limping Child
Physical ExamPassive ROM of the hip
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Evaluation of the Limping Child
Trauma is the most common cause in all age groupsAcute or repetitiveOftentimes, parents will endorse minor trauma
as cause of limpCoincidence or Causation?
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Differential Diagnosis for Non-Traumatic Limp Transient Synovitis Septic Arthritis Legg-Calve-Perthes disease (Avascular
Necrosis of the Capital Femoral Epiphysis) Slipped capital femoral epiphysis (SCFE) Other
Peripelvic Pyomyositis Osteomyelitis Tumor/Leukemia Occult Fracture (e.g. Toddler’s Fx)
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Case 1 A 5-year-old boy presents with a 4-week
history of limp that has worsened progressively. There are no significant findings on the past medical history. He has not been ill recently. There is not history of trauma. Physical examination reveals a decreased range of motion of the left hip and an obvious limp with walking.
What is the MOST likely etiology of this child’s limp?
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Legg-Calve-Perthes DiseaseAvascular necrosis of the capital
femoral epiphysisMost common between 4-10 years of
age.Male:Female is 4:1Child may complain of pain in hip,
thigh or knee.often insidious and can lead to
disuse of affected limbXray findings are pathopnomonic
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4 distinct radiographic stagesSynovitis/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
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 Disease
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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 ©
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Treatment 50% recover without treatment Goal: maintain femoral head within the
acetabulumAbduction splints/casts and non-weight bearing stateSurgically with an osteotomy of the proximal femur
Prognostic factors Better Prognosis
Younger (<6y)<50% epiphyseal necrosis
Worse OutcomeObesity
Legg-Calve-Perthes Disease
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Case 2 A 6 year-old boy presents with a 3-day history of a
limp. He has had a URI for 1 week. There is no history of trauma. On physical examination, his temp is 100.4 F (38C), he does not bear weight on the right leg, and there is decreased ROM at the right hip. WBC count is 8,000, and the ESR is 20 mm/hr.
What is the MOST likely etiology of this child’s
pain?
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Transient SynovitisAlso called “toxic synovitis” or “irritable
hip”Most common cause of non-traumatic hip
pain in children Accounts for 30-40% of all non-traumatic limps
Occurs in children 2-6 years old typically <4 years old
Associated with recent URI in 32-50% of cases
Male:Female is > 2:1Almost always unilateral
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Transient SynovitisBenign, self-limited disorder
Sterile inflammation of the synovium of the joint With or without a joint effusion Unclear etiology (? Post-viral)
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Transient Synovitis Clinical History
Acute onset of pain and limited ROM of the hipLimp or refusal to bear weight
Physical ExamHip is flexed and externally rotated
mildly decreased ROMAfebrile/low-grade fever (<38.5)
LaboratoryNormal WBC (<12,000)Normal or mildly elevated CRP (<2) and ESR (<40)
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Transient Synovitis X-Ray
Most commonly normalJoint space widening (joint effusion)
UltrasoundJoint effusion and/or synovial swelling
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Transient Synovitis
TreatmentRest; weight bear as tolerated Ibuprofen
Decreased pain vs Placebo (2d vs. 4.5d) 80% of all patients with resolution by 7 days
Prognosis Generally good Recurrence in 4-15% have been reported
So why is it important to make the diagnosis of transient synovitis?
Annals of Emergency Medicine 2002; 40:3:297
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Case 3 A 6-month-old female infant presents to
you with fever to 102°F (38.9°C), poor feeding, and decreased activity for 5 days. Her mother has noted that over the last 7 days she cries whenever her diaper is changed, and for the last 2 days she has refused to move her left leg. On physical examination, you note a febrile infant who cries with passive movement of the left leg.
What is the MOST likely etiology of this child’s leg pain?
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Septic ArthritisTrue Orthopedic emergency
Single most important prognostic factor for a good outcome is early treatment!!!Results from bacterial invasion into the joint space
Most commonly hematogenous spreadContiguous spread from neighboring osteomyelitisDirect inoculation from penetrating wound
Can occur at any age but >50% of cases are in children <3 years old Hip is most commonly affected joint in children
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Septic Arthritis Organisms
Staphycoccus aureus (most common) Streptococcus species
Strep pneumoniae Strep pyogenes Group B Strep (neonates)
Haemophilus Influenzae Neisseria gonorrhea (adolescents) Salmonella (sickle cell disease) Gran negative bacilli (neonates)
Acute inflammatory response (TNF-α, IL-1, proteases destroy the articular cartilage Continues after eradication of the bacteria
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Septic ArthritisDiagnosis may be very difficult
Usually previously healthy children <5 years (>50% of cases occur in children <3 years)Early peak in the first months of infancy
1/3 w/ URI’s within the past month
Usually temp > 38.5Usually unable to bear weightOther symptoms include:
Malaise, fatigue, irritability, abdominal pain, etc.
