Limping Child

Question 1

What are the 4 main causes of limp in a child and the age groups that they are seen

Answer 1

DDH 0-2yrs painless
Transient synovitis 2-5years painful post URTICARIA
Perthes disease 4-10years gradual
Slipped capitate femoral epiphysis 10-15years

Question 2

DDH

Answer 2

Girls :Boys 6:1
4/1000 spectrum illness 1/250

Risk factors
Family history ( parents or sibling 1/250)
Breech 10%
First born
Race
Packing assoc with other issues eg torticolisis/ foot deformity

Question 3

Clinical features of DDH

Answer 3

1 asymmetrical skin creases ( 30% normal kids have this so not reliable sign
2 LIMITED ABDUCTION OF THE HIP most important sign
3 shortening of the leg
4 Barlow’s flex hip 90degrees and then push on knee ‘clunk’ felt + test
5 Ortolairis test as above and then abduct hip and lift up from below ‘clunk’ felt
5 packing

Question 4

Who should have investigations for DDH

What tests should be performed

Answer 4

1 history of breech / family history of DDH
2 Examination abnormal signs

USS of hip <6/12. Can do dynamic testing
X-ray of hip >6/12

Question 5

Treatment of DDH

Answer 5

Reduce the dislocated hip

Closed <6/12 and then brace in flex position ( Pavlich harness <6/12)
Older than 6/12 rigid brace
Open reduction if older child and may need surgical treatment
2 Acetabulomplasty
If the child is young they can remodel
If older >18/12 no remodeling

Question 6

List 3 causes of a limp/ irritable hip in a 4 year old

Answer 6

1 transient synovitis
2Perthes disease
3 septic arthritis ( PAIN Unwell FEVER looks sick MEDICAL emergency)

Question 7

Features of transient synovitis

Answer 7

Child limps but is well pain limp stiffness ( + trendelenberg sound side sags)
2-5 years
Post URTI say 2/52
M:F. 3 : 2

95% get better with rest and NSAI
5% perthes

Question 8

perthes disease features

Answer 8

Can take 4-6/12 to appear to have X-ray changes
4-10 year old age group
1/1000 Caucasian ( 1/4000 Asian)
Limp
Cause unknown 
Clinically.  
1. Muscle wasting 
2. Reduced abduction 
3. Trendelenberg positive 

Treatment is containment keep the femoral head in the acetabulum
Mostly conservative treatment 
Occasionally surgery needed 
Poor prognosis
     >8years 
     Whole head involved
     Lateral subluxation 
Outcome is that 50% OA of hip by 40 years THR

Question 9

Slipped Capital Femoral Epiphysis

Answer 9

Limp. (Knee pain 25% -50% thigh pain hip pain 50%)
Males 12-15
Females 10-13. Pubertal growth spurt

Examination reduced internal rotation of the hip

Linked to obesity ( 50% are >97% for weight 50% are overweight don’t forget that some can be normal weight)
Physiological ( growth spurt)
Out toeing

Investigations AP/ Frog Lat view. BOTH HIPS

Treatment surgical fixation pin-in-situ
Trauma ( parents often report but not thought important in the causes)

Out come 50% OA of hip requiring THR