Children’s Orthopaedics – The Limping Child Flashcards
what is a limp?
A limp is an abnormal gait commonly due to pain, weakness or deformity
A common presentation with many causes
Defined as a shorter stance phase (weight-bearing) on the affected limb
It is often, though not always, due to pain
what ar ethe different types of limps that may be seen and their causes?
what is the Surgical sieve for limps as there are many causes
Trimodal age specific causes - what are the cause sof limp in years 0-5
‘Normal variant’
Trauma
Transient synovitis
Osteomyelitis
Septic arthritis
DDH
JIA
Trimodal age specific causes - what are the cause sof limp in years 5-10
Trauma
Transient synovitis
Osteomyelitis
Septic arthritis
Perthes disease
Trimodal age specific causes - what are the cause sof limp in years 10-15
Trauma
Osteomyelitis
Septic arthritis
SUFE
Chondromalacia
Neoplasm
what are important things to aks in the history and what may it look like?
- Duration and progression of limp?
- Recent trauma and mechanism?
- Associated pain and its characteristics?
- Accompanying weakness?
- Time of day when limp is worse?
- Can the child walk or bear weight?
- Has the limp interfered with normal activities?
- Presence of systemic symptoms like fever, weight loss?
- Medical history, —birth history, immunisation history, nutritional history, and developmental history
- Drug history, allergies
- Family history
when exmaining a child who should you get information from?
what different things need to be done on examination?
• Look:
Check sole of foot for foreign bodies !
Deformity? Erythema? Swelling? Effusion?
limitation of active ROM, asymmetry
Assess shoes for unusual wear on the soles, asymmetry, point of initial foot strike, and also assess the fit
In older children look for scoliosis, midline dimples, and hairy patches, which could indicate spinal pathology
Assess gait with the child barefoot
Assess thigh or calf circumference for asymmetry
Leg length assessment
- Feel & Move - Spine, Hip, Knee, Ankle, Foot
- Neurological assessment
If you know about a condition and the presentation, diagnosis can be ____
easy
Infection and inflammation
Sometimes it is important to identify & differentiate
what conditions may be hard to tell apart?
- Septic arthritis – infection in joint that causes rapid damage and immediate treatment
- Osteomyelitis – infection in a bone, doesn’t need emergency intervention but neds IV antibiotics
- Transient synovitis – post viral inflammation of joints, diagnosis of exclusion
- Septic arthritis
- Osteomyelitis
- Transient synovitis
in a history what do you ask and how do you differentiate between these 3
- Limp (age dependent)
- Pain
- General malaise/ loss of appetite/ listless
- Temperature
- Recent URTI/ ear infections
- Trauma
- Pseudoparalysis – wont move joint
- Listen to the parent, they are usually right
- Septic arthritis
- Osteomyelitis
- Transient synovitis
in a examination what do you ask and how do you differentiate between these 3
- Do they look sick?
- Limp?
- Absolute refusal to weight bear? (suggests infection, tumour or facture)
- Localising area- ankle/ tibia/ knee/ thigh/ hip
- Hip - obligatory ER?, which movements hurt?
- Ankle- distal tibia or joint line?
- Knee- joint line or metaphyseal area?
- Upper limb disuse
what are some Differential Diagnosis (pre-investigation) of
- Transient synovitis
- Osteomyelitis
- Septic arthritis
- Sarcoma
- Myositis
- Osteoid osteoma
- Abscess
- Inflammatory arthropathy
Initial investigations
What are you looking for, which tests to do?
- Temperature
- X-ray?
- USS? - experience of the operator makes a great difference to result, can confirm effusion of joint as not apparent clinically
- Bloods - WCC, CRP, ESR, CK, Cultures
what is the clinical prediction rules for septic arthritis?
CRP over 30 is significant
whatis the distribuption of septic arthritis in the body?
what ar ethe routes of entry in septic arthritis?
Most common way infection gets into a joint is through haematogenous spread, infection got in blood stream then moved to joint
Dissemination form osteomyelitis
Infection often in growth plate as highest blood supply
what is the pathogenesis of acute haematogenous osteomylitis?
- Rare in adults
- 3 factors
Vascular anatomy - Vascular loops, Terminal branches
Cellular anatomy - Inhibited phagocytosis (low pO2)
Trauma - A factor in 30%?
More common in children due to vascular anatomy and loops of vessels around the growth plate
Some areas more infection than others
what symptoms are seen in osteomyelitis?
Poorly localised pain
More incidental history
Some will have osteomyelitis rather than septic arthritis
what is the microbiology of osteomyelitis?
this is changing
what are the different kids of JIA?
Present with limping, swollen and stiff joints in morning that gets better
who does JIA occur in?
AG 8 year old :
- Kicked by a friend
- Temp 39.80C recorded earlier in week at home
- NWB, night pain
- O/E pain on rotation of hip
- WCC 10 (upper limit of normal), CRP 107 (very high), ESR 88 (very high), Hb 122
- Apyrexial on admission
- Normal pelvic radiograph
- U/S fluid in both hips ? normal
- Differential Diagnosis?
–Septic arthritis
–Transient synovitis
–Osteomyelitis
Normally takes day to arrange
Abscess of the short external rotator muscles
Treated with antibiotics
25/03/18- 12 years old 2 week history of vague heel pain
Red swollen over posterior heel
Fit and well, toe weight bearing, Hb 127 CRP 34 WCC 6.4
Re-presented with ongoing heel pain 08/04/18
- Mild pyrexia
- Touch weight bearing, sore heel, ankle joint no effusion on examination
- CRP 44 (increased)
- WCC 11.5 (increased)
- Hb 127
- Blood cultures done
Low grade osteomyelitis - on MRI
AN July 2016
- 14 months old
- Increasingly unwell at home pyexial, off milk
- Mum noticed leg swelling
- Admitted to medical ward with sepsis
- USS left knee done reported as no effusion
- Group A Strep grown in blood culture
- MRI scan of leg done, verbal & written report of no collection, scant effusion in knee, extensive muscle involvement
High signal in muscle typical of infected myositis
ER 12 years old, Nov 2014
- 2 week sudden onset L buttock pain
- GP dx ischial bursitis & gave injection with some improvement (unusual in 12 year old)
- Presented to RACH with pyrexia & unwell reduced hip movement but not terrible
- Hb 104, WCC 12 (upper limit of normal), CRP 83 (raised), ESR 95 (raised)
Large fluid collection in iliacus muscle suggestive of an underlying abscess in the muscle and signal in bone is normal so not an osteomyelitis originally
Abscess drained under CT scan
No formal open surgery
JS April 2015
- Asked to see in passing by a physiotherapist
- 15 year old boy, groin strain playing football 6 months ago
- Increasing pain now radiating down thigh
- Walks with a limp, stopped football
- Woken at night
Osteosarcoma and was resected and artificial femur inserted
