THE CHILD WITH A LIMP Madesa Espana, MD, FAAP Pediatric Emergency Medicine St. Joseph’s Regional Medical Center Paterson, New Jersey

LIMP An uneven, jerky or laborious gait, usually caused by pain, weakness or deformity. 4/1000 visits in a pediatric ED

A CHILD WITH A LIMP Epidemiology Median age: 4 years old Male:female ratio: 2:1 Most common diagnosis: Transient synovitis Pain is present in 80% of cases Localization: hip and knee Benign cause: 77%

THE CHILD WITH A LIMP HISTORY Duration Trauma Fever

THE CHILD WITH A LIMP HISTORY Location of the pain Pain characteristics Constant severe pain Intermittent mild to moderate pain Bilateral pain Modifying factors

THE CHILD WITH A LIMP HISTORY Other symptoms Morning stiffness Incontinence, weakness or sciatica Recent viral or bacterial illness Recent medications Endocrine and other systemic diseases

THE CHILD WITH A LIMP PHYSICAL EXAMINATION General appearance Ill or toxic appearing Fever Obvious discomfort/pain at rest

THE CHILD WITH A LIMP PHYSICAL EXAMINATION Gait evaluation Phases of a gait Stance: time when the foot is in contact with the surface Heel-strike to toe flat (contact) Foot-flat to heel-off (mid-stance) Heel-lift to toe off (propulsion) Swing: time from toe-off to heel strike

THE CHILD WITH A LIMP PHYSICAL EXAMINATION Young child (<4 years) vs. adult gait Increased flexion of the hips, knees and ankles Rotation of the feet externally, wider base of support Faster cadence, slower velocity, shorter stride length Smaller percentage of the gait cycle is spent in single limb stance

THE CHILD WITH A LIMP PYSICAL EXAMINATION Gait examination Expose the legs Bare feet or wearing only a pair of socks Listening to the gait Cadence Foot slap Scraping

THE CHILD WITH A LIMP PHYSICAL EXAMINATION Gait examination Observe several gait cycles Includes jumping/hopping

Gait evaluation

THE CHILD WITH A LIMP PHYSICAL EXAMINATION Musculoskeletal Muscle strength Muscular atrophy Bony tenderness Bony deformity

THE CHILD WITH A LIMP PHYSCIAL EXAMINATON Musculoskeletal Active and passive ROM Joint swelling/tenderness Muscle tenderness Tenderness on the tendons, insertions sites

THE CHILD WITH A LIMP PHYSICAL EXAMINATION Musculoskeletal Back and spine Hip Thigh Knee Leg Ankle Foot

THE CHILD WITH A LIMP PHYSICAL EXAMINATION Musculoskeletal Limb length discrepancy Hip rotation Galeazzi test Trendelenburg test FABERE test

THE CHILD WITH A LIMP PHYSICAL EXAMINATION Skin Bruises Rashes and other lesions Swelling Redness Tenderness

THE CHILD WITH A LIMP PHYSICAL EXAMINATION Lymphatic Lymphadenopathy Localized vs. systemic Lymphadenitis Lymphangitis

THE CHILD WITH A LIMP PHYSICAL EXAMINATION Neurologic Muscle strength Muscle tone DTR’s

THE CHILD WITH A LIMP PHYSICAL EXAMINATION Gastroentestinal Abdominal tenderness Abdominal swelling Genitourinary Testicular or scrotal pain/swelling Inguinal swelling

THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES Age of the child Location of abnormal findings Duration of symptoms Type of gait abnormality

THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES OSSEOUS Fractures Salter-Harris or growth plate injuries Toddler’s: tibia, calcaneous and cuboid Stress Incomplete: buckle, greenstick Complete Plastic or bowing deformity Avulsion Child abuse: bucket-handle fractures

THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES OSSEOUS Apophysitis Sinding-Larsen-Johnson disease Kohler disease Sever disease Freiberg disease Osgood-schlater disease

THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES OSSEOUS Vasoocclussive crisis of SCD Slipped capital femoral epiphysis Legg-Calve-Perthes disease

THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES TUMORS Leukemia Lymphoma Spinal cord tumor Osteogenic sarcoma Ewing’s sarcoma Osteoid sarcoma Metastatic neuroblastoma

THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES ARTICULAR Transient synovitis of the hip Septic arthritis Osteochondritis dessicans Acute rheumatic fever Juvenile rheumatoid arthritis

THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES ARTICULAR Serum sickness Discitis Developmental dysplasia of the hip Chondromalacia of the patella Hemarthrosis: traumatic, hemophilia

THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES ARTICULAR Henoch-Schonlein purpura Lyme disease SLE Patellar dislocation

THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES SOFT TISSUE Contusion Muscle strain Sprain Tendonitis Viral myositis Foreign body

THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES SOFT TISSUE Cellulitis Abscess Pyomyositis IM vaccination Insect envenomation Plantar warts

THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES SOFT TISSUE Bunion Ingrown toenail Baker’s cyst rupture Myositis ossificans Bursitis Benign hypermobility syndrome

THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES NEUROLOGICAL Meningitis/Intracranial abscess Cerebral palsy Peripheral neuropathy Epidural abscess Spinal cord tumor Complex regional pain syndrome (reflex sympathetic dystrophy)

THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES INTRA-ABDOMINAL Appendicitis PID Pelvic abscess Psoas abscess Perirectal abscess Iliac adenitis

THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES GENITO-URINARY Incarcerated inguinal hernia Testicular torsion STD’s

THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES PSYCHIATRIC Conversion disorder Malingering

THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES DERMATOLOGIC VASCULAR Erythema multiforme VASCULAR Henoch-schonlein purpura

THE CHILD WITH A LIMP DIFFERENTIAL DIAGNOSES LIFE OR LIMB-THREATENING CAUSES OF LIMP IN CHILDREN Septic arthritis SCFE Osteomyelitis Fracture Tumors Appendicitis Testicular torsion Discitis Meningitis Epidural abscess Developmental dysplasia of the hip

CAUSES OF LIMP IN CHILDREN OF ALL AGES ACUTE Contusion Foreign body Fracture Osteomyelitis Reactive arthritis Septic arthritis Transient synovitis Lyme arthritis Poor shoe fit CHRONIC Rheumatic disease JRA Acute rheumatic fever SLE Inflammatory bowel disease

THE CHILD WITH A LIMP SEPTIC ATHRITIS Clinical signs/symptoms Fever Pain Decreased ROM Minor trauma

THE CHILD WITH A LIMP SEPTIC ARTHRITIS Clinical signs/symptoms Toxic or ill appearance Painful ROM Joint effusion Warmth/erythema

THE CHILD WITH A LIMP SEPTIC ARTHRITIS Laboratory findings Elevated WBC count with left shift Elevated ESR Elevated CRP Positive blood culture

THE CHILD WITH A LIMP SEPTIC ARTHRITIS Laboratory findings Synovial fluid analysis Volume > 3.5 ml Clarity: opaque Color: yellow to green WBC: > 100,000/mm3, >75% PMN’s Gram stain/Culture: positive Total protein: 3 – 5 g/dl Glucose: <25 mg/dl LDH: variable compared to blood level

THE CHILD WITH A LIMP SEPTIC ARTHRITIS Common organisms Staphylococcus aureus Beta hemolytic streptococcus Group A strep Hemophilus influenzae Neisseria gonorrhea

THE CHILD WITH A LIMP SEPTIC ARTHRITIS Radiologic findings Plain films: Soft tissue swelling Widened joint space Periosteal reaction of the adjacent bone, suggestive of osteomyelitis

THE CHILD WITH A LIMP SEPTIC ARTHRITIS Radiologic findings Ultrasonography Increased joint space and amount of joint fluid Increased vascularity CT scan Joint effusion Erosion of the cartillage Periosteal reaction or osteomyelitis

THE CHILD WITH A LIMP SEPTIC ARTHRITIS Radiologic findings MRI Radionuclide studies

CAUSES OF LIMP IN PRE-SCHOOL CHILDREN ACUTE Fractures Abusive injuries Toddler’s fracture Salter I fractures Hemarthrosis HSP Septic hip IM shots Toxic synovitis CHRONIC Blount disease Cerebral palsy Developmental dysplasia of the hip Discitis Kohler disease Leg length discrepancy Vertical talus

CAUSES OF LIMP IN SCHOOL-AGE CHILDREN ACUTE Fractures Myositis CHRONIC Legg-calve-Perthes disease Baker cyst Kohler disease Leukemia Spinal dysraphism (tethered cord) Tarsal coalition

THE CHILD WITH A LIMP LEGG-CALVE-PERTHES DISEASE Idiopathic vascular necrosis of the femoral head More common in boys Common in 5 – 9 years old, may affect 2 – 11 years old Transitional stage of development of the vascular anatomy of the femur

THE CHILD WITH A LIMP LEGG-CALVE-PERTHES DISEASE Preceding history of minor trauma Predisposing factors SCD Steroid use Hip dysplasia

THE CHILD WITH A LIMP LEGG-CALVE-PERTHES DISEASE Radiologic studies Plain films Radioisotope studies MRI

