T&O - The Limping Child

Question 1

What are the 5 main causes of hip pain (and age ranges) in children?

Answer 1

• Congenital hip dysplasia: birth 1/1000
• Septic hip/infections: 0-5 years old
• Transient synovitis (4-8 ya)
• Perthes’ disease: 5-10 years old 1/10 000
• Slipped femoral physis: 10-15 1/100 000

Question 2

Congenital Dislocation of hip: what is it? Incidence and age range

Answer 2

• Congenitally determined developmental deformation of the hip joint, in which the head of the femur is or may be completely or partially displaced from the acetabulum
• 2:1000 live births, F>M, higher incidence in breech presentation

Question 3

What test do you perform to check for CHD?

Answer 3

• Ortolani’s test: hips and knees flexed to 90 degrees, thighs grasped in each hand and hips are abducted to 90 degrees. Should be able to do so easily and without resistance.
• Can also do Barlow’s test
• If either test + : do US - shows shape of cartilaginous socket and position of head femur

Question 4

CHD: Rx

Answer 4

-Put child in harness Pavlik, closed or open reduction: aim to reduce hip in position until acetabulum rim is sufficiently developed.

INSERT PICTURE OF PAVLIK SPINT

Question 5

Septic hip: demographics, presentation and notable imaging results

Answer 5

• 0-4 ya
• Presentation: limping, minor or no trauma, limited ROM
• X-ray findings: no abnormalities

Question 6

What criteria do you use to diagnose septic hips in children?

Answer 6

Kocher criteria:

• Fever >38.2
• Non weight bearing
• ESR >40
• WBCs >12000
• If 2 criteria met (60%), if 3 criteria met (93%)

Question 7

What is the pathophysiology of septic hip in children?

Answer 7

• Inflammation causes compression of head of femur, which obstructs blood supply to head of femur
• Leads to rapid onset of pain in swollen joint

Question 8

Transient synovitis: demographics and presentation

Answer 8

• 4-8 years old
• Presentation: limping, minor or no trauma. Might have a Hx of recent infection of vaccination (but aetiology unknown) and have limited ROM. Self limiting condition where there is inflammation of synovium, most common cause of sudden hip pain in children

Question 9

Transient synovitis: imaging findings

Answer 9

• X ray findings: no abnormalities

- Us scan: may show some collection

Question 10

How do you differentiate between septic knee and transient synovitis?

Answer 10

• Will be Kocher negative
• Only exception: may have mild WBC elevation
• Can fully weight bear

Question 11

Perthes Disease: demographics, pathophysiology and presentation

Answer 11

• Type of osteochondritis (AVN of femoral head - occurs when the blood supply to the rounded head of the femur is temporarily disrupted. Without an adequate blood supply, the bone cells die and get AVN)
• usually male pt, 4-10ya, with limp
• Pain: initially painful (difficult to differentiate from infection/transient synovitis), can become painless or be in groin/radiate to the knee)

Question 12

Perthes Disease: important imaging findings

Answer 12

• X ray initially normal: earliest change is increased density in bony part of epiphysis, which later flatters and fragments.

INSERT PICTURE

Question 13

Perthes Disease: Rx

Answer 13

• Rx: bed rest until pain subsides + further surgical Rx is based on trying to contain head in acetabulum to enable it to retain best shape possible.

Question 14

What is a SUFE? Age range, presentation and pathophysiology

Answer 14

• Slipped capital/upper femoral epiphysis (10-15 ya)
• Children of pubertal age: affects either fat and sexually underdeveloped kids or tall and thin kids (M>F)
• Presentation: limping, knee pain, minor trauma, no fever
• Epiphysis slips posteriorly in either acute (20%) or chronic slip (60%) or combination (20%)
• Acute: pt presents with groin pain/referred to thigh or knee, can be shortened and externally rotated

Question 15

SUFE: Rx

Answer 15

• Rx: usually involves surgery to reduce epiphysis (fix with pin)
• Chronic slip: don’t reduce b/c AVN may result - epiphysis usually pinned in situ to prevent further slippage
• Always do a hip exam on a child 8-10 ya with painful knee as can get referred pain. These people may develop deformity/OA/disability risk

Question 16

SUFE: what is a klein line?

Answer 16

-The line of Klein describes a line along the superior edge of the neck of the femur. It is useful in detecting early slipped upper femoral epiphysis​ in adolescents. The line should normally intersect the lateral part of the superior femoral epiphysis. If the line of Klein fails to intersect the epiphysis during the acute phase, it is called Trethowan sign 3. In very subtle cases, asymmetry between the lines of Klein might be the only way of determining a slipped upper femoral epiphysis.

INSEERT PICTURE