Approach to Limping Child

Points to be discussed… Causes of limping in children: Age distribution. Differential diagnosis of a limp in children: History P/E Investigations Red flag presentations. Hip : Septic arthritis Transient synovitis.

Approach to a limping child Any deviation from the normal gait cycle is considered to be : a limp. Different types of limping (gait) : Antalgic. Trendlenberg. Tip toe. Circumduction. Stiff knee.

Approach to a limping child Three major factors cause a child to limp: Pain. Weakness. Structural or mechanical abnormalities of the spine, pelvis, and lower extremities.

Approach to a limping child Limping is a common pediatric problem. Presentations are variable : Painful Vs Painless. Acute Vs Chronic. Isolated Vs Associated. Age distribution …

Differential diagnosis 1-3 years Painful Painless Trauma Infection : septic arthritis/ osteomyelitis Inflammatory Neoplastic Developmental hip dysplasia. Neuromuscular problems: cerebral palsy Leg length discrepancy : congenital lower limb deficiencies.

Differential diagnosis 4-10 years Painful Painless Trauma Infection : septic arthritis/ osteomyelitis/ synovitis Inflammatory Neoplastic Hemtological AVN ( Perthes disease ) Developmental hip dysplasia. Neuromuscular problems: cerebral palsy Leg length discrepancy : congenital lower limb deficiencies.

Differential diagnosis 11-18 years Painful Painless Trauma Infection : septic arthritis/ osteomyelitis/ synovitis Inflammatory Neoplastic Hemtological AVN ( Perthes disease ) Slipped capital femoral epiphysis (SCFE) Developmental hip dysplasia. Neuromuscular problems: cerebral palsy Leg length discrepancy : congenital lower limb deficiencies.

Clinical evaluation HISTORY Age Onset: Acute : trauma related Gradual Pain : Painful limp (refusal to walk). Painless limp Associated sypmtoms: Fever. Stiffness. Backach. Abdominal pain. Skin rash.

Clinical evaluation HISTORY Night pain. Developmental history. Family history. Nutritional history. Raw milk ingestion.

Clinical evaluation HISTORY Medical illnesses: Hematological Neurological. Rheumatological. Medication history: antibiotics. Steroids. Growth hormone.

Clinical evaluation PHYSICAL EXAMINATIONS General look: Well looking Ill looking Dysmorphic features. Body position. Temp

Clinical evaluation PHYSICAL EXAMINATIONS Type of gait. Local examination : Look…… Feel …….. Move Erythema, redness, swelling, skin abrasions Local temp, localized tenderness, masses Move the joints: active and passive.

Clinical evaluation INVESTIGATIONS Laboratory: CBC: WBC ESR CRP Blood cultures. Procalcitonin. RF ANA ASO titers Brucella titers.

Clinical evaluation INVESTIGATIONS Radiological : X-rays. US. MRI Invasive : Joint aspiration.

RED FLAGS Limping (refusing to walk), ill looking, febrile child Hip septic arthritis. Significant night pain Neoplasia. Limping adolescent with/without trauma SCFE.

Hip transient (toxic) synovitis

Hip transient (toxic) synovitis It is the commonest cause of limping in toddlers and young children (3-10 years) . Boys are affected more (2:1). Idiopathic. Benign condition with no consequences. It is a diagnosis of EXCLUSION.

Hip transient (toxic) synovitis The child presents with hip pain and a limp (mostly able to walk). No associated symptoms. No fever. ? H/O recent URTI.

Hip transient (toxic) synovitis Looking well. Restricted hip ROM (mainly internal rotation). Normal or slightly elevated WBC. Normal or slightly elevated ESR. Normal CRP. Low procalcitonin. Negative blood culture.

Hip transient (toxic) synovitis Normal X-ray. US: positive for hip effusion. MRI: may differentiate from septic arthritis.

Hip transient (toxic) synovitis The most important step in working out this problem is to role hip septic arthritis . Sometimes it is difficult to differentiate …… invasive hip aspiration. Aspirate in transient synvitis: clear synovial fluid, low WBC count, negative culture, normal glucose level.

Hip transient (toxic) synovitis If the diagnosis is turned to be transient synovitis, treatment will be : Careful observation. Analgesics. Gradual return to normal activities.

Hip transient (toxic) synovitis Prognosis : Usually benign with no consequences. Weak evidence correlating transient synovitis with future Perthes disease (AVN)

HIP SEPTIC ARTHRITIS

HIP SEPTIC ARTHRITIS Hip septic arthritis in kids is a catastrophic event if lift untreated. It is caused by inclusion of the invding organism into the hip joint and its synovial tissues.

