Prof. Mamoun Kremli AlMaarefa College The limping child Prof. Mamoun Kremli AlMaarefa College

Introduction Limping is a common presentation in children Seen by orthopedic surgeons, pediatricians, primary care physicians Need to take a proper History physical examination Investigations Some diseases related to specific age groups

History Duration, when first noticed Pain History of trauma Associated systemic symptoms Fever, night sweating, anorexia, weight loss

Limping Painful Painless History of trauma often reported in all cases Antalgic gait – short stance phase of gait cycle Child may not complain of pain Painless History of trauma often reported in all cases Relevant Irrelevant

Types of gait High steppage: Trendelenburgh: Circumduction: Tip-toe Foot drop – neurologic disease Trendelenburgh: DDH, weak hip abductors, could not abduct Circumduction: Stiff hip, neurologic disaese Tip-toe Tight achilles tendon, CTEV, Cerebral Palsy, habitual, compensating length discrepency Lurching: Short length

Types of gait Wide-base: Scissoring Hemiplegic gait Ataxic To gain balance – neurologic disease Scissoring Tight hip adductors – Cerebral Palsy Hemiplegic gait Cerebral palsy - neurologic Ataxic Neurologic disease Foot inversion / eversion Foot deformity / avoiding pain

Types of gait Stiff-knee Hand-knee Knee disease / arthrogryposis Weak quadriceps femoris muscle

Causes of painful limping Trauma Major musculoskeletal Splinter into foot Infection Acute OM, Septic arthritis Malignant bone tumor Rheumatic disease Acute slipped capital femoral epiphysis Perthes disease (Avascula necrosis)

Causes of painless limping Benign bone tumors Congenital DDH, club foot, congenitally short femur, short tibia Post injury deformity / length discrepancy AVN – Perthe’s disease Slipped capital femoral epiphysis (chronic) Deformity and leg length discrepancy

History Sudden onset: Trauma Gradual onset: Disease

Pitfalls Misled by parents’ history Misled by patients’ complaint History of trauma Always a leg length inequality Misled by patients’ complaint Hip problems may present with knee pain Children below 5 years do not complain of pain

Many causes Different diseases occur more commonly at specific age groups

Age 1-4 years CDH – DDH History: at risk groups Physical findings: Asymmetrical folds Limited abduction Hamstring stretch sign Ortolani / Barlow Shortening Trendelenburgh

Age 3 – 6 years Transient synovitis Septic arthritis Limping, painful to move, ?WBC, ? Fever, ? ESR Resolves in days Disappears without treatment Septic arthritis Limping-refuses to walk Fever >38.5 WBC >12,000 ESR >40 mm If in doubt: Aspiration

Age 5 – 10 years Legg-Calve-Perthes disease Boy, antalgic gait Pain and muscle spasm with passive motion Limitation of rotation and abduction Positive Trendelenburgh

Legg-Calve-Perthes Age usually: 4-8 years, Boys= 4X girls Idiopathic avascular necrosis of femoral head Blood supply of femoral head: Neonates: metaphyseal,lateral epiphyseal, and scanty ligamentum teres vessels 4 years: no epiphyseal vessels 7 years: ligamentum teres vessels developed well 4 – 7 years: dependent on lateral epiphyseal vessels If trauma or synovitis, pressure occludes blood supply

Legg-Calve-Perthes Stages: Bone death: may still look normal on x-ray Revascularization and Repair: Increased density and fragmentationon x-ray Distortion and Remodelling Distortion, falttening (coxa plana), and enlargement (coxa magna), with partial uncoverage

Legg-Calve-Perthes Clinical picture: Limping (painful / painless) May present with knee/thigh pain Early: limitation of all movements Later: limitation of abduction and internal rotation

Apley’s System of Orthopedics and Fractures Legg-Calve-Perthes Apley’s System of Orthopedics and Fractures

Apley’s System of Orthopedics and Fractures Legg-Calve-Perthes Apley’s System of Orthopedics and Fractures

Legg-Calve-Perthes Different stages of Perthes in a patient Sclerosis Collapse Fragmentation Remodelling http://community.tsrhc.org/Perthes-disease-about-perthes-disease

Legg-Calve-Perthes Treatment: Rest Physiotherapy: abduction Containment by splint Surgery: Containment, improved cover Later: for aftermath

Age 10 – 15 years Slipped Capital Femoral Epiphysis (SCFE) Acute Vs. chronic Boys, overweight, ?hypogonadism Limited internal rotation Hip externally rotates when flexed X-ray: AP and Frog lateral Really is an antero-lateral slippage of the metaphysis www2.massgeneral.org/ortho/SCFE.htm

Apley’s System of Orthopedics and Fractures SCFE Around puberty ? Hormonal imbalance between gonadal and growth hormones Tall, or obese, gonads underdevelopment Presents with limping May present with thigh/knee pain Acute slip Vs. chronic slip Apley’s System of Orthopedics and Fractures

Apley’s System of Orthopedics and Fractures SCFE Externally rotated hip Loss of internal rotation External rotation on flexion Slippage of other hip in one third of patients Apley’s System of Orthopedics and Fractures

Apley’s System of Orthopedics and Fractures SCFE X-rays diagnosis: Apley’s System of Orthopedics and Fractures

SCFE http://reference.medscape.com/

SCFE Treatment Complications: Manipulation to try to reduce the slip may cause AVN Fixation in situ ? Fix the other hip Complications: Avascular Necrosis Coxa vara Slippage of opposite hip Secondary osteoarthritis http://bestpractice.bmj.com/

3 – 12 years Acute osteomyelitis: Constitutional symptoms WBC, CRP, ESR X-ray may initially be normal MRI

5 – 18 years Trauma – place related to age Household - early Playground - childhood School and Sports 0 older child - teenager RTA – teenager A prick or a splinter in sole of foot

Time algorithm years Infection Trauma SCFE Perthes DDH 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 years