The limping child Flashcards
What are the potential causes of a child under 4 limping?
Toddler’s fracture of tibia or foot
Osteomyelitis, septic arthritis, discitis
Arthritis (juvenile rheumatoid, Lyme disease)
Discoid lateral meniscus
Foreign body in foot
Benign or malignant tumour
What are the potential causes of a child between 4 and 10 limping?
Fracture - physeal Osteomyelitis, septic arthritis, discitis Legg-Calve-Perthes disease Transient synovitis Osteochondritis dissecans (knee/ankle) Discoid lateral meniscus Sever's apophysitis Arthritis (juvenile rheumatoid, Lyme disease) Benign/malignant tumour
What are the potential causes of a child over 10 limping?
Stress fracture - femur, tibia, foot, par intraarticularis Osteomyelitis, septic arthritis, discitis SCFE Osgood-Schlatter disease Sindig-Larsen-Johanssen syndrome Osteochondritis dissecans (knee/ankle) Chrondromalacia patellae Arthritis (Lyme disease, gonococcal) Accessory tarsal navicular Tarsal coalition Benign/malignant tumour
What is the most common site of limp in children in order?
Hip Leg Knee Foot Thigh
What is the most common cause of childhood limp in order?
Toxic synovitis Trauma Septic arthritis Viral syndrome Osteomyelitis Perthes disease Fracture Soft tissue infection JRA
What are the most common causes of limp in children aged 0-3?
Fracture/soft tissue injury (toddler’s fracture/non-accidental injury)
Osteomyelitis/septic arthritis
Developmental dysplasia of the hip
What are the most common causes of limp in children aged 3-10?
Trauma
Transient synovitis/irritable hip
Osteomyelitis/septic arthritis
Perthes disease
What are the most common causes of limp in children aged 10-15?
Trauma Osteomyelitis/septic arthritis Slipped upper femoral epiphysis Chondromalacia (anterior knee pain) Perthes' disease
What questions is it important to ask in a limp history?
Duration and progression of limp?
- Trauma vs infection
Recent trauma and mechanism? Beware limitations of history, possibility of unintentional harm
Associated pain and it’s characteristics
Accompanying weakness?
Time of day when limp is worse?
Can child walk/bear weight?
Has limp interfered with normal activities? - severity
Presence of systemic symptoms - fever, weight loss?
PMHx, BIND - birth history, imms, nutritional Hx, developmental Hx
DHx, allergies, FHx
What is the examination like for a limping child?
Pain or stiffness in joints/back?
Gait/general - temp, observe gait on tiptoes and heels
Legs - knee effusion, bend + straighten, creps?, apply passive flexion with internal rotation of hip
Spine - observe from behind, bend and touch toes
Look
- Feverish
- Standing? Spine straight? Pelvis level?
- Deformity, erythema, swelling, effusion
- Limitation of movement, asymmetry
- Shoes - unusual wear on soles, asymmetry, point of initial foot strike, assess fit
- Older - scoliosis, midline dimples, hairy patches
Feel
- Begin from contralateral side
- Localise pain?
- Measure true leg length
- Assess thigh or calf circumference - atrophy?
- Feel for warmth, flutuance, palpable masses, stiffness, focal tenderness
Move
- Assess ROM, laxity, stiffness with guarding pain, discomfort, fluidity
- Assess gait with child barefoot
- Any discomfort as child bends down
- Hips - move normally? Internally rotate symmetrically? No pain?
Examine abdomen and testes in boys! - intra-abdominal and testicular torsion
What investigations should you do for a limping child?
Radiological
- XR - trauma, Perthes’, DDH, slipped femoral epiphysis, malignancy
- USS - septic arthritis, collections
- MRI - equivocal cases (osteomyelitis, occult injuries, malignancy)
Bloods - CRP/ESR, FBC
What should you do for a trauma patient?
Plain XR as primary Ix - AP and lateral views
Immobilisation
What is a toddler’s fracture?
Subtle undisplaced spiral fracture of tibia
Usually in pre-school children
Sudden twist after unwitnessed fall
Local tenderness over tibial shaft or gentle strain on tibia
How is a suspected toddler’s fracture managed?
Immobilise
What is transient synovitis?
