A Child with a Limp Lydia Burland

Learning Outcomes By the end of the session you should be able to; Recognise common orthopaedic conditions List important risk factors Explain investigations and management to parents Answer questions on key topics

Case 1: DDH Left hip affected more often than the right 20% of cases are bilateral More common in cultures where swaddling is used Detection methods include newborn and 6-8 week screening and ultrasound Most stabilise spontaneously by 2-6 weeks Developmental dysplasia of the hips affects 1-3% of all newborns and is still responsible for a 1/3 of hip replacements before the age of 60 years of age. The left hip is more commonly affected than the right, and around 20% of cases are bilateral. The condition is more common in cultures where swaddling is used as the hips a forcibly extended and adducted. Other risk factors include positive family history or previous affected sibling, female sex, breech delivery, oligohydramnios, prematurity and multiple pregnancies. DDH is screened for at both the newborn and 6-8 week check with the Barlow and Ortolani tests. Barlow’s test puts backwards pressure on the femur and partial or complete displacement is felt for. Ortolani’s test applies forwards pressure to each hip in turn, attempting to re-locate a subluxed of displaced femoral head back into the acetabulum. If any abnormality is felt children should be referred for bilateral hip ultrasound. Benign hip clicks (soft tissue moving over bony prominences) should be distinguished from the clunks heard when the femoral heads or reduced.

Case 1: DDH If still unstable the need prompt treatment Bracing is 1st line under 6 months of age Surgery is needed if bracing fails (~5%) or for children >6 months at presentations Risk of surgery include re-dislocation, stiffness and avascular necrosis (5-15%) Long-term complications include OA and lower back pain The majority of unstable hips stabilise by 2-6 weeks of age, however if they do not prompt treatment is required to reduce the need for surgery and long term complications. For children under 6 months of age at presentation bracing is 1st line treatment, and should be in place at all times to keep hips reduced. Bracing is much less successful if started after the first 6-8 weeks of age. Surgery is indicated for those who fail to respond the bracing and for children who present late. Surgery usually involves open reduction followed by 3-4 months in a plaster cast or brace. For children presenting aged 18-24 months pelvic and/of femoral osteotomy may be required. The short term complications include re-dislocation, stiffness and avascular necrosis. Longer term complications include early degenerative changes and lower back pain.

Case 2 A 6 year old boy presents with cough, fever and refusal to weight bear on the left Has been ‘not quite himself’ for 2 days He is happy at rest, but cries as soon as you try to examine the left leg Obs: T 37.8, HR 105, RR 28 What are your differentials?

Case 2 Differential diagnosis; Septic arthritis Transient synovitis Perthe’s disease Discitis What tests would you do? The three primary differentials are; Septic arthritis – less common but the most important to rule out, also has a history of fever Transient synovitis – common, more so in boys, ?preceeding viral illness Perthe’s disease (avascular necrosis of the femoral head) – he’s make and in the right age group (5-10 yrs), usually more gradual onset Investigations should include; Bloods including inflammatory markers (WCC/CRP – ESR rarely used now) Imaging – xrays and hip ultrasoun

Case 2 Bloods; FBC 145 WCC 11.5 plt 395 CRP 18 What do you think of the results? Mildly raised WCC and CRP so likely that some infective process is going on. Difficult to know if these are going up of down – serial measurements may be needed.

Case 2 Left hip USS: small effusion, synovial thickening http://radiopaedia.org/cases/hip-synovitis-1 To a trained radiologist this shows some soft tissue swelling in the left hip compared to the right, but no bony abnormality. What are your differentials now? Transient synovitis Septic arthritis It is still difficult to rule out a septic arthritis, and much would depend on how unwell the child is. In this case the child remains relatively well during his 3 hours in the CAT unit and is afebrile.

Case 2: Transient Synovitis Acute onset hip pain +/- refusal to weight bear Generally no pain at rest Child is otherwise well, bloods unremarkable Often preceded by a viral URTI Treat with rest and analgesia Usually resolves spontaneously in 2 weeks Transient synovitis, or irritable hip, usually presents with acute onset hip pain. It may only be moderately severe, though the child may refuse to weight bear. Children tend to not have any pain at rest, and may only have pain at the extremes of their range of movement on examination. Generally the child is otherwise well and bloods unremarkable – they may have slightly raised inflammatory markers due to a preceding viral illness or inflammation. Treatment is conservative with rest and analgesia. Once the pain is under control the child should be encouraged to move as normally as possible to avoid stiffness developing. The condition usually resolves within 2 weeks, though may recur. There are no long term complications.

