Afraa Al-sabbagh Consultant Paediatrician Peterborough Hospital The Child with a limp Afraa Al-sabbagh Consultant Paediatrician Peterborough Hospital

Limp in a child Limp is uneven or laborious gait caused by pain, weakness or deformity. Never normal Common in childhood, accounting for 4:1000 visits in one A&E. History of trauma or fever will decide further management. The cause of gait disturbance in 425 pediatric patients. Pediatr Emerg Care. 1985;1(1):7.

Limping Child Prospective study evaluated 243 children < 14 years presented with limp and no history of trauma: Boys > girls by 2:1 Median age was 4 Transient synovitis most common diagnoses Most patients (77 %) had a benign cause 1999 Nov;81(6):1029-34.The limping child: epidemiology, assessment and outcome.Fischer SU, Beattie TF. Accident and Emergency Department, Royal Hospital for Sick Children, Edinburgh, Scotland, UK.

Approach to a Child with Limp History Duration Characteristics Pain Fever Other features

Approach to a child with a limp Duration Recent onset trauma acute infection Chronic limp Perthes disease Slipped Upper Femoral Epiphysis (SUFE) Systemic illness e.g rheumatic disease or tumor

Approach to Limp Pain characteristics Constant severe pain fractures, septic arthritis, osteomyelitis. Intermittent, less severe pain JIA, Perthes, SUFE, transient synovitis. Pain at night neoplastic conditions Bilateral pain-seen in myositis Pain worsens with activity - stress fracture, overuse injury, or hypermobility syndrome Pain improves with activity rheumatologic conditions and complex regional pain syndrome

Other features Morning stiffness-JIA Back pain- discitis, vertebral osteomyelitis Recent viral or streptococcal illness post-infectious arthritis myositis, Henoch-Schönlein purpura hypothyroidism, panhypopituitarism, and hypogonadism slipped upper femoral epiphysis.

Fever Osteomyelitis, Septic arthritis- Temp >38.5 C. Transient Synovitis ? low grade fever Leukaemia Hx of fever or recent illness may obscure traumatic aetiology and visa versa. Retrospective study of 163 infants and children with OM of the long bones, a history of preceding blunt trauma was elicited in one-third of cases. Dich VQ, Nelson JD, Haltalin KCSOAm J Dis Child. 1975;129(11):1273.

Causes of limp Osseous Neurological Other Articular Soft tissue Osteomyelitis Fractures NAI Vasoocclusive crisis of SC Slipped Femoral Epiphysis Perthe’s disease Leukemia Metastatic Neuroblastoma Neurological Complex regional pain syndrome Spinal cord tumors Other Conversion disorder Articular Transient Synovitis of the hip Septic arthritis JIA HSP Discitis Soft tissue Myositis Muscle strain Abdominal Psoas abscess Pelvic abscess

Examination General examination: Well or unwell On parents lap Watch children playing and walking Examine gait Walking Running Hopping Walk on heel then toes

Examination Spine Upper and lower limb examination (musculoskeletal and neurological examination), pGALS Abdominal examination Genitalia Skin

6 week old male 2 day history swelling left thigh, child not moving leg No history trauma Apyrexial well normal baby Swollen left thigh #femur NAI

6 week old baby What is your diagnosis? How will you manage this child?

Metaphyseal "corner" fractures, as shown here (white arrows), are highly suggestive of child abuse. Metaphyseal corner fracture of the distal femur (arrows). This classic metaphyseal lesion occurs when the extremity is pulled or twisted, or the child is shaken. The resultant shearing force undercuts an isolated fragment of the metaphysis that includes the subperiosteal bone collar. When viewed tangentially, the lesion appears as a triangular fragment of the metaphysis (ie, the "corner" fracture).

Child abuse Fractures due to child abuse seen in < than three years of age 50 % occur in children younger than 12 months long bones most commonly injured, femur, humerus, and tibia Diaphyseal fractures are 4X more common than metaphyseal fractures (more specific) Skeletal survey is required in these cases and referral to social services. (do not forget underlying bone conditions such as OI)

Case 15 month old female Sister of a 3 year old girl with JIA Her sister came for a routine appointment and mum mentioned her odd gait Was reassured by the physiotherapist who looks after her sister ? Normal toddler’s gait.

Developmental Dysplasia of the Hip May present with limp Second year of life In one series of 148 children with a limp who presented to a paediatric orthopedic clinic, six children had DDH Children with unilateral DDH child may walk on the toes of the affected side to compensate for the shortened thigh. Trendelenburg gait decreased hip abduction. positive Galeazzi test ? extra skin folds on the affected limb (common reason why children referred to the paediatric clinic for hip assessment).

2½ year old female Fell from sofa onto floor Non weight bearing left leg but crawling Mum is concerned about her ankle Missed toddlers # crawling? X-ray ankle reported as normal

2½ year old female What is your diagnosis?