THE CHILD WITH A LIMP KOHLER DISEASE Affects more boys than girls Most common in 5 – 10 years old, as early as 2 years old Impaired perfusion to the navicular bone of the talus Inflammatory changes over the navicular bone

THE CHILD WITH A LIMP KOHLER DISEASE Treatment Weight bearing with below the knee cast followed by arch support

CAUSES OF LIMP IN ADOLESCENTS ACUTE Sprain Strain Tendonitis CHRONIC Arthritis Herniated disc SCFE Scoliosis Spinal dysraphism Spondylolisthesis Chondromalacia RSD Osgood-Schlatter

THE CHILD WITH A LIMP OSGOOD-SCHLATTER DISEASE Over use injury affecting the insertion site of the patellar tendon on the anterior tibial tubercle Inflammatory changes over the tubercle Treatment goal: decrease the stress on the tubercle Rest Cast Excision of an ossicle

Surface Anatomy of the Knee

Saggital view of the knee

Osgood-Schlatter Disease radiographs

THE CHILD WITH A LIMP SINDING-JOHANSSON-LARSEN DISEASE Traction tendinitis of the proximal attachment of the patellar tendon (inferior pole of the patella) Boys more than girls Age of presentation: 10 –16 years old Overuse injury, athletes

THE CHILD WITH A LIMP SINDING-JOHANSSON-LARSEN DISEASE Radiologic findings Irregular calcification of the inferior pole of the patella Treatment Rest Cast

THE CHILD WITH A LIMP SLIPPED CAPITAL FEMORAL EPIPYSIS (SCFE) Epiphyseal dislocation in superolateral displacement and external rotation of the femoral metaphysis, Salter I injury Causes kinking of the epiphyseal vessels that leads to compromised blood to the epiphysis

THE CHILD WITH A LIMP SCFE Incidence 10/100000 Boys: 13.5, Girls 8.5/100000 Regional and seasonal variation Initial presentation 20% bilateral hip 20 – 40% eventually develop bilateral involvement within 18 months of initial presentation

THE CHILD WITH A LIMP SCFE Radiologic classification I: < 33% II: 33 – 50% III: > 50% Displacement in relation to the femoral neck

THE CHILD WITH A LIMP Treatment Depends on the onset of symptoms and grade Internal fixation with single cannulated screw Prophylactic fixation of the unaffected hip Osteomy of the proximal femur

SCFE radiographs

THE CHILD WITH A LIMP LABORATORY STUDIES Blood tests CBC, differential ESR CRProtein Blood culture Lyme studies ANA ASO

THE CHILD WITH A LIMP LABORATORY STUDIES Normal synovial fluid characteristics Highly viscous Clear Essentially acellular Protein concentration is 1/3 of plasma protein Glucose concentration is similar to plasma

THE CHILD WITH A LIMP LABORATORY STUDIES Components of synovial fluid analysis Clarity Color Viscosity Glucose content Protein content

THE CHILD WITH A LIMP LABORATORY STUDIES Components of synovial fluid analysis Microscopic examination WBC count Crystal search Gram satin Culture Routine bacterial culture GC culture Unusual organisms

THE CHILD WITH A LIMP RADIOLOGIC TESTS Plain radiographs Affected site Comparison views Skeletal survey

THE CHILD WITH A LIMP RADIOLOGIC TESTS MRI Radionuclide studies Ultrasonography CT scan

THE CHILD WITH A LIMP DISPOSITION In-patient Out-patient IV antibiotics Diagnostic work-up Surgical intervention Out-patient Observation with close follow up NSAID’s Sub-specialty referrals

THE CHILD WITH A LIMP DISPOSITION Consultation Orthopedic Joint aspiration Surgical intervention Hematology-Oncology Bone marrow aspiration Chemotherapy

THE CHILD WITH A LIMP DISPOSITION Consultation Gynecologic Urology Pelvic examination Surgical intervention Urology

THE CHILD WITH A LIMP DISPOSITION Consultation Neurosurgery Pediatric or general surgery Surgical intervention Infectious disease Choice of antibiotics Length of treatment

THE CHILD WITH A LIMP DISPOSITION Consultation Rheumatology Pain specialist Psychiatry Physiatry Physical/occupational therapy Orthotics

THE CHILD WITH A LIMP DISPOSITION Diagnoses that require immediate intervention Septic arthritis Osteomyelitis Meningitis Epidural abscess

THE CHILD WITH A LIMP DISPOSITION Diagnoses that require immediate intervention Fractures Dislocated patella SCFE Developmental dysplasia of the hip

THE CHILD WITH A LIMP DISPOSITION Diagnoses that require immediate intervention Neoplasms/tumors Testicular torsion Appendicitis PID with tuboovarian abscess Discitis