Paediatric Orthopaedics - The Limping Child

Question 1

What can the different gaits be for limping child?

Answer 1

Pain - antalgic gait
Weakness - Trendelenburg gait
Short limb - toe walk
Stiff joint - adducted and loss of rotation

Question 2

What is the definition of a limp?

Answer 2

Abnormal gait commonly due to pain, weakness or deformity
Is often but not always due to pain
Shorter stance stage of affected limb

Question 3

What are the causes for limping child?

Answer 3

Trauma, infective/ inflammatory, neoplastic, endocrine, neuro, degenerative, vascular, idiopathic, congenital, metabolic and occupational

Question 4

What are causes for limping in a child aged 0-5 years?

Answer 4

Normal variant, trauma, transient synovitis, osteomyelitis, SA, DDH and JIA

Question 5

What are some causes of limping in 5-10 year olds?

Answer 5

Trauma, transient synovitis, osteomyelitis, SA and Perthes disease

Question 6

What are some causes of limping in a child aged 10-15 years old?

Answer 6

Trauma, osteomyelitis, SA< SUFE, chondromalacia and neoplasm

Question 7

What should be asked in history?

Answer 7

Acute or chronic
Localise pain
Constant/ intermittent
Morning pain
Uni/ bilateral
Systemic illness

Question 8

How is the limping child examined?

Answer 8

Sole feet, is child ill, is child splinting/ protecting, gait, look at spine, Gower’s manoeuvre (test of muscular dystrophy), comfort position and rash + swelling

Question 9

What test is done if Gower’s manoeuvre is positive?

Answer 9

Creatinine kinase - elevated in muscular dystrophy

Question 10

What are important infection and inflammation diseases?

Answer 10

Septic arthritis - drainage and antibiotics
Osteomyelitis - IV antibiotics
Transient synovitis

Question 11

What are symptoms and signs of infection and inflammatory disease?

Answer 11

Limp, pain, general malaise, temp., recent URTI/ ear infection, trauma and pseudo paralysis

Question 12

What does refusion to weight bear suggest?

Answer 12

Infection, tumour or fracture

Question 13

What are some differential diagnosis for infection and inflammatory disease?

Answer 13

Sarcoma, myositis, osteoid osteoma, abscess and inflammatory arthropathy

Question 14

What investigations are looked for in infection and inflammation?

Answer 14

Bloods - WCC, CRP, ESR, CK, and cultures
Temp.
X-ray and US - better for seeing bone and not infection

Question 15

What is the Kocher criteria for septic arthritis?

Answer 15

Pyrexia >38 degrees
No weight bearing
WBC >12000/ml
ESR >40mm/hr
If 1 positive then 3% of SA
If 4 positive then 99%

Question 16

What is the presentation of septic arthritis?

Answer 16

Limping, pseudo-paralysis, swollen, red joint, refusal to move joint, pain, and temp.

Question 17

What is the distribution of septic arthritis?

Answer 17

Knee - 37%
Hip - 33%
Ankle - 13%
Sacroiliac - 1%
More common in lower limb

Question 18

What is the route of entry of septic arthritis?

Answer 18

Hematogenous spread
Dissemination from osteomyelitis
Spread from adjacent soft tissue infection
Diagnostic or therapeutic measures
Penetrating trauma

Question 19

What is the treatment for septic arthritis?

Answer 19

Typically staph. aureus infection
Aspiration
Arthroscopy and arthrotomy
Antibiotics - IV 2 weeks and 4 weeks oral

Question 20

What is the incidence of osteomyelitis?

Answer 20

3/1000000 per year
Mean age is 6 years
Risk factors - blunt trauma and recent infection

Question 21

What are the 3 factors for acute haematogenous osteomyelitis?

Answer 21

Vascular anatomy - vascular loops and terminal branches
Cellular anatomy - inhibited phagocytosis (low PO2)
Trauma

Question 22

What is the presenting features of osteomyelitis?

Answer 22

Pain, localised signs/ symptoms, fever, reduced range of movement and reduced weight bearing

Question 23

What is the most common organism causing osteomyelitis?

Answer 23

Staph. aureus

Question 24

What are the indications for surgery in osteomyelitis?

Answer 24

Aspiration for culture
Drainage of subperiosteal abscess
Drainage of joint sepsis
Debridement of dead tissue
Failure to improve
Biopsy in equivocal cases

Question 25

What is the presentation of transient synovitis?

Answer 25

Limping, often touch weight bearing, slightly unwell, history of viral infection, apyrexial, allowing joint to be examined, low CRP and normal WCC, may have joint effusion and not that unwell

Question 26

What is the presentation of juvenile idiopathic arthritis?

Answer 26

Limping, swollen joints, stiffness in morning which gets better
3 groups - polyarticular (seronegative or positive), pauciarticular (early or late onset) and systemic onset

Question 27

What is the definition of juvenile idiopathic arthritis?

Answer 27

Persistent arthritis of at least 6 weeks duration in one or more joints where forms of arthritis have been excluded
More common in girls

Question 28

When is juvenile idiopathic arthritis refered?

Answer 28

Refer pauci-articular to eyes as can lead to blindness

Question 29

What are some features which raise concern of neoplasm?

Answer 29

Night pain, often incidence trauma, stops doing sports, sweats and fatigue, and abnormal blood results (low Hb, atypical blood film, and atypical platelets)