the limping child wendalyn king md, mph. walking 2 phases stance swing both feet in contact with...
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The Limping Child
Wendalyn King MD, MPH
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Walking
2 phasesStance Swing
Both feet in contact with ground only 20% of gait cycle
Developmental processToddlers – short, rapid stepsAdult gait pattern present around age 3
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Limp
Antalgic gait Pain leads to shortened stance phase on affected side Most common acute presentation of limp
Trendelenberg Underlying proximal muscle weakness or hip instability Equal stance phase, but trunk shifts over affected
extremity Usually non-painful “waddling” gait if bilateral process
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Differential Diagnosis Trauma
Acute Repetitive
SCFE, AVN
Infectious/inflammatory Septic arthritis Inflammatory arthritis Osteomyelitis Diskitis
Neoplastic Leukemia Primary and
metastatic bone lesions
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By Age
Toddler (1-3yr) Infection Occult trauma Neoplasia
Child (4-10) Infection Transient synovitis LCPD / AVN Rheumatologic disorder Trauma Neoplasm
Adolescent (11+) SCFE Rheumatologic
disorder Trauma
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Evaluation
HistoryOnset of symptomsFever, systemic symptomsHistory of trauma
Often present, may be misleading
Physical examination Inspection Observe gaitRange of motion (feet, knees, hips)
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Evaluation
Xray Labs
CBC, ESR, CRP may be helpful in some instances
Other imagingUltrasound (hips)CT /MRIBone scan
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Case #1
18 month old with acute onset limp Afebrile, otherwise no complaints Happy and playful until stands up
Fussing, resists weight bearing on R Normal examination
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Toddler Fracture
Spiral fracture of distal 1/3 of tibia Usually simple fall while running or stepping on
object May occur up to 6 yr age (peak 2-4yr) May not be visible on normal AP/Lat film
Oblique film Repeat films
Callous formation within 1-2 week
Splint/cast Healing within 3-4 weeks
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Case #2
2yo male with 1 week of progressive limp and leg pain
Xray at beginning of symptoms negative Splinted for presumptive fracture Low grade fever, increasing fussiness, now “dragging
leg” and refusing to walk Exam
Fussy, ?tender to palpation distal L leg CRP, ESR elevated
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Osteomyelitis
Most common in children <10 Usually hematogenous seeding of bone
Trauma (even minor) may predispose Usually begins in metaphaseal region of long bone Inflammatory exudate collects in marrow, cortex,
subperiosteal space Ischemia leads to infarction and pain Form area of necrotic bone called sequestrum
Eventually separates to form free body or may be reabsorbed
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Osteomyelitis
Common organismsStaph aureus most commonGroup B strep in neonatesH. flu, Strep pyogenes, Salmonella,
Pseudomonas, Kingella kingae May be difficult to localize
NeonatesSpine, pelvis
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Osteomyelitis
Diagnosis Radiographs
May be normal or nonspecific for 10-14 days Bone scan, CT, MRI may be needed
Acute phase reactants WBC normal initially in 60% cases CRP rises in 8 hours, peaks 2 days, normalizes over 1 week ESR normal in 25% new onset cases, may be useful for monitoring
therapy Blood culture positive 50-60% cases Bone aspiration or biopsy Treatment is 3-6 weeks of antibiotic therapy
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Case #3
4 year old female with worsening limp and leg pain. Tactile fever at home
Recent URI, otherwise healthy Exam
Uncomfortable, lying in bed, cries when approached
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Septic Arthritis
Usually hematogenous seeding Extension of osteomyelitis Direct inoculation into joint from penetrating trauma
Etiology Staph aureus (H. flu historically) Kingella kingae Neonates: E. coli, Candida, GBS Adolescents: N. Gonorrhea
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Septic Arthritis
Presentation Acute joint inflammation
Swelling, redness, pain “Pseudoparalysis”
Joint held in position to maximize intra-articular space and minimize pressure and pain
Hip – flexion, abduction, external rotation Knee - partial flexion Shoulder – adduction and internal rotation Elbow – midflexion
Often have fever and ill appearance
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Septic Arthritis
Diagnosis Blood culture positive 30-40% Elevated CRP, ESR Arthrocentesis Imaging
Widening of joint space, soft tissue swelling Ultrasound useful for hip effusion
Treatment Antibiotic Irrigation and drainage Prompt surgical drainage of hip (and often shoulder) needed to reduce
intra-articular pressure and avoid avascular necrosis of femoral head
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Diagnostic Dilemmas
Transient synovitis of hip (“toxic synovitis”) Non-infectious, inflammatory condition Usually children 3 – 8yrs May follow viral URI Mild fever, limp, fussiness Minimal limitation of range of motion ESR, CRP, WBC usually normal Managed with rest, NSAIDs, close follow up
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Diagnostic Dilemmas
Overlying cellulitis vs Septic Arthritis Other causes of acute arthritis
HSPSerum sicknessJRA, lupusTick borne illness
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Case #4
4 yo male with 3d h/o limp and thigh pain No fever Some improvement with ibuprofen Active and playful Uncomfortable with rotation of hip
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Avascular Necrosis
Legg-Calve-Perthes Disease Usually occurs 2 – 12 yrs (avg 7) Males > female May be secondary to repeated micro-
trauma Recurrent episodes of hip irritability
common
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AVN
Risk of later degenerative arthritisWorse prognosis with older age (>10) and
extensive femoral head deformityVery good prognosis in children <5
TreatmentSymptomatic – rest, pain medsObservation for children <6Surgery for older children with severe
involvement
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Case #5
5yo female with several days of leg and back pain, decreased appetite and activity and ?weight loss
Xrays pelvis at outside facility negative 2 d before Pt alert, thin, ill and uncomfortable appearing.
Cries with manipulation of hips/legs. ? Firmness to palpation in upper abdomen
CBC, chemistry normal
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Neoplastic
Leukemia Neuroblastoma Primary bone tumors
Benign Unicameral bone cyst Osteoid osteoma
Malignant Ewing and osteogenic sarcomas
Spinal tumors
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Case #6
12yo male with chief complaint of knee pain
Present for a couple weeks, acutely worsened after playing basketball
No fever, no other symptoms Exam: walks with limp
Knee – no swelling, no tenderness, normal range of motion
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Slipped Capital Femoral Epiphysis(SCFE) Most common adolescent hip disorder Type of epiphyseal fracture Common in obese adolescents
(also in tall, thin kids after growth spurt)
May present with chronic limp, acute pain or combination
Hold leg in slight external rotation and have limited internal rotation
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SCFE
XrayNeed both hips for comparisonNeed frog-leg radiographEarliest sign is widening of epiphysis
“pre-slip” conditionLine drawn along outer aspect of femoral
neck should intersect the femoral capital epiphysis
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Case #7
15 yo male brought in by EMS for sudden onset severe hip and leg pain
Was running 40 yard dash for football tryouts when developed severe pain and difficulty ambulating
Exam: very uncomfortable, pelvis stable but painful to palpation, pain with hip movement, especially hip flexion
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Avulsion
Probably secondary to repetitive stress/microfracture
3 common sites (at major muscle insertions) Anterior inferior iliac spine Superior iliac crest Ischial tuberosity
Initial therapy is rest, crutches, pain meds Outpatient orthopedic follow up
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Summary
Many causes of acute limpRange from trivial (new shoes) to life
threateningThorough history and physical importantLiberal use of imaging studiesKeep in mind common conditions for each
age groupClose follow up if diagnosis in doubt
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Questions???