The Limping Child AAPA

Definition Limp = Asymmetry Joint - Range of motion Bone - Deformity Pain Control

The Limping Child Diagnosis Mechanism

The Limping Child Pitfalls Being misled by the parents’ analysis Always a leg length discrepancy Being misled by the patient’s complaint Hip problems can cause knee pain Complaints of pain AGE NEWBORN INFANT TODDLER CHILD PRE-TEEN TEENAGER ADULT 5 COMPLAINS LIMPS

The Limping Child Causes of limp Joint - Range of motion Bone - Deformity Pain Hip Control -Physical exam -X-ray -‘Antalgic’ gait -Abductor lurch -Upper limb

Too much to cover The Limping Child Hip Best Bets Age

The Limping Child Age 1 – 3 years Age 3 – 6 years Age 6 – 10 years Age 10 – 14 years

DDH Developmental Dysplasia of the Hip CDH Congenital Dislocation of the Hip Best Bet The Limping Child: Age 1 – 3 1

The Limping Child: Age 1 – 3 DDH Physical findings Girl Asymmetrical skin folds Limited abduction Short leg Pistoning Ortolani’s sign Barlow’s sign

X-ray findings Delayed appearance of ossific nucleus Small ossific nucleus Dysplastic acetabulum Proximal displacement of femur The Limping Child: Age 1 – 3 DDH

Treatment 0 – ½:Pavlik harness ½ – 1½:Closed reduction, cast 1 ½ - 5 or 8:Open reduction, pelvic osteotomy Older:Leave dislocated Pavlik Harness Check at 3 weeks to confirm reduction Adjust position every 6 – 12 weeks Continue until the hips are clincally and radiologically normal

Transient synovitis Septic arthritis Best Bet The Limping Child: Age 3 – 6 s Flu Tonsillitis 2

The Limping Child: Age 3 – 6 Transient synovitis Child refuses to walk Movement of hip is painful May have fever Moderately elevated WBC Lasts a few days Disappears without treatment

The Limping Child: Age 3 – 6 Septic arthritis Child refuses to walk Movement of hip is painful May have fever Elevated WBC Progressively sicker Progressive joint destruction WIDENED JOINT SPACE

The Limping Child: Age 3 – 6 Septic Arthritis Bacteria Enzymes Destroy cartilage Irreversable joint damage White cells Enzymes

The Worst Scenario Destruction of articular cartilage Destruction of femoral head Destruction of femoral neck The Limping Child: Age 3 – 6 Septic Arthritis

Treatment 1.Kill the bacteria Antibiotics 2.Eliminate the white cells Incision and drainage 3.Don’t delay 48 hour window The Limping Child: Age 3 – 6 Septic Arthritis

How to tell the difference? Four predictors History of fever Refusal to weight-bear ESR > 40 mm/hr WBC > 12,000 If in doubt Review in 12 hours Do incision and drainage! The Limping Child: Age 3 – 6 Transient Synovitis vs. Septic Arthritis Kocher, Kasser, et al. JBJS 86-A: 1629, 2004

Legg-Calvé-Perthes Disease Best Bet The Limping Child: Age

Physical findings Boy Limp Antalgic gait Pain with passive motion Limited abduction Positive Trendelenburg sign The Limping Child: Age 6 – 10 Perthes Disease

X-ray findings Perhaps nothing MRI Irregular consistency Flattening Lateral bump/ridge Lateral hinging

The Limping Child: Age 6 – 10 Perthes Disease

Treatment 1.Maintain range of motion Physical therapy Anti-inflammatory medication 2.“Containment” Bracing in abduction Femoral osteotomy Pelvic osteotomy The Limping Child: Age 6 – 10 Perthes Disease

50% need a Total Hip by age 50

Slipped Capital Femoral Epiphysis (SCFE – skiffey) Best Bet The Limping Child: Age 10 – 14 4

The Limping Child: Age 10 – 14 SCFE Always get a frog lateral view Always check the other side

Pediatric orthopaedic surgeons See 6 per year General orthopaedic surgeons See 1 every 6 years Same as fixing a fracture The Limping Child: Age 10 – 14 SCFE

ClassificationClassification Acute or chronicAcute or chronic Stable or unstableStable or unstable Severity of displacementSeverity of displacement Slip angleSlip angle BilateralityBilaterality 10 – 15% at presentation10 – 15% at presentation The Limping Child: Age 10 – 14 SCFE

Useful Classification StableStable Walks inWalks in UnstableUnstable Wheels inWheels in Bone in one piece Bone in one piece Slow plastic deformation of the growth plate Slow plastic deformation of the growth plate Bone in two piecesBone in two pieces Physeal fracture Physeal fracture No reduction One screw Closed reduction Two screws

Unstable SCFE

Xray Findings Displacement of neck on headDisplacement of neck on head Mainly anteriorMainly anterior Somewhat superiorSomewhat superior Decreased projected femoral head heightDecreased projected femoral head height ChronicityChronicity Inferior new boneInferior new bone Superior rounding off of metaphysisSuperior rounding off of metaphysis Curved neckCurved neck

CastroAP

Silva Chronic Slip Degree of slip??

Castro Right Lateral Slip angle

Concept Displacement of head on neck Gradual change in shape The femoral neck “curves” posteriorly

Starting Point – Severe Slips

Correct Path

Controlling Depth Approach WithdrawApproach Withdraw Rotate hip through full rangeRotate hip through full range Observe projected distance of pin tip from subchondral boneObserve projected distance of pin tip from subchondral bone Watch for change in directionWatch for change in direction That moment presents the critical viewThat moment presents the critical view BLIND SPOT

3–D Geometry The Critical View

Approach-Withdraw 1 1

Approach-Withdraw 2 2

Approach-Withdraw 3 3

Approach-Withdraw 4 4

Approach-Withdraw 5 5

Approach-Withdraw 6 6

Approach-Withdraw 8 7

Approach-Withdraw 7 8

Approach-Withdraw 5 5 The Critical View

The Contralateral Hip Out of 100 patients: 10 are bilateral at presentation 10 will slip on the other side later 5 will have painless slips on the other side

Follow-up for Bilaterality Follow radiologicallyFollow radiologically Every three monthsEvery three months For 18 monthsFor 18 months

The Limping Child Age 1 – 3 years- DDH Age 3 – 6 years- Septic arthritis Age 6 – 10 years- Perthes Disease Age 10 – 14 years- SCFE Best Bets

The Limping Child AAPA