1. The Approach to the Limping Child George C. Phillips, MD, MBA, CAQSM, FAAP April 16, 2015

2. Objectives Recognize key elements of history and physical that help discriminate between differential diagnoses for a limping child. Review judicious use of radiographs and other imaging studies for the evaluation of a child with a limp. Discuss possible pitfalls in the evaluation and treatment of a child with a limp.

3. Disclosures I have no relevant financial relationships to disclose. I will not be discussing off-label uses of pharmaceuticals or other medical devices.

4. Case #1 An almost 2-year-old male is brought to clinic by his parents for refusing to bear weight on his right leg. He has been observed to limp slowly. The symptoms started a few hours ago. No trauma was observed.

5. Case #5 A 13-year old male presents for evaluation of right knee pain and limping. He plays basketball and soccer. The pain has occurred intermittently over the last several months. He denies any direct trauma to his knee. The pain is especially noted after practices and games. The pain often lasts into the next day.

6. The Limping Child Spine, hip, knee, foot ??? Something in the abdomen? Fever, nighttime pain, weight loss, unusual bruising or bleeding, or other systemic symptoms? Any recent infection or chronic illness?

7. The Limping Child Observe the child at rest –Position of protection? Assess passive range of motion –Work toward the affected leg to gain assurance Test weight-bearing, gait, running –Make it fun, involve others –Look for consistency

8. Differential Diagnosis Unobserved trauma Toxic synovitis Septic arthritis Osteomyelitis Malignancy Idiopathic arthritis Fracture Joint derangement Behavioral

9. Workup for a Limping Child Xrays – Can you localize the limp? CBC with differential – How does the child look overall? CRP, ESR – Can help rule out “badness”. Joint ultrasound – Is there effusion? Bone scan – Are things just not adding up? CT/MRI – What is going on??

10. Indicators for X-rays Localized tenderness over bone Inability to bear weight Possible growth plate injury –Opposite side radiographs for comparison Limited passive range of motion Joint effusion

11. The “Basics…” History/PhysicalEvaluation Red flags?Localizable? Infection/illness?Overall appearance (sick/well)? Position of protection?“Badness”? Passive range of motion?Effusion? Active range of motion?Lost?

12. Case #1 An almost 2-year-old male is brought to clinic by his parents for refusing to bear weight on his right leg. He has been observed to limp slowly. The symptoms started a few hours ago. No trauma was observed. The child has otherwise been well, with no fevers or other signs of illness.

13. Case #1 Physical exam shows normal vital signs and an exam that is normal except for the right lower extremity. While there is no localizable tenderness to palpation, the child guards a little against movement of the leg, resists bearing weight, and ambulates slowly with an obvious limp.

14. The “Basics…” History/PhysicalEvaluation Red flags?Localizable? Infection/illness?Overall appearance (sick/well)? Position of protection?“Badness”? Passive range of motion?Effusion? Active range of motion?Lost?

15. The “Basics…” History/PhysicalEvaluation Red flags? - NoLocalizable? - Yes, regionally Infection/illness? - NoOverall appearance (sick/well)? - Well Position of protection? - No“Badness”? - No Passive range of motion? - ABNLEffusion? - No Active range of motion? - ABNLLost? - Don’t think so…

19. Toddler’s Fracture Classically described by Dunbar in 1964. Subtle, nondisplaced oblique fracture of the distal tibia in a child between 9 months and 3 years of age. Early ambulatory stage fits with supposed mechanism of a twisting fall, often unobserved.

20. Toddler’s Fracture X-ray findings often raise suspicion of non- accidental trauma. How to differentiate from abuse: –Location: distal tibia versus mid-tibia or femur –Development: what stage of ambulation –Mechanism: concordance with extent of injury –Timeframe: suspicion for delayed presentation

21. Toddler’s Fracture Treatment is immobilization, with choices of posterior splint or long-leg cast. Healing will usually occur quickly, on the order of 3-4 weeks. Repeat radiographs are often obtained to document healing. Orthopedic consultation may be helpful.

22. Case #2 A 4-year-old female presents to your office with a limp. No injury or trauma was observed yesterday evening. Upon awakening this morning, the child did not want to bear weight on the affected leg, and she visibly limped when attempting to walk.

23. Case #2 Other than the limp, the child has had no sign of illness in the past few days. The child did have an upper respiratory illness with low-grade fever about 2-3 weeks ago. The review of systems is otherwise unremarkable.

24. Case #2 The child is sitting comfortably, reading a book, and no obvious problems are seen. Passive range of motion is full, except for a little wincing with full internal rotation of the hip on the affected side. The child cries when initially urged to walk, but with coaxing can bear weight with a consistently antalgic gait.

25. The “Basics…” History/PhysicalEvaluation Red flags?Localizable? Infection/illness?Overall appearance (sick/well)? Position of protection?“Badness”? Passive range of motion?Effusion? Active range of motion?Lost?

26. The “Basics…” History/PhysicalEvaluation Red flags? - NoLocalizable? - Yes, well-localized Infection/illness? – Yes, mildOverall appearance (sick/well)? - Well Position of protection? - No“Badness”? - No Passive range of motion? – Mildly abnlEffusion? - No, but hips are tough Active range of motion? - AbnlLost? - Pretty sure I’m not…

27. Toxic Synovitis Also known as transient synovitis Hip = #1 joint; Boys > Girls Often preceeded by a URI May have effusion on U/S, but: –1) Often not enough to tap –2) Child isn’t sick enough to be invasive Self-limited, usually 5-10 days NSAIDs, let child restrict activities

28. Case #3 13-month female is brought in by her parents for concerns that her feet turn in and cause her to trip and fall. They are concerned because her grandparents said she probably needs special shoes or braces to fix the problem.