Acute onset after resp illness
Affects young children boys > girls
Most common cause of acute hip pain children 3-10
Unilateral
May refuse to walk/limp
Usually no pain at rest and passive movement only painful at extreme ranges
What do the investigations for transient synovitis look like?
FBC and ESR normal/slightly raised
XR normal
USS effusion
What is the treatment for transient synovitis?
Rest and physio
NSAIDs - can short symptom duration
Usually resolves in 2 weeks
What joints are most often affect in septic arthritis?
Hip
Knee
Shoulder
Elbow
What age groups is most often affected by septic arthritis?
< 2
How does septic arthritis present?
Early features non-specific
Child often very unwell
Pain often at rest, resistance to attempted movement of hip
Older children usually reluctant to weight bear, may be more aware of referred pain to knee
Hip kept flexed, abducted and externally rotated
What do the investigations for septic arthritis look like?
BCs +ve Raised WCC and CRP XR shows delayed changes Bony changes not evident for 14-21 days By 28 days 90% show some abnormality 40-50% focal bone loss necessary to cause detectable lucency on plain films
How do you differentiate between irritable hip and septic arthritis?
Kocher’s criteria for septic arthritis
- Fever > 38.5
- Cannot weight bear
- ESR > 40 in 1st hr
- WCC > 12
What is Perthes’ disease?
Self-limiting disorder of hip caused by varying degrees of ischaemia and subsequent necrosis of femoral head most often affecting boys (80%) aged 5-10
Unilateral in 85% cases
What can increase your risk of Perthes’ disease?
Low birth weight
Short stature
Low socio-economic class
Passive smoking
How does Perthes’ disease present?
Presents with pain in hip or knee, causes limp
Pain (often in knee) + effusion (from synovitis)
On examination all movements at hip limited
No history of trauma
Roll test with patient lying supine, roll hip of the affected extremity into external + internal rotation - should invoke guarding or spasm, especially with internal rotation
Classic x-ray features
- Sclerosis, fragmentation and eventual flattening of proximal femoral epiphysis
Absent in early disease
What might Perthes’ disease be misdiagnosed as?
Irritable hip
How is Perthes’ disease treated?
Depends on age and severity
What can increase your risk of a slipped capital femoral epiphysis?
Usually occurs at the onset of puberty and most often in children who are either very tall and thin, or short and obese
Other RF - Afro-Caribbean, boys, FHx
Prepubescent male children 12-15
How does slipped capital femoral epiphysis present?
1/4 cases bilateral • Hip, thigh, and knee pain
Often initially a several week history of vague groin or thigh discomfort
May be able to weight bear, but painful
Flexion of hip often causes external rotation
May be leg shortening
XR shows widening and irregularity of the plate of the femoral epiphysis
Displacement of epiphyseal plate is medial and superior
How is slipped capital femoral epiphysis treated?
Surgical pinning of the hip is usually required and should be done quickly
What is DDH?
Dislocation of hip
Hip doesn’t properly fit in joint in babies and infants
What can increase your risk of DDH?
Female Breech C-section 1st child Premature Oligohydramnios FHx Club feet, spina bifida, infantile scoliosis
Why is it important to detect DDH early?
Delayed identification leads to more prolonged morbidity
What are the screening tests/investigations for DDH?
Classic screening tests are Barlow and Ortolani
- Ortonlani assesses if the hip is dislocated
- Barlow assesses whether the hip is dislocatable
Asymmetrical skin creases in the thigh or buttock
Unequal leg length
Up to 60% of abnormal hips become normal without Tx after 1m
USS
How is DDH treated?
Mx depends on age
What neoplasms might cause a child to limp?
Primary bone/soft tissue tumours
Benign/malignant
How common are malignant bone tumours in children?
Malignant - prevalence < 1:5000
How might a neoplasm causing a child to limp present?
Pain
34-39% palpable mass
70-92% tenderness
What is juvenile rheumatoid arthritis?
Autoimmune disease may present affecting a single ankle or knee
Presence of associated systemic findings eg high fever, salmon coloured pink rash, eye inflammation also useful in diagnosis
How is JRA treated?
Treatment MDT - paediatric rheum, ophthalmology, ortho, rehabilitation specialists, OT
