Limping Child

Question 1

Osgood-Shlatter:

Answer 1

AKA tibial tub apophysitis

**Inflammation at insertion of patella tendon at tibial tuberosity

Pubertal growth spurt, 10-15yo
Males
Particularly if run/jump sport

Clinical diagnosis- don’t need imaging
XR: +- fragmentation at tuberosity

Self-limiting once growth over
Rest, ice, NSAIDs
Protected activity

Question 2

Avascular necrosis femoral head:

Answer 2

AKA Legg-Calve-Perthes

Age 4-10yo
Boys (4:1)
Can be bilateral

Aetiology unclear

Self-resolves and remodels
Avoid high-impact exercise
Few need OT

1/3 full recovery, 1/3 some pain, 1/3 arthritis

Question 3

Slipped upper femoral epiphysis

Answer 3

AKA SUFE

Clinical
Obesity
Pubertal growth spurt
Boys (3:1)
HYPOTHYROID
–> Consider when prepubertal

Onset is insidious OR sudden

Dx:
XR with frog leg views: widened –> slipped
Abnormal Klein line

Mx:
All need surgical fixation
Risk is Avascular necrosis of femoral head

Question 4

Klein line:

Answer 4

Line along upper femoral neck should transect 1/3 of femoral head

If not: suspic. for SUFE

Question 5

Transient synovitis

Answer 5

AKA irritable hip

Most common causeof hip pain in kids

Prepubertal 3 - 10yo
Unilateral
Follows viral illness
+/- low grade fever
Inflamm markers usually mild

Main DDx is septic arthritis (Kocher criteria)

Mx:
Limit activity
NSAIDs
Improves in 2-3 days, gone by 2 weeks

Question 6

Kocher criteria:

Answer 6

Septic arthitis vs Transient Synovitis in KIDS with HIP pain

0- Not septic arthritis
–> Discharge

1- 3%
2- 40%
3- 93%: asp in OT
4- 99%: asp in OT

Question 7

DDX of child with limp (by age):

Answer 7

INFANT/TODDLER (0-4)
DDH
Toddler fracture
NAI

CHILD (up to 10)
Perthes

ADOLESCENT (10+)
Osgood-Schlatter
SUFE

ALL
Traumatic
–> Fractures, pelvic avulsions (ASIS, PSIS, isch tub)
Infective:
–> Transient synovitis, Acute myositis, Septic arthritis, osteomyelitis
Malignancy
–> Leuk, sarcoma, osteo
Haeme
–> Sickle cell, haemophilia, vWB
Rheum/Imm
–> Juvenile arthritis, HSP, serum sickness, reactive arthritis, vasculitis
Abdominal/ GU
–> Appendicitis, ovarian torsion, ectopic, testicular torsion
Spinal
–> Discitis, epidural abscess
Functional

Question 8

Examination of the child with a limp:

Answer 8

General
- Fever
- ‘Toxic’
- Hygeine/ presentation, interaction with carers
- Cachexia, pallor
- Bruising, petechiae

Mobility/gait
Move toy/ parent out of reach

Examine limb
Look: position, deformity, redness, swelling, rash
Feel: warm, tenderness, masses
Move: Active + passive full ROM
Neurovascular

Examine systems
Spine
Abdomen
Testes

Question 9

When is it appropriate to do NO investigations on limping child?

Answer 9

No red flags (incl Kocher)
Mobilising after simple analgesia
Able to follow up within 5 days

Most likely DDx transient synovitis, acute myositis or MSK