Case 3 A 7 year old boy presents with left knee pain and a limp He is otherwise well There is no history of trauma All movements of the hip are limited There is guarding when the examiner rolls the hip internally and externally

Case 3 What can be seen on the x-ray? http://radiopaedia.org/cases/perthes-and-coxa-magna Widening of the joint space on the left. What’s you diagnosis?

Case 3: Perthe’s Disease Loss of blood supply (avascular necrosis) to the femoral epiphysis Leads to abnormal growth of the epiphysis and eventual remodelling of the bone Risk factors; Boys 4-8 years of age Caucasians +ve family history Low birth weight Perthe’s disease is avascular necrosis of the femoral epiphysis, leading to abnormal growth and eventual remodelling of the femoral head. Boys are 5 times more likely to be affected than girls, most commonly aged 4-8 years. Other risk factors include being caucasion, a positive family history, low birth weight and abnormal delivery.

Case 3: Perthe’s Disease Presents with hip/knee pain and effusion 12% of cases are bilateral Early x-rays show joint widening Later x-rays show femoral head collapse and deformity MRI may be needed to better define anatomy Perthe’s disease tends to present with hip and/or knee pain and effusion. Around 12% of cases are bilateral, though each side tends to be at a different stage and progress is asymmetrical. Early x-rays may be normal, or show widening of the joint space and patchy density of the femoral head. Later in the disease the femoral head may collapse, before new bone growth appears as deformity.

Case 3: Perthe’s Disease Conservative management for; Children <8 years Bone age <6 years This involves physio and strengthening Surgery involves proximal varus osteotomy Prognosis is good for children < 6 or less severe disease Around 50% of cases will get better on there own without treatment. Children under the age of 8, or those that have a bone age of less than 6 years, at presentation can be managed conservatively with physio and strengthening exercises. Early surgery should be used for children over 8 years at presentation or with severe disease. Long term complications include osteochondritis, shortening of the neck of femur and broadening of the head.

What are you differentials? Case 4 A 13 year old boy has severe left hip pain He has had mid-thigh pain for the last 2 months Worse on running and jumping He is otherwise well PMH: of hypothyroidism What are you differentials?

Case 4: SUFE The most common adolescent hip disorder Due to instability of the proximal femoral growth plate 4 types exist Pre-slip: wide epiphyseal line, no slippage Acute: sudden slip, usually spontaneous Acute-on-chronic: acute pain on chronic slip Chronic: steadily progressive slip Slipped upper femoral epiphysis is the most common hip disorder in adolescence. It is due to instability of the proximal femoral growth plate. 4 different types of SUFE exist of which chronic is the most common form. Symptoms at presentation range from mild groin, hip or knee discomfort to acute, severe pain with inability to weight bear. The leg may be externally rotated on examination, with limitation of hip pain due to pain, especially internal rotation and abduction.

Case 4: SUFE Commonly affects boys, aged 10-17 years Other risk factors include; Obesity Pelvic radiotherapy Trauma Hypothyroidism The left hip is more often involved 20-40% of cases are bilateral

Case 4: SUFE http://radiopaedia.org/cases/slipped-capital-femoral-epiphysis-1 (Who knew willies were this visible on x-rays?!) X-rays should be taken in the AP and ‘frog-leg’ position and may show widening or displacement of the epiphyseal line.

Case 4: SUFE Management involves; Immediate bed rest and analgesia Immediate ortho opinion Urgent surgical closure of the epiphysis Complications include chondrolysis and AVN Prognosis is best if there is <1/3 displacement If SUFE is suspected you should avoid rotating or moving the leg, and prevent the child from walking. An urgent orthopaedic opinion should be requested so that immediate closure of the epiphysis can be arranged. This is done with the placement of percutaneous screws. If the deformity is severe osteotomy should be performed. Long term complications include chondrolysis, which is degeneration of the articular cartilage, and avascular necrosis. Overall prognosis depends on the severity of the slippage – displacement of less than 1/3 of the diameter of the femoral neck has excellent outcomes.

