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TRANSCRIPT
Satheesh Krishna Jeyaraj
Khaldoun Koujok
Julie Hurteau
Kawan Rakhra
Adnan Sheikh
Neither I nor my immediate family members have a financial relationship with a commercial organization that may have a direct or indirect interest in the content.
By the end of this exhibit the participant will be able to:
Identify the role of the radiologist in diagnosing cause of limping in children
Identify spectrum of imaging findings (plain films, ultrasound, CT and MR) in children with limping
Evaluate the limping child with a comprehensive algorithmic imaging approach
• Incidence - 1.8 per 1,000 children < 14 years
• Male : female - 1.7 : 1
• Median - 4.4 years
• Painful limp - 80%
• Localised to hip - 34%
• Localised to knee- 19%
• Benign causes - 77%
• Most common - transient synovitis
Fischer SU, Beattie TF. The limping child: epidemiology, assessment and outcome. J Bone Joint Surg Br. 1999;81:1029-34
LimpCauses
Osseous
Developmental
Traumatic
Infection
Neoplasm
Joints
Traumatic
Infection
Inflammatory
Soft tissueInfection
Overuse injury
Intraabdominal
Incidence: 1.5 to 2 per 1000 births
Age: neonatal
Girls>boys
Features: USG < 6 months Alpha angle < 60 degrees
Beta angle > 77 degrees
Bony coverage 5 degrees
Plain radiographs Broken Shenton’s line
Femoral head in upper outer quadrant
‘Developmental dysplasia of hip’ in a 20-month-old girl since she started walking. Radiograph shows a broken Shenton’s line on right with femoral head in upper outer quadrant
Perkin
Shenton
Hilgenreiner
Upper Outer
LowerInner
Incidence: 6% of population
Age: 8 to 16 years
Boys > girls
Features
Calcaneonavicular
Anterior process
Anteater nose sign
Talocalcaneal
Middle facet
C-sign
Talar beak sign
‘Talocalcaneal coalition’
‘Calcaneonavicular coalition’
Incidence: 0.4 to 29.0 per 100,000 children <15 years
Age: 4-8 years; boys>girls
Early
Joint effusion
Smaller femoral epiphysis
Apparent increased density of femoral epiphysis
Blurring of physeal plate
Radiolucency of proximal metaphysis
‘Early Legg Calve Perthe’s’Subchondral lucent crescent andDecreased uptake on bone scintigraphy
Incidence: 0.4 to 29.0 per 100,000 children <15 years
Age: 4-8 years; boys>girls
Late
Femoral head deformity with widening and flattening
Coxa magna‘Advanced Legg Calve Perthe’s’Flattening and increased density of headand widening and shortening of femoral neck
Incidence: 5 to 15 cases per 100,000 children
Age: 8 to 15 years
Boys > girls, obesity
Preslip
Blurring of physeal edges
Demineralisation of metaphysis
‘Preslip left hip’Ill defined growth plate and radiolucencyand abnormal signal along growth plate
Incidence: 5 to 15 cases per 100,000 children
Age: 8 to 15 years
Boys > girls, obesity Acute slip – posteromedial
Better seen in frog-leg lateral view
Epiphysis appears smaller as it moves posteriorly
Trethowan’s sign
Loss of triangular sign of Capener
‘Acute slip right hip’Normal Klein’s line on the leftTrethowan’s sign on the right
Klein
Age: 14 to 25 years
IschialTuberosity
(hamstrings)
Symphysis Pubis and IPR
(adductors;gracilis)
Lesser Trochanter(iliopsoas)
Greater Trochanter
(hip rotators)
AIIS(rectus femoris)
ASIS(sartorius;
tensor fascia lata)
Iliac Crest(abdominal muscles)
‘Avulsion right ischium’Cortical irregularity and periostealreaction in a 11 year old competitive dancer
Incidence:
Age: 9 months to 3 years
Stress due to increasing ambulation
Features
Spiral fractures of tibia
Minimally or not displaced
Mild sclerosis and peritoneal reaction on follow up
NOT non-accidental injury !!!
Spiral femoral fracture = Non accidental injury
‘Toddler’s fracture’Subtle spiral fracture in the right tibiawith increased uptake on bone scan
Incidence:
Age:
4 to 5 weeks after starting a new exercise
Features
Linearly oriented sclerosis
Marked marrow edema
Cortical break
Periosteal reaction
‘Sacral stress fracture’Bone marrow edema withhypointense fracture line in this 15 year old boy
T1 T1 with gadolinium
T2 T2
Incidence: 1 in 500 to 5000
Age: 4 months to 5 years
Boys > girls
Features
Soft tissue swelling
Blurring of fat planes
Periosteal reaction
Endosteal scalloping
Cortical defect
Loss of architecture
T2
‘Acute osteomyelitis’Small effusion of the left hip with bone marrow edema in left femoral neck.Normal right hip for comparison.
Chronic
Sequestrum
Involucrum
Cloaca
MR
Bone marrow edema
Enhancement
Indium111 labelled WBC
Gallium67 scintigraphy
FDG-CT/PET‘Acute osteomyelitis’Left femoral neck show hypointensity on T1 andenhancement following contrast administration.Also note thin reactive synovial enhancement.
