The Limping Child Flashcards
Outline the differential diagnosis in a limping child.
- Developmental Dysplasia Hip (DDH)
- Septic hip; irritable hip (transient synovitis)
- Perthes Disease
- Slipped Upper Femoral Epiphysis
Outline the likely age group for each differential in the limping child.
- Infant/toddler = DDH
- <5 years = septic hip ( or irritable hip)
- 5-10 years = Perthes
- >10 years = slipped upper femoral epiphysis
What MUST you always consider as a possibility in a limping child?
- Trauma (non-accidental injury)
Knee pain is often referred pain from where?
The hip.
In which hip is developmental dysplasia of the hip usually found.
Left hip.
What risk factors are associated with DDH?
– Female (7:1)
– Breech (decr. intrauterine space)
– First born (decr. intrauterine space)
– Oligohydramnios (decr. intrauterine space)
– Family History
– packaging disorders’ like torticollis (20%) & Metatarsus Adductus (10%)
What is the natural history of DDH?
- 90% of unstable hips stabilise by 9 weeks of age.
- The maximum remodelling of the acetabulum occurs
below the age of 18 months . - The false acetabulum is smaller than a true
acetabulum will develop osteoarthritis between 20-60
years of age if not treated.
Which infants require routine screening for DDH via USS?
- first-degree family history of hip problems in early life
- breech presentation at or after 36 weeks gestation, irrespective of presentation at birth or mode of delivery
- multiple pregnancy
- all infants are screened at both the newborn check and also the six-week baby check using the Barlow and Ortolani tests
Outline Ortolani and Barlow’s test for DDH in post-natal baby checks
- OrtaLani’s = disLocated (attemps to relocate a dislocated hip)
- Barlow’s = dislocataBle (attepts to dislocate an articulated femoral head)
- Will have extra leg crease on affected side
What is the imaging modality of choice?
USS:
Up to 4-6 months old
X-ray:
After 4 months old
Outline the non-operative treatment options of DDH
- Abduction bracing (Pavlik harness)
• Reducible, under 6 months - Closed reduction (+ arthrogram/GA) + spica cast
• Reducible, over 6 months
Outline the operative treatment of DDH
1. Open reduction + spica cast
• Not reducible closed, age 6-18 months
2. Osteotomy (femoral / pelvic) + open reduction + spica cast
• Ongoing dysplasia, over 2 yr
How does septic arthritis present?
Symptoms:
- joint pain
- limp
- fever
- systemically unwell: lethargy
Signs:
- swollen, red joint
- typically, only minimal movement of the affected joint is possible
What are the routes of spread in septic arthritis?
– Haematogenous
– Spread from metaphyseal osteomyelitis
– Spread from soft tissue infection
– Direct inoculation
Outline the most common causative organisms of septic arthritis by age group
– <12 mos staphylococcus, group B streptococcus
– 6 mos. to 5 yrs staphylococcus, H influenzae
– 5-12 yrs S. aureus
– 12-18 yrs. N. gonorrhoeae, S. aureus
What investigations must you perform in suspected septic arthritis?
– Temperature
– FBP, ESR, CRP, Blood Cultures
– USS +/- aspiration before antibiotics
– Kocher criteria
• 90% chance of septic arthritis if 3 of these:
– inability to bear weight
– fever > 38.5
– WBC > 12
– ESR > 40
– CRP>20 now also considered an indicative factor
Why is septic arthritis a surgical emergency?
- Proteolytic enzymes from inflammatory and synovial cells, cartilage, and bacteria can cause articular surface damage within 8 hours
- Increased joint pressure may cause femoral head osteonecrosis if not relieved promptly
How is septic arthritis treated?
– Emergency washout of hip (with GA)
– Smith Peterson approach
– IV antibiotics for up to 6 wks
– Repeat wash out if necessary
– Clinical review and monitor CRP
What is transient synovitis?
Hip pain due to inflammation of the synovium of the
hip
What may be seen on USS in transient synovitis?
Hip effusion
In which age group is transient synovitis the most common in?
4-8 years old
What is the most common aetiology of transient synovitis?
- Recent viral infection (usually URTI)
- Allergy
- Trauma
What is the natural history of transient synovitis?
- Symptoms usually last 1-2 days and resolve
- Completely resolved in <1 week
- Bed rest + analgesia will help resolve symptoms
How is septic arthritis and transient synovitis differentiated?
Similarities: Non-Specific presentation:
– Irritability, inability weight bear, fever
Differneces: Differente using Kocher criteria, CRP &
USS/aspiration
Outline the blood supply to the femoral head
What is Perthe’s disease?
- Idiopathic osteonecrosis of the capital femoral epiphysis
- Aetiology unknown
- Flattening and collapse of femoral head
- Cartilage is resistant to ischaemia and preserved
Discuss the aetiology, risk factors and epidemiology of Perthe’s disease
- 15-20 % bilateral
- 1/1200
- Male (x4)
- Aged 3 –12 (Median 7)
- 6% Family Hx
What is the typical history in Perthe’s disease?
– Active boy
– 15% Bilateral
– Hip/groin pain
– Intermittent pain
anterior thigh/ knee
– Limp
– No Hx trauma (?)
– Worse with exercise
What is typically seen O/E in Perthe’s disease?
– Decreased ROM (internal rotation/abduction)
– Painful Gait
– Muscle atrophy
– Leg length inequality
– Short Stature (children with perthes
have delayed bone age)
What are the four phases of Perthe’s disease?
- Necrotic
- Fragmentation
- Remodelling
- Reossification
List some poor prognostic factors in Perthe’s disease
- Age < 5 or >9, or female
- Increased femoral head involvement
- Lateral subluxation
- Persistent decreased ROM
- Premature closure of physis
Outline the treatment options for Perthe’s disease
- Aim to maintain ROM and acetabular containment of the femoral head during the active process of the disease
- Physio
- Braces (abduct the leg to maintain head inacetabulum)
- Traction
- External Fixator (rarely used)
- Varus/Valgus Osteotomy of proximal femur
- Inominate (pelvic) osteotomy
What is SUFE?
Disorder of the proximal femoral physis that leads to slippage of the epiphysis relative to the femoral neck
What age group is SUFE most common in?
12-15 years old
Who most commonly gets SUFE
- Obese
- Males
- Endocrine problems
- Rapid growth during adolescence
How does SUFE normally present?
1. Pre-slip
– Pain in hip, thigh or knee associated with limited internal rotation
2. Acute slip
– < 3/52
– Usually follows significant trauma
– Salter Harris 1 #
3. Chronic slip (60%)
– > 3/52
– FFD
– Flexion causes hip to externally rotate
– Decreased int rotation
4. Acute on Chronic (20%)
What is the displacement in SUFE?
Displacement of the femoral head epiphysis posteroinferiorly
Outline the Faber test
What is the investigation of choice in SUFE?
AP and lateral (typically frog-leg) views are diagnostic
How is SUFE treated?
- In Situ Pinning (internal fixation: typically a single cannulated screw placed in the center of the epiphysis)
– No forceful reduction - Osteotomy (rarely used)
– Varus and external rotation deformity with severe slips
– Note considerable remodelling - Consider prophylactic pinning of the other hip
What are the complications of SUFE?
- Chondrolysis
- Avascular necrosis
– especially with severity of slip, reduction attempts, multiple screws and high osteotomies - Subtrochanteric fracture
- Osteoarthritis
LIMPING CHILD = ?
Hips
KNEE PAIN IN CHILD = ?
Hips
