The Child with a Limp

Question 1

How does irritable hip present?

Answer 1

• Diagnosis of exclusion
• Occurs acutely in 3-8 year olds usually post-viral
• Child is able to walk, but with pain. Severity varies with time
• Afebrile and well-appearing
• Mild-mod decrease in ROM, especially internal rotation. Severe limitation - ?septic arthritis

Question 2

What is Perthes disease? How does it present?

Answer 2

• AVN of the capital femoral epiphysis
• Presentation
  
  • Generally in older (2-12) children developing over a month. Worse when tired.
  • May be leg length discrepancy, muscle wasting
  • Early: irritable and decreased movement on examination.
  • Late: fixed flexion deformity (positive Thomas test)
  • Flattened femoral head on Xray

Question 3

How is Perthes disease managed? What might the complications be if it isn’t?

Answer 3

• Non-operative: rest, traction (up to 18 months). Especially effective in early irritable stage
• Early OA

Question 4

How does a slipped upper femoral epiphysis present?

Answer 4

• Generally in children with weight over the 90th centile
• Can be acute or chronic
• Pain in hip (or referred to knee) with limp. Externally rotated and shortened leg.
• External rotation exaggerated if hip flexed to 90 degrees
• Decreased ROM, particularly internal rotation
• May be bilateral

Question 5

How is slipped upper femoral epiphysis diagnosed? What is the managment?

Answer 5

• XR pelvis and XR frog-lateral of hip
• No weight-bearing
• Immediate transfer to hospital and surgery (pinning)

Question 6

What screening is appropriate for detection of developmental dysplasia of the hip?

Answer 6

• Soon after birth - Ortolani and Barlow
  
  • Repeatedly during first year of life
• Selective screening (high-risk or abnormal exam) - US (up to 6/12) or XR (6+/12)

Question 7

How is developmental dysplasia of the hip managed?

Answer 7

• Trial of brace treatment (e.g. Pavlik harness) 3-4/52 if < 8 months only (else surgery)

Question 8

What is Still’s disease? How does it present?

Answer 8

• Systemic onset juvenile idiopathic arthritis
• Joint involvement with fever, rash and lymphadenopathy
• Once or twice daily fever spikes for over 2 weeks, with salmon-pink maculopapular rash, lymphadenopathy, hepatosplenomegaly (Still’s)

Question 9

A child presents with a limp. What are the red flag conditions to be excluded and how will you do this?

Answer 9

• Septic arthritis (FBE, ESR, CRP +/- blood cultures), Perthes disease (XR)
• Other DDx: SUFE, DDH, transient synovitis/irritable hip