Presentation with a Limp

Limping is a common and often challenging problem in children and adolescents. A limp is defined as asymmetric deviation from a normal gait pattern. Most common cause is trauma, awareness of other potential causes is important Main concern is not to miss serious pathology Age relevant differential diagnosis History, physical examination, appropriate investigations and follow-up

Limping child- History and Exam Duration of and progression of limp Recent trauma and mechanism, be aware of limited paediatric history, unintentional trauma Associated pain and characteristics Accompanying weakness Time of day when limp is worse Has limp interfered with normal activities Presence of systemic symptoms like fever and weight loss Medical history, family history Can the child walk/weight bear- ideally observe child barefoot with minimal clothing Palpate for tenderness and warmth All joints should be taken through normal ROM actively and passively History of limp that appears worse in morning suggests a rheumatologic process Night pain, especially pain that wakes child from sleep may be an indicator of a malignancy Growing pains- leg pain is bilateral, pain occurs only at night, pt has no pain, limp, symptoms during day Recent URTI could be instigating event of septic process, pyrexia suggests infection or inflammatory process

A 4yr old child presents with a 24 hr history of right sided limp Normally fit and well, recent coryzal episode No history of trauma All observations within normal parameters OE can pinpoint pain to rt hip

Transient synovitis/ Irritable hip Most common cause of acute hip pain or limp in children Incidence of 1-4:1000 Age group 3-8 yrs Male: female 2:1 Formation of effusion within hip joint In approx 30% cases pain may originate in knee/thigh Aetiology unknown- viral infection, minor trauma, allergy have been implicated Sudden onset of pain in hip, or limp, as a result of intra-articular pressure caused by effusion Reduced ROM Hip held flexed and externally rotated to relieve pain Signs of sepsis absent

Irritable hip X ray- may be NAD, or slight widening of joint space from effusion USS- small effusion may be detected Simple analgesia and bed rest TS rarely lasts longer than few days or weeks Effusion in affected hip

Septic arthritis Usually affects children under 10 years Sudden onset of significant groin/hip pain, may radiate down medial aspect of thigh Child looks toxic and has a fever All movements of joint exquisitely painful, leg often held in flexed abduction Child will resist all attempts to move hip

Xray- may reveal increased joint space ( secondary to infection) Inflammatory markers raised May have positive blood cultures for organism (20%) Joint fluid aspiration (80%) Admit Surgical irrigation of joint IV antibiotics

Leukaemia Leukaemia is the most common malignancy of childhood ( 400 new cases per yr in UK) Peak incidence at 2-5yrs Incidence higher in boys, and white population Massive proliferation of malignant blast cells in medullary canal- mass effect producing bone and joint pain- often manifested as limp, refusal to weight bear Mild pyrexia, lymphadenopathy, raised ESR, anaemia, thrombocytopaenia etc! Presentation may mimic other orthopaedic disorders Almost 40% in study had musculoskeletal problems 12.3% had limp

Metaphyseal band sign can indicate Lead Poisoning Normal variant Infection Malignancy Healing stages of rickets, leukaemia and scurvy

6 year old boy presents with a 4 day history of limp No significant trauma Normally fit and well Differentials at this age group before you start examination?

Perthe’s disease Avascular necrosis of the femoral head, collapse, fragmentation and progressive deformity of hip joint Unknown aetiology Affects ages 2 - 12years (peak incidence between 6 and 9 years Male:female, 4:1 History of persistent hip pain( limp can be painless) referred knee pain common O/E loss of internal rotation, loss of abduction, overall decreased ROM May be ‘wasting’ of affected leg Necrosis,fragmentation,healing, remodelling

Perthe’s Good prognosis- age<6yrs at diagnosis < 50% head involved no stiffness or shortening O/E Poor prognosis- age > 7 yrs at diagnosis > 50% head involvement significant stiffness and shortening

Containment Corrective Osteotomy

Kohler’s disease Avascular necrosis of navicular Typically 2-10 yrs Boys: girls 4:1 May have history of minimal trauma Disease is usually unilateral POP has demonstrated reduction in duration of symptoms Navicular is last bone to ossify ( approx 3 yrs) ? Makes it more vulnerable to trauma

Slipped upper femoral epiphysis Slow, chronic Late childhood, adolescence Male:female 2:1 Child may be obese Stress fracture through femoral epiphysis, resulting in progressive slip of femoral neck over femoral head Limping or non weight bearing, referred pain to thigh or knee Bilateral disease in 30% Pain, exacerbated by activity Trendelenburg gait Preserve blood supply May require surgery

2 views – seen clearly on lateral Clinical signs

SUFE

Osteomyleitis Can affect any age, peak incidence under 10 years 50% in pre school aged children( rich vascular supply in bones) Male:female 2:1 Caused by spread of infection ( septic arthritis), puncture wound, compound fracture Organisms age-dependant (>4 yrs 80% staph) Severe constant pain, aggravated by movement Fever, unwell child May have localized redness, swelling, and warmth Raised inflammatory markers Initial X-ray NAD Rapid spread of infection Severe case may have abscesses to skin surface Bone aspiration to identify pathogen IV antibiotics ( normally 4 weeks)

References Fischer,S. Beattie,T.(1999) The limping child:epidemiology, assessment, and outcome British Journal of Bone & Joint Surgery 81,6 pp1029-1034 Goldsworthy,L. (revised 2008) Paediatric Emergency Department Handbook, Bristol Children’s Hospital Hoary et al (2007) Kohler Disease: Diagnoses and Assessment by Bone Scintigraphy Clinical Nuclear Medicine 32, 3 pp 179-181 Leet,A. Skaggs,D. (2000) Evaluation of the Acutely Limping Child American Family Physician 61,4. Paediatrics A Clinical Guide for Nurse Practitioners (2003) d Katie Barnes Elsevier Science Limited, London Roew et al (2006) Outcome of Cheilectomy in Legg-Calve-Perthes Disease Minimum 25-Year Follow-Up of Five Patients Journal of Paediatric Orthopaedics 26 pp 204-210 Sinigaglia et al (2008) Musculoskeletal Manifestations in Pediatric Acute Leukemia Journal of Paediatric Orthopaedics 28, 1 pp 20-28