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Septic Arthritis Physical Exam
DOES NOT present with erythema, warmth or swelling (hip)
Hip is usually held in flexion, external rotation, abduction Usually very painful ROM
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Septic Arthritis
Joint Aspiration is definitive diagnosis Cloudy, turbid WBC count >50,000; predominantly PMNs Glucose levels < ½ of serum 50% positive gram stain 50-70% with positive culture
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Septic Arthritis Joint Aspiration
Performed under ultrasound guidanceUsually needs procedural sedationComplications
iatrogenic infectionBleedingneurovascular injury
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Septic ArthritisOther Diagnostic Tests
WBC: elevated with left shift (>12,000)ESR: elevated (>40)CRP: elevated (>2)Xray: may show wide joint space (effusion)
late findings (10 days): osteopenia, joint narrowing, soft tissue swelling
Ultrasound: may demonstrate joint effusion early in disease
MRI: helps evaluate for abscess and/or osteomyelitis
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Septic Arthritis vs Transient Synovitis Kocher et al. Journal of
Bone and Joint Surgery. 1999 Boston Children’s Retrospective study Risk Factors
WBC >12,000/mm3
ESR >40 mm/hr Temp >38.5 OralRefusal to bear weight
Caird et al. Journal of Bone and Joint Surgery. 2006 CHOP Prospective study 53 patients who all had hip
aspiration Risk Factors
WBC >12,000/mm3
ESR >40 mm/hrCRP >2 mg/dLTemp >38.5 OralRefusal to bear weight
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# of factors
Caird et al Kocher et al
0 16.9 0.2
1 36.7 3
2 62.4 40
3 82.6 93.1
4 93.1 99.6
5 97.5 N/A
PPV of Septic Arthritis
Septic Arthritis vs Transient Synovitis
Fever (>38.5 C) was best predictive factor
CRP >2mg/dL was only other independent risk factor
Caveat: studies evaluated children
with high clinical suspicion for septic arthritis
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Septic Arthritis Treatment
Joint drainage (“wash-out”) IV antibiotics for 2-4 weeks
<2 months: Nafcillin + Gentamicin>2 months: Ceftriaxone +/- Vancomycin
• Prognosis: risk of avascular necrosis• 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
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Case 4
• A 14 year-old boy presents to your office for evaluation of low-grade, diffuse knee pain on the right. On exam you have the child stand on the right leg and notice that he has a mild downward tilt of the pelvis to the left.What is the most likely etiology of his knee pain?
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Slipped Capital Femoral Epiphysis (SCFE)
An acquired growth plate injury (Salter-Harris I) Separation of the proximal femoral epiphysis from the metaphysis
Most commonly occurs in adolescents and preadolescents 81% BMI >95th Percentile Peak age is 10-13y in females and 12-16y in males
Overweight boysRare after menarche
African Americans and Pacific Islanders >> Caucasian and Hispanics Associated with endocrinopathies (growth hormone deficiency) in 8%
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Slipped Capital Femoral EpiphysisClinical History
Preceding history of trauma with acute pain/limp common
Subacute or chronic pain with insidious onset that can be referred to the hip or knee
Pain increased with physical activity May be able to bear weight if stable
Examination Hips is 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%
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Slipped Capital Femoral EpiphysisRadiography
X-ray of both hips AP, Lateral, and Frog-Leg Views“Ice Cream falling off Cone”
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Slipped Capital Femoral Epiphysis
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Slipped Capital Femoral EpiphysisKlein’s Line
Line drawn along the posterior aspect of the femoral neck
Normal Abnormal
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Slipped Capital Femoral Epiphysis
Treatment Strict non-weight bearing to prevent further slip
Occasionally may discharge on crutches Surgical fixation
Screw fixation under flouroscopy Some prophylactically fix contralateral hip as well
Osteotomy may be necessary for advanced slippage
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Slipped Capital Femoral Epiphysis
25-40% have bilateral SCFEsContralateral slip usually occurs within 6-12
months of index side Prognosis
Usually good prognosis (stable and chronic slips) Increased risk of subsequent acute chondrolysis,
avascular necrosis, and premature hip arthritis
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Other Etiologies of LimpPeripelvic PyomyositisOsteomyelitisOccult Fractures (Toddler’s Fx)TumorsLeukemiaDeep Muscle Hematomas/AbscessesAbdominal and Genitourinary Dx
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Disease Age Onset Systemic Symptoms Labs Radiology Treatment
Transient Synovitis
2-6y (typically
<4y)acute
Preceding URI common; afebrile of low-grade
fever (<38.5)
WBC <12ESR <40CRP <2
none NSAIDssupportive
Septic Arthritis
<5y(50% <3y) acute
Fever (>38.5) malaise
irritability
WBC >12ESR >40CRP <2
Joint Asp:>50k WBC
U/S: joint effusion
Xray: joint widening
Abx“wash-out”
Leg-Calves-Perthes (AVN)
4-6yAcute
or insidious
none none
Xray: various
stages of epiphyseal
necrosis
NWBOsteotomy
SCFE M: 12-16F: 10-13
Acute or
insidiousnone none
Xray: “ice cream
scoop off cone,”
Klein’s line
Screw fixation,
Osteotomy
Non-Traumatic Limp/Hip Pain
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