Summary DDH Hip instability is common under 6 weeks More common in girls Detected by Barlow’s/Ortolani’s It should be treated with a long-term harness Transient Synovitis Acute onset hip pain More common in boys Treated with rest and analgesia Usually resolves within 2 weeks

Summary Perthe’s Disease Avascular necrosis of the femoral head More common in boys aged 5-10 years Usually managed conservatively Surgery if severe or >8 years SUFE Hip, thigh and knee pain More common in boys at puberty Treated with percutaneous screws

Questions

Questions 6 MCQs 2 EMQs 4 clinical images Review of answers

Questions: MCQs Which of the following is a common cause of septic arthritis? a. Strep. viridans b. E. coli c. Staph. aureus d. N. meningitidis A Pavlik harness is used in the treatment of which condition? a. Perthes’ disease b. SUFE c. Genu valgum d. DDH

Questions: MCQs 3. A 15 year old has knee swelling, sore red eyes and dysuria. What’s the diagnosis? a. Osgood-schlatter’s b. Reiter’s syndrome c. Perthe’s disease d. Osteochondritis 4. A boy presents with delayed walking, bowed legs and short stature. What’s the diagnosis? a. Osteoporosis b. Ehlers-danlos syndrome c. Rickets d. Osteochronditis

Questions: MCQs 5. A tall thin boy has arachnodactyly has a high arched palate. What’s the diagnosis? a. Marfan’s disease b. Ehlers-danlos syndrome c. Osgood-schlatter’s d. Osteomyelitis 6. Duchenne muscular dystrophy is classically associated with which of the following signs? a. Kernig’s sign b. Trendelenburg’s sign c. Gower’s sign d. Dysdiadokinesis

Questions: EMQ 1 Select the most likely diagnosis. a. Osgood-schlatter’s b. Irritable hip c. Perthe’s disease d. Henoch-schonlein purpura e. SUFE f. DDH A 7 year old boy presents with right knee pain and an antalgic gait. There is no history of trauma. A 5 year old girl presents refusing to weight bear. She has been suffering with a cold for the last 4 days and is febrile.

Questions: EMQ 1 Select the most likely diagnosis. a. Osgood-schlatter’s b. Irritable hip c. Perthe’s disease d. Henoch-schonlein purpura e. SUFE f. DDH 3. A 13 year old presents with 2 months of below knee pain and swelling. Made worse by running and jumping. 4. A 13 year old boy presents with groin discomfort of walking and jumping. The leg is externally rotated.

Questions: EMQs 2 Select the most likely diagnosis. a. Impetigo b. Eczema c. Scabies d. Erythema nodosum e. Kawasaki’s disease f. Rheumatic fever A 7 year old presents with an itchy red area on his chin. Over the course of the day the skin breaks and a yellow scab forms. A 5 year old presents with high fevers, knee and hip pain and a red rash on the trunk and arms.

Questions: EMQs 2 Select the most likely diagnosis. a. Impetigo b. Eczema c. Scabies d. Erythema nodosum e. Kawasaki’s disease f. Rheumatic fever 3. A mum brings in her two children with intensely itchy rashes on their hands. The rash is in little lines between the fingers. 4. A 16 year old is diagnosed with a chest infection. 10 days later he returns with tender, purple lesions on this shins.

Questions: Image 1 A 6 year old boy has the following x-ray signs. What is the most likely cause of this condition? b. Give 2 risk factors.

Questions: Image 2 This 12 year old presents with fever and shoulder pain. What investigation should be performed? What treatment should be started? Gait disorders in children, Best Practice BMJ

Questions: Image 3 This 3 year old boy presents with a painful rash following 4 days of cough, coryza and sore throat. What’s the diagnosis? b. What other symptoms would you ask about? http://trialx.com/curebyte/2012/12/01/henoch-schonlein-purpura-photos-and-a-listing-of-clinical-trials/

Questions: Image 4 A 14 year old presents pain and refusal to weight bear on the left. What’s the diagnosis? Give two risk factors.

