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Acute painful limp in children Dr Sayed nasser Mostafavi 15/8/1392

Case 1 A 2 year old girl brought to emergency department with chief complaint of inability to walking and standing. What's the common causes? What's the emergency causes? What's the major clues in history, physical examination, and para clinic evaluations? 15/8/1392

Common causes of limp in children Painful limp(short stance phase on the affected limb, point tenderness, normal neurologic exam): Bone: fracture, osteomyelitis, tumors Joints: septic arthritis, toxic synovitis of hip, brucellosis, serum sickness, henoch-schoenline purpura, acute rheumatic fever Muscles: trauma, viral myositis Non-painful limp(Toe-to-heel sequence of gait): guilain barre syndrom, transverse myelitis 15/8/1392

Emergency causes of limp in children Painful limp: Bone: fracture, osteomyelitis, tumors, cycle cell crisis, Joints: septic arthritis, brucellosis, serum sickness, Henoch-Schonlein purpura, acute rheumatic fever, acute rheumatic fever, Hemarthrosis, Slipped capital femoral epiphysis, Legg-Calvé-Perthes disease Intra-abdominal: Appendicitis, psoas abscess, testicular torsion Non-painful limp: Neurological: Guillain-Barré Syndrome, transverse myelitis, botulism 15/8/1392

Major clues in diagnosis of acute limp 1 Fracture, contusion, hemarthrosis History of trauma immediately before limp, X ray with or without local tenderness Septic arthritis Fever, quite painful mono-arthritis, usually ↑ ESR Osteomyelitis local bone tenderness + fever or ↑ ESR Tumors(Leukemia and neuroblastoma, bone tumors) Bone pain/ sometimes arthritis which wake the child from sleep, Hepatosplenomegaly, lymphadenopathy, cytopenia, ↑ ESR , prolonged fever Acute rheumatic fever Age 5-15 yr( 3-40), poly arthritis, heart murmur, jones criteria, ↑ASO, ↑ ESR 15/8/1392

Major clues in diagnosis of acute limp 2 Henoch-Schönlein purpura Age 3-10 yr, palpable purpura, colicky abdominal pain, hematuria, proteinuria), large joint arthritis Serum sickness-like illness 8-12 days after drug ingestion, large joint arthritis, urticaria or morbiliform rashes, fever Brucellosis consumption of unpasturized milk, splenomegaly, fever, large joint and sacroiliac arthritis, positive wright test, Slipped capital femoral epiphysis Age 8-15 yr, overweight boys, Mostly chronic sometimes acute severe hip pain, Increasing pain with activity, specific by X ray Legg-Calvé-Perthes disease Age 3-12 yr, male sex, Insidious onset, recurrent painless hip pain, often NL initial x ray then fragmentation 15/8/1392

Toddlers fracture 15/8/1392

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Major clues in diagnosis of acute limp 3 Transient synovitis of the hip Age 3-8 yr , Acute hip pain, Mild restriction of ROM, no or mild fever, NL or mild ↑ WBC and ESR, no or mild hip effusion, sometimes bilateral Reactive arthritis Quite painful mono- or poly- arthritis, large joint, no or mild fever and leukocytosis, sometimes ↑ ESR, Viral myositis Muscle pain during influenza infection, severe calf pain, ↑ CPK and LDH, Viral arthritis Mild and transient arthritis or arthralgia during viral infection( rubella, 5th disease, varicella, … foreign bodies, plantar warts, or calluses from poorly fitting shoe Localized pain at the soles of the feet 15/8/1392

Physical exam Observation of the gait, asking the child to run, hop on one leg and then the other, walk on his or her heels and then toes Through exam of the CNS, spine, peripheral nervous system, abdomen, external genitalia , hips, knees, ankle, and feet 15/8/1392

Major clues in diagnosis of acute limp 4 Abdominal tenderness, rebound, guarding, or a positive psoas sign appendicitis Painful, swollen testicle and loss of the cremasteric reflex Testicular torsion Inability to standing, ↓ muscle tone, ↓ DTR guilain barre syndrom, transverse myelitis 15/8/1392

Para clinic evaluation Indication X ray Usually all acute limp especially if trauma or localizing point Hip sonography and AP and frog leg views x ray Abnormal hip exam Joint fluid aspiration Monoarticular arthritis with fever Wright test Usually all arthritis in endemic areas CBC, ESR, CRP Usually all, Suspected infectious, malignancy, rheumatologic ECG, throat culture, ASO Suspected acute rheumatic fever 15/8/1392

Conclusion Limp can be created by many osseus, infectious, soft tissue, abdominal, and neurological diseases Limp can be caused by both benign and life-threatening conditions The cause of limp usually can be determined by obtaining a careful history and physical examination. Radiographic and laboratory studies often are necessary to confirm clinical suspicions but diagnostic procedures rarely are required. 15/8/1392

Conclusion Fever and history of trauma is two key factor in finding the cause of limping Most cases had benign and self limited conditions and can be followed by NSAIDS and follow up 15/8/1392

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