HIP SEPTIC ARTHRITIS The offending bacterial organism is usually spread to the hip joint by the mean of hematological spread. Incidence is correlated to age, and as the child grows the probability is reduced. Boys are affected twice as girls.

HIP SEPTIC ARTHRITIS The proteolytic enzymes secreted by the inflammatory cells and the offending organisms destroy the immature cartilage. The increased pressure of the intra-articular fluids will : Destruct the joint ligaments. Obstruct the tenacious blood supply to the femoral head causing avascular necrosis, and destruction of the femoral head.

Early recognition and Prompt treatment HIP SEPTIC ARTHRITIS The key in successfully treating hip septic arthritis in kids: Early recognition and Prompt treatment

HIP SEPTIC ARTHRITIS The hip joint is one of the deep joints in the body, making early recognition of septic arthritis is a challenging task. In neonates and infants , the challenge is overwhelming, and it requires very high index of suspicion to point a finger to this tragedy. Unfortunately, this age group usually have the worst outcomes.

HIP SEPTIC ARTHRITIS CLINICAL EVALUATION Hip pain, limping, and fever are the hallmark of clinical presentation. The child is ill looking, irritable, splinting the involved extremity in FABER position. Inability to walk. High grade temp (> 38.5)

HIP SEPTIC ARTHRITIS CLINICAL EVALUATION Elevated WBC. High ESR. High CRP. High Procalcitonin. Level of 0.4 ng/ml, is very sensitive and specific for infection. Positive blood culture. Karthikeyan et al. Journal of Orthopaedic Surgery and Research 2013Level of 0.4 ng/ml, is very sensitive and specific for infection. , 8:19

HIP SEPTIC ARTHRITIS CLINICAL EVALUATION The prediction probability of : History of fever inability to walk ESR > 40 mm WBC > 12,000 0 variable >> 0.2% 1 variable >> 3% 2 variables >> 40% 3 variables >> 93.1% 4 variables >> 99.6 % Kokher et al. JBJS. 1999, 81(12): 1662-70

HIP SEPTIC ARTHRITIS CLINICAL EVALUATION Pelvis X-ray: ??? NAD To rule out bony lesions 2mm lateralization, is indicative of joint effusion >>> septic arthritis . Hip US: positive for joint effusion S.T. Jung et al. JPO. 2003, 23(3): 368-72

Diagnosis was reached …. HIP SEPTIC ARTHRITIS Diagnosis was reached …. What is next ??

Management Goals of Treatment Control and eradicate the infection. Prevent complications: Cartilage damage. Damage to growth plate. Joint dislocation. Avascular necrosis

How to achieve the treatment goals ? Management How to achieve the treatment goals ?

Urgent Management Joint decompression. Antibiotic therapy. Joint immobilization.

Joint aspiration Management Technique: Either infero-medial , lateral, or supero-lateral entry sites. C-arm guided. Arthrography confirmed.

Arthrotomy With Joint Drainage Management Arthrotomy With Joint Drainage After positive aspiration, joint arthrotomy and drainage is elemental in the management of septic hip. Utilizing anterior approach, the joint capsule is incised, and the joint is thoroughly irrigated.

Arthrotomy With Joint Drainage Management Arthrotomy With Joint Drainage Further fluids should be sent with tissues for culture and histopathology. Through irrigation should be done to evacuate the chondrolytic enzymes, followed by drain insertion. Joint stability should be assessed, and if in doubt consider skin traction, abduction bracing, or even Spica cast.

Management Arthrotomy With Joint Drainage Pediatric J.O.I.N.T.S Hip Spetic Arthritis : Pediatric J.O.I.N.T.S Thamer Alhussainan, M.D. 10/26/15

Management Arthrotomy With Joint Drainage Pediatric J.O.I.N.T.S Hip Spetic Arthritis : Pediatric J.O.I.N.T.S Thamer Alhussainan, M.D. 10/26/15

Management Antibiotic therapy … Start with broad spectrum covering the common pathogen, then convert to the C/S guided. (staph aureus, strept pyogen, Gp A strept, H-influenzae, kingella kingae, CAMRSA) Start with IV rout, and monitor the clinical and laboratory response. Antibiotic therapy will be stopped when CRP is normalized and the clinical recovery is almost complete.

Management Antibiotic treatment is dependent on : Severity of infection. Virulance of the organism. Host response .

Management Follow up needs to be continued till : Avascular necrosis and proximal femur growth disturbance is ruled out .