Answers

Answers: MCQs Which of the following is a common cause of septic arthritis? a. Strep. viridans b. E. coli c. Staph. aureus d. N. meningitidis A Pavlik harness is used in the treatment of which condition? a. Perthes’ disease b. SUFE c. Genu valgum d. DDH Half of all cases of septic arthritis present in the first 2 years of life. 75% of cases occur in the lower limbs, predominantly affecting knees, then hips and then ankles. Staph aureus is the commonest cause of septic arthritis in all age groups.

Answers: MCQs Which of the following is a common cause of septic arthritis? a. Strep. viridans b. E. coli c. Staph. aureus d. N. meningitidis A Pavlik harness is used in the treatment of which condition? a. Perthes’ disease b. SUFE c. Genu valgum d. DDH Previously known as congenital dislocation of the hip, developmental dysplasia of the hip is screened for at both the newborn and the 6-8 week check using Barlow’s and Ortolani’s tests and ultrasound scanning. If the child is under 6 months of age bracing is the 1st line of treatment – it maintains flexion and mild abduction and should be warn at all times.

Answers: MCQs 3. A 15 year old has knee swelling, sore red eyes and dysuria. What’s the diagnosis? a. Osgood-schlatter’s b. Reiter’s syndrome c. Perthe’s disease d. Osteochondritis 4. A boy presents with delayed walking, bowed legs and short stature. What’s the diagnosis? a. Osteoporosis b. Ehlers-danlos syndrome c. Rickets d. Osteochronditis Reiter’s syndrome is an autoimmune condition that occurs in response to infection. It is a triad of nongonococcal urethritis, conjunctivitis and arthritis. It is strongly associated with HLA-B27.

Answers: MCQs 3. A 15 year old has knee swelling, sore red eyes and dysuria. What’s the diagnosis? a. Osgood-schlatter’s b. Reiter’s syndrome c. Perthe’s disease d. Osteochondritis 4. A boy presents with delayed walking, bowed legs & short stature. What’s the diagnosis? a. Osteoporosis b. Ehlers-danlos syndrome c. Rickets d. Osteochronditis Rickets presents with slow growth in the first year of life, reluctance to weight bear and delayed walking. Once they start walking the weight-bearing long bones of the legs quickly become bowed.

Answers: MCQs 5. A tall thin boy has arachnodactyly has a high arched palate. What’s the diagnosis? a. Marfan’s disease b. Ehlers-danlos syndrome c. Osgood-schlatter’s d. Osteomyelitis 6. Duchenne muscular dystrophy is associated with which of the following signs? a. Kernig’s sign b. Trendelenburg’s sign c. Gower’s sign d. Dysdiadokinesis Marfan’s disease is inherited in an autosomal dominant pattern and affects both sexes equally. It is the most common connective tissue disorder. The majority of children are asymptomatic, and tend to be tall and thin with disproportionally long arms and fingers. Clinical features include; Thoracic aortic aneurysm, dissection and rupture Aortic regurgitation Lens dislocation Closed angle glaucoma Joint hypermobility Pectus excavatum or carinatum High arched palate

Answers: MCQs 5. A tall thin boy has arachnodactyly has a high arched palate. What’s the diagnosis? a. Marfan’s disease b. Ehlers-danlos syndrome c. Osgood-schlatter’s d. Osteomyelitis 6. Duchenne muscular dystrophy is classically associated with which of the following? a. Kernig’s sign b. Trendelenburg’s sign c. Gower’s sign d. Dysdiadokinesis Duchenne’s is the most common of the muscular dystrophies. It is an X-linked recessive condition which presents early in childhood. Gower’s sign is ‘climbing’ up the legs when trying to stand due to proximal muscle weakness. Kernig’s sign: pain and resistance to passive extension of the knee when the hip is flexed, seen in meningitis. Trendelenburg’s sign: pelvic tilting whilst standing on one leg due to abductor muscle weakness, seen in several diseases including SUFE. It may be seen in Duchenne’s and other muscle wasting disorders but is less common. Dysdiadokinesis: is the inability to perform rapid, alternating movements, seen in cerebellar disorders and MS.