Heterogenousspectrum of conditions
Age: Mostly in second decade
Limp by pain, fracture or limitation of motion
Features Small zone of
transition
Benign type of periosteal reaction
‘Osteoid osteoma’
‘Aneurysmal bone cyst’
Incidence: 6% of all childhood malignancies
Age: 10 to 20 years
Features Wide zone of
transition
Aggressive periostealreaction
Cortical destruction
Extraosseous soft tissue component
‘Ewings sarcoma’ withLytic destruction,and periosteal reaction
soft tissue component
‘Osteosarcoma’ withLytic destruction,and periosteal reaction
soft tissue component
Incidence: 1/3 of all childhood malignancies
Age: 2 to 8 years
Boys > girls
Features
Metaphyseal lucency
Osteolytic lesions
Osteopenia
Vertebral fractures
Periosteal reaction
Altered bone marrow signal
T1 T2
‘Acute lymphoid leukemia’Metaphyseal lucent bandsand replaced bone marrow
Incidence: 5 to 37 per 100,000 children
Age: any age; most common <3 years
Boys>girls
Features Joint effusion
Juxta-articular osteoporosis
Bone erosions
Fat fluid level
Synovial enhancement
Perisynovial edema‘Septic arthritis’ Right hip effusion. Note mild secondary inflammation of bone and muscles.Right hip effusion.
Incidence: 76.2 per 100,000 children <15 years
Age: 3-8 years
Self limiting condition
Features
Symptomatic hip effusion
Synovial thickening
Synovial enhancement
Altered signal in surrounding tissue
No altered signal in bone marrow !!!
‘Transient synovitis’ Subtle synovial enhancement of the left hip. No bone marrow edema.
Incidence: 1-4% in tropical countries
30% in patients with HIV
Age: 2 to 5 years
Features
Muscle edema
Muscle enlargement
Intramuscular abscess
Gas within the abscess or muscle planes
‘Pyomyositis’ - 15 year old boy with fever and pain on internal rotation showsedema and inflammation of muscleand intramuscular abscess
Incidence
Age: 10 to 14 years
Children with cerebral palsy
Features
Thickening of proximal patellar tendon
Heterogeneity of posterior fibers
Abnormal signal in inferior pole of patella ‘Sinding Larsen Johansson disease’
High signal in the proximal patellar tendon,inferior patella on either side of the synchondrosis
Incidence: 13-21% in athletic adolescents
Age: 12 to 15 years
Boys > girls
Features Thickening and edema of
inferior patellar tendon
Soft tissue swelling
Loss of sharp inferior angle of Hoffa’s fat pad
Infrapatellar bursitis
Fragmentation of tibial tuberosity
‘Osgood Schlatter disease’ High signal seen in the distal patellar tendon,and tibial tuberosity
antero inferior Hoffa’s fat pad
Thrombophlebitis Appendicitis
Pelvic teratoma Pelvic abscess
Emergencies UrgenciesSeptic arthritis Open fractures
Neurovascular compromise Stable slipped capitalfemoral epiphysis
Compartment syndrome
Unstable slipped capital femoral epiphysis
Age
Type of gait
Toddler (1-3)
Occult Fracture
Transient Synovitis
Infection:
• Septic arthritis
• Osteomyelitis
• Pyomyositis
Neoplasm (neuroblastoma mets, leukemia)
Child (4-10)
Perthe’s disease
Transient synovitis
Infection:
• Septic arthritis
• Osteomyelitis
• Pyomyositis
JRA
AVN/Sickle cell pain
Neoplasm/Leukemia
Adolescent (11-16)
Slipped Capital Femoral Epiphysis
Infection:
• Septic arthritis
• Osteomyelitis
• Pyomyositis
JRA
AVN/Sickle cell pain
Neoplasm/Leukemia
Traumatic:
• Avulsion injuries
• Muscular tear
Non-antalgiclimp
Steppage gaitNeurologic condition
with loss of dorsiflexion
Trendelenburg gait
DDHabnormality in
adductor mechanism
Perthe’s
SUFE
Circumduction gait
Positive GaleazziLimb-length discrepancy
Neurologic or mechanical condition
leading to ankle or knee stiffness
Equinus gait
CTEVCerebral palsy
Idiopathic tight Achilles tendon
Calcaneal fractureForeign body in foot
Sever’s disease
Stooping gait
Appendicitis
Pelvic inflammatory disease
Psoas abscess
NOT SICK
< 2 yearsX ray of lower leg
for Toddler’s fracture
If negative hip
radiograph / US
2 to 10 years
No imaging or US to confirm transient
synovitis
Hip radiograph and ultrasound
> 10 years Hip radiograph
SICK Ultrasound
Effusion = septic arthritis
No effusion – Radiograph / bone scan / MR for
osteomyelitis
<5 days
>5 days
Persistent unexplained symptoms or
high suspicion
with negative radiography
MRI
Kocher criteria1. Non weight bearing2. Temp > 38.5oC 3. ESR > 40mm/h4. WBC > 12,000/mm3
Step 1
• Radiograph of hip (AP and frog leg)
• In toddler, radiograph of leg
Step 2
• Ultrasound hip in sick patients
• Ultrasound abdomen
Step 3
• MRI in negative cases with high index of suspicion
8 year old girl
Ischiopubic synchondrosis
9 year old girl
Normal or abnormal?
Normal irregularity of iliac crest
Normal apophysisin teenager Lucencies from
bowel gas.Rarely seen over the lateral half of the iliac crest.Always ask your self: “could these be a lytic bone lesion?”
Normal irregularitiesof the acetabular roofseen between 7 and 12 years old
15 year old
Limp is caused by myriad of trivial to life threatening causes with management varying from reassurance to major surgery depending upon the diagnosis.
The age of the child and clinical presentation has major bearing on the differentials to be considered.
An algorithmic imaging approach enables us to ‘walk towards the correct diagnosis’ to institute prompt management.
Satheesh Krishna Jeyaraj
Fellow in Emergency Radiology,
The Ottawa Hospital,
501, Smyth Road,
Ottawa,
K1H 8L6
Email: [email protected]