Toddlers fractures Following trivial injury involve the distal half of the tibia children refuse to bear weight physical findings usually are subtle. Bruising and deformity are absent tenderness, swelling, or warmth may be present Pain elicited by dorsiflexion of the ankle radiographic finding, a faint lucent oblique line crossing the distal tibia and terminating medially Initial radiographs may be normal in as many as 43 % of cases

Transient synovitis Transient synovitis (TS) is the most common cause of hip pain in children Typically presents between three and eight years Presentation symptoms for one to three days Fever typically is absent or low-grade, and children are nontoxic in appearance, Ultrasound can detect bilateral effusions in 25 percent of children Children with TS have an antalgic gait and usually prefer to keep the hip in abduction and external rotation. Management of TS Conservative nonsteroidal antiinflammatory drugs (NSAIDs) and return to full activity as tolerated. Good prognosis with full recovery to be expected within one to four weeks. Recurrence rates from 4%-15% have been reported

5 year old male Twisted leg whilst playing ‘chasey’ 4 days ago limping since on right leg On examination of the right hip, flexion, internal rotation, abduction are reduced Perthe’s Reduced abduction & internal rotation XR- increased density of bony epiphysis, apparent widening of joint space.flattening, fragmentation and lateral displacement of epiphysis and broadening of metaphysis

6 year old boy 6 month history limping right leg Diagnosed x2 ‘Irritable Hip’ No history trauma or fever Examination shows 2 cm leg length discrepancy, pain with hip extension & external rotation

6 year old male What is your diagnosis?

Legg-Calvé-Perthes On examination X-Ray Iidiopathic avascular necrosis of the hip Between 3 and 12 years. The peak incidence is between 5 & 7 years of age. bilateral in 10% to 20 % of patients Llimp of insidious onset On examination limited internal rotation and abduction of the hip. Trendelenburg gait positive X-Ray early stages smaller, more dense-appearing epiphysis later stages fragmentation and healing of femoral head, often with residual deformity

11 year old boy 6 day history right hip pain increasing intensity Pelvic XR normal, WCC, ESR , USS guided aspiration of hip normal RLQ tenderness Normal ROM hips Tender right lumbar paraspinal region, unable to weight bear right leg

What is your diagnosis? How will you manage this child?

Slipped Upper Femoral Epiphysis (SUFE) Displacement of the capital femoral epiphysis from the femoral neck. Typical patient is adolescent obese male Age between 10 and 15 years. Bilateral in 30-60% of cases. Obesity and endocrine problems often a risk factor. Presentation: limp and hip pain Limited hip movements in all directions Trendelenburg test positive

Case 3 year old male, 3 week history of shoulder and leg pain. Family reported on and off temperature and not being himself. O/E no joint swelling, tenderness or deformity. Intermittent limp. CRP 300, ESR 102, FBC normal. How will you manage, what’s your DDx?

Other causes of limp Leukaemia — Bone and joint pain may be the presenting feature in 21% to 33 % of cases. Radiographic changes are present in as many as 44 % diffuse osteopenia, periosteal new bone formation, geographic lytic lesions.

286 children diagnosed with ALL between 1992 and 2013. Brix N, Rosthøj S, Herlin T, et al. Arthritis as presenting manifestation of Acute Lymphoblastic Leukemia in children. Arch Dis Child Children with acute lymphoblastic leukaemia (ALL) may present with arthralgia or signs of arthritis. 286 children diagnosed with ALL between 1992 and 2013. Fifty-three (18.5%) presented with localised joint pain. (half had objective signs of arthritis) Reactive arthritis (19/53), osteomyelitis (9/53) juvenile idiopathic arthritis (8/53). The clinical signs of leukaemia are less prominent, but non-articular pain should alert the clinician of a possible diagnosis of leukaemia.

Septic Arthritis Knee and hip are the joints most commonly affected. A review of 425 children who were admitted in the A&Edepartment during a 12-month period for a gait disturbance, 14 (3 %) had septic arthritis. Infants irritability and pseudoparalysis, with or without fever Refusal to weight bear febrile and ill-appearing, Joint effusion, periarticular warmth and tenderness, and severe pain on range of motion.

Septic arthritis ESR –the most sensitive test, elevated in 90 % of cases but lacks specificity. Plain radiographs- may show joint effusion. Bone scans rarely indicated. Definitive diagnosis made by examination of synovial fluid. In a retrospective comparison of 94 children with septic arthritis and 38 children with transient synovitis, the combination of ESR > 20 mm/hr and/or temperature greater than 37.5ºC detected 97%of those with septic arthritis.

Discitis Inflammation of the intervertebral disc Aetiology is controversial, 60 % of biopsied discs (not necessary for diagnosis) grow bacteria usually Staphylococcus aureus Children often recover without antibiotic therapy. Rare condition. At a single centre, the incidence was one to two cases per 32,500 paediatric hospitalisations and clinic visits per year Typically in children younger than five years. Gradual onset back pain, limp, or refusal to crawl or walk, without systemic toxicity; fever usually is absent or low grade.

Diagnosis Blood tests all normal apart from raised ESR in 90% of cases. MRI Aspiration of the affected disc for culture is not required. IV antibiotics until the child shows improvement, followed by oral antibiotics.

Case: 7 year old child Calf pain for 2 days Cough, runny nose & low grade temperature WBC * 2.9 109/L 4.5 - 13.5 Hb 126 g/L 110 - 151 PLT * 125 109/L 150 - 400 Lymphs * 1.3 109/L 1.5 - 5.0 Neuts * 1.0

Myositis During epidemics of influenza A and B. Calf muscles typically affected. The child may refuse to walk or walk on his or her toes, and refuse to dorsiflex the feet Muscle enzymes elevated Myoglobinuria and acute renal failure do not occur Full clinical recovery seen in 3 to 10 days

The is the X-Ray of a child with mucopolysaccharidosis type VI. X-Linked metabolic condition. Treatment is enzyme replacement.

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