Answers: EMQ 1 Select the most likely diagnosis. a. Osgood-schlatter’s b. Irritable hip c. Perthe’s disease d. Henoch-schonlein purpura e. SUFE f. DDH A 7 year old boy presents with right knee pain and an antalgic gait. There is no history of trauma. A 5 year old girl presents refusing to weight bear. She has been suffering with a cold for the last 4 days and is febrile.

Answers: EMQ 1 Select the most likely diagnosis. a. Osgood-schlatter’s b. Irritable hip c. Perthe’s disease d. Henoch-schonlein purpura e. SUFE f. DDH A 7 year old boy presents with right knee pain and an antalgic gait. There is no history of trauma. A 5 year old girl presents refusing to weight bear. She has been suffering with a cold for the last 4 days and is febrile.

Answers: EMQ 1 Select the most likely diagnosis. a. Osgood-schlatter’s b. Irritable hip c. Perthe’s disease d. Henoch-schonlein purpura e. SUFE f. DDH 3. A 13 year old presents with 2 months of below knee pain and swelling. Made worse by running and jumping. 4. A 13 year old boy presents with groin discomfort of walking and jumping. The leg is externally rotated.

Answers: EMQ 1 Select the most likely diagnosis. a. Osgood-schlatter’s b. Irritable hip c. Perthe’s disease d. Henoch-schonlein purpura e. SUFE f. DDH 3. A 13 year old presents with 2 months of below knee pain and swelling. Made worse by running and jumping. 4. A 13 year old boy presents with groin discomfort of walking and jumping. The leg is externally rotated.

Answers: EMQs 2 Select the most likely diagnosis. a. Impetigo b. Eczema c. Scabies d. Erythema nodosum e. Kawasaki’s disease f. Rheumatic fever A 7 year old presents with an itchy red area on his chin. Over the course of the day the skin breaks and a yellow scab forms. A 5 year old presents with high fevers, knee and hip pain and a red rash on the trunk and arms.

Answers: EMQs 2 Select the most likely diagnosis. a. Impetigo b. Eczema c. Scabies d. Erythema nodosum e. Kawasaki’s disease f. Rheumatic fever A 7 year old presents with an itchy red area on his chin. Over the course of the day the skin breaks and a yellow scab forms. A 5 year old presents with high fevers, knee/hip pain & a red rash on the trunk/ arms.

Answers: EMQs 2 Select the most likely diagnosis. a. Impetigo b. Eczema c. Scabies d. Erythema nodosum e. Kawasaki’s disease f. Rheumatic fever 3. A mum brings in her two children with intensely itchy rashes on their hands. The rash is in little lines between the fingers. 4. A 16 year old is diagnosed with a chest infection. 10 days later he returns with tender, purple lesions on this shins.

Answers: EMQs 2 Select the most likely diagnosis. a. Impetigo b. Eczema c. Scabies d. Erythema nodosum e. Kawasaki’s disease f. Rheumatic fever 3. A mum brings in her two children with intensely itchy rashes on their hands. The rash is in little lines between the fingers. 4. A 16 year old is diagnosed with a chest infection. 10 days later he returns with tender, purple lesions on this shins.

Answers: Image 1 A 6 year old boy has the following x-ray signs. What is the most likely cause of this condition? Vitamin D deficiency b. Give 2 risk factors. Almost no sunlight exposure and low dietary calcium intake

Answers: Image 2 This 12 year old presents with fever and shoulder pain. What investigation should be performed? Joint aspiration b. What treatment should be started? IV antibiotics (flucloxacillin +/- benpen) Gait disorders in children, Best Practice BMJ

Answers: Image 3 This 3 year old boy presents with a painful rash following 4 days of cough, coryza and sore throat. What’s the diagnosis? Henoch-schonlein purpura b. What other symptoms would you ask about? Arthritis, haematuria and abdo pain http://trialx.com/curebyte/2012/12/01/henoch-schonlein-purpura-photos-and-a-listing-of-clinical-trials/

Answers: Image 4 A 14 year old presents pain and refusal to weight bear on the left. What’s the diagnosis? SUFE b. Give two risk factors. Male gender, obesity and trauma

Any questions? Lydia Burland