Evaluation of the Child with a Limp DD Aronsson University of Vermont

Hx – 2-year-old boy limps because of pain in the right thigh (antalgic) PE – pain and swelling just above the knee

Differential Diagnosis Bone infection (osteomyelitis) Joint infection (septic arthritis) Fracture Toxic synovitis

Bone & Joint Infections Hematogenous origin – Strep throat Implantation – Stepping on a nail

Osteomyelitis Metaphyseal origin Vessels don’t cross the growth plate

Septic Arthritis Infection can decompress into a joint Septic dislocation

Clinical Findings Systemically ill Irritable Refusal to bear weight Pseudoparalysis Pain & the site

Laboratory Studies Elevated WBC,ESR, & CRP 50% Positive blood culture Infant – May be normal

Imaging Radiographs – Soft tissue swelling Bone scan – Increased uptake

Treatment Aspiration is the “key” to the diagnosis Don’t wait for imaging Subperiosteal aspiration

Treatment IV antibiotics – S aureus, gram-negative enteric, & Group B Streptococcus Surgical decompression – Hip & shoulder

Hx – 18 month-old girl limps on the left leg (no pain) PE – short left lower extremity is causing the limp

Differential Diagnosis Developmental dysplasia of the hip Limb-length discrepancy

DDH Instability Subluxation Dislocatable Reducible dislocation Irreducible dislocation

Etiology Unknown Multifactorial Geneticwhites Physiologicgirls Mechanicalbreech Environmentalswaddling

Barlow Provocative Test Dislocates hip (exit) Clunk

Ortolani Maneuver Reduces dislocated hip (entry) Abduction Clunk

PE > 3 Months 57º 43º Limited abduction is key

PE > 3 Months Asymmetric thigh folds – Limb-length discrepancy

Radiographs

Ultrasound Alpha > 60º – Slope of osseus acetabulum

Pavlik Harness Success Dysplasia 95% Dislocated 80%

Hx – 6-year-old boy limps on the right leg PE – limp with painful range-of-motion of the hip

Differential Diagnosis Infection Toxic synovitis Slipped capital femoral epiphysis (endocrine) Legg-Calv  -Perthes disease

Legg-Calv  -Perthes Loss of blood supply of the epiphysis

Legg-Calv  -Perthes History – Pain in the groin or knee – Limp – Aggravated by exercise

Legg-Calv  -Perthes Physical examination – Decreased internal rotation – Decreased abduction – Irritable hip

Necrotic stageFragmentation stage

Reossification stageRemodeling stage

Treatment Containment – Physical therapy ROM exercises – Orthosis Abduction & internal rotation – Osteotomy

Toxic synovitis History – sudden onset – Pain in groin or thigh – Painful limp – URI 2 weeks ago

Physical Examination Limp Irritable hip with guarding Mimic septic hip

Treatment Activity modification Expect improvement Question diagnosis if not responding

Hx – 14-year-old obese boy has pain in the right knee and limps PE – no swelling and full ROM of the knee but decreased internal rotation of the hip

Differential Diagnosis Infection Osgood-Schlatter disease Anterior knee pain Slipped capital femoral epiphysis

Slipped Capital Femoral Epiphysis (SCFE) Most common hip disorder in adolescents Age – Boys 14 y/o – Girls 12 y/o

Etiology Endocrine – Hypothyroid – Growth hormone treatment Mechanical – 63% > 95th percentile weight

Hip Flexion Causes Abduction & External Rotation FABER

AP Pelvis Radiograph Wide & irregular physis Epiphysis at or below Klein’s line Klein’s line

Frog Pelvis Radiograph Posterior slip Wide, irregular physis

Preop AP pelvisPreop frog pelvis

Postop AP pelvisPostop frog pelvis

Limp Think hips