29. Normal Childhood Development Flat feet Pigeon-toed Bow-legged Knock-kneed Babies don’t have arches Normal during first 1-2 years of life, femoral anteversion Typically normal until age 3 Common ages 3-6

30. Possible Concerns Progression in falling, especially at an age where gait is normally more consistent Toe-walking beyond age 2 Persistent bowlegged appearance –Rickets Vitamin D recommendations for breastfed infants –Blount’s disease Rapid growth of proximal tibia causing malalignment

31. Case #4 A 12-year old male presents with a complaint of right thigh pain. He plays basketball in a recreational league. His mother is concerned because the pain has lasted for nearly 3 weeks and now there is a noticeable limp. There is no history of trauma. The patient is currently comfortable, although you notice he is laying on the table with his right hip externally rotated and slightly flexed.

32. Case #4 The patient localizes maximal pain to his proximal right thigh. There have been no fevers, night pains, or other systemic symptoms. The past medical history is only remarkable for obesity, as this patient has been > 97%ile for weight for some time. The gait is obviously antalgic. No significant leg length discrepancy is noted. Decreased internal rotation of the right hip is detected.

33. The “Basics…” History/PhysicalEvaluation Red flags?Localizable? Infection/illness?Overall appearance (sick/well)? Position of protection?“Badness”? Passive range of motion?Effusion? Active range of motion?Lost?

34. The “Basics…” History/PhysicalEvaluation Red flags? - NoLocalizable? - Yes, well-localized Infection/illness? – NoOverall appearance (sick/well)? Well Position of protection? - YES“Badness”? - No Passive range of motion? – ABNLEffusion? - No Active range of motion? - ABNLLost? - No

37. Slipped Capital Femoral Epiphysis (SCFE) Microtrauma to the proximal femoral growth plate During/near peak adolescent growth spurt Boys > girls 3:2 Most cases very obese and/or very tall Can be unilateral or bilateral 80-90% symptomatic > 2 weeks

38. SCFE SCFE is an urgent (near-emergent) problem Keep patient lying down and contact orthopedist for management Primary risk is avascular necrosis of the femoral head

40. Legg-Calve-Perthes Disease (LCP) Avascular necrosis of the capital femoral epiphysis Ages 2-10 years, boys 5:1 Limp,  pain, limited ROM (internal < external), muscle guarding/spasm X-ray shows irregularities of the epiphysis and femoral head Remodels over 18-24 months with variable functional outcome

41. Case #5 A 13-year old male presents for evaluation of right knee pain. He plays basketball and soccer. The pain has occurred intermittently over the last several months. He denies any direct trauma to his knee. The pain is especially noted after practices and games. The pain often lasts into the next day. The patient indicates a “bump” below the right knee as the area that hurts the most.

42. Osgood-Schlatter Disease Tibial tubercle apophysitis, first described by Dr. Robert Osgood in 1903 Traction force of patellar tendon on tibial tubercle with micro-avulsion injury Pain, and often “bump”, over tibial tubercle

43. Osgood-Schlatter Disease Average age 10-14 years; typically resolves by age 15 in girls, 16 in boys – closure of apophysis Relative rest, ice, quadriceps / hamstring stretching X-ray not helpful – normal tubercle often “irregular”

44. Other Apophyseal Injuries Calcaneal apophysitis –Sever’s disease –Look to the medial side of the calcaneus –Often ages 9-11, usually for about 1 year –Beware of extended use of heel cups Inferior patellar apophysitis –Sinding-Larssen-Johanssen Disease –Patellar strap may be beneficial

45. Case #6 16 yo male football player presents with right knee pain and limp. Symptoms were initially noted after a tackle ~ 4 weeks ago. Patient reports having a helmet hit his knee. Initially evaluation by trainer suggested anterior knee swelling, pain, but no obvious ligamentous instability. Removed from participation, rest, anti-inflammatories.

46. Case #6 Held out from practice and treated symptomatically. One week later, still complaining of pain but thinks limp is better. Since upcoming opponent is easy, decision made to hold out another week. During practice next week, able to advance drills (non-contact). Still not full speed but performing well.

47. Case #6 Prior to game (now 2 weeks out), pain has changed to included front of knee and proximal tibia. Diagnosed with patellar tendonitis due to advancing training too fast. Held again from competition, and focused on rehab sessions during next week. Returned to next game (now 3 weeks out), and performed well in first half. With game in hand, sat out second half with knee pain.

48. Case #6 No improvement over the next few days with rest and continued therapy. Medical appointment scheduled prior to game against arch-rival. Limps into exam room. Mild effusion present. Passive ROM full but uncomfortable. Pain and decreased strength on ROM against examiner.

49. The “Basics…” History/PhysicalEvaluation Red flags?Localizable? Infection/illness?Overall appearance (sick/well)? Position of protection?“Badness”? Passive range of motion?Effusion? Active range of motion?Lost?

50. The Rest of the Story… Pain actually began during the summer, near start of workouts – not reported. 15# weight loss since workouts began. Magnitude not recognized. Pain had been awakening patient from sleep at night during last 4 weeks – neither queried nor reported. Patient also with intermittent night sweats – neither queried nor reported.

51. The “Basics…” History/PhysicalEvaluation Red flags? - YESLocalizable? - YES Infection/illness? - NoOverall appearance (sick/well)? - Well Position of protection? – No“Badness”? - YES, I’m worried… Passive range of motion? – ABNLEffusion? - YES Active range of motion? - ABNLLost? - Maybe…

53. The Limping Child Spine, hip, knee, foot ??? Something in the abdomen? Fever, nighttime pain, weight loss, unusual bruising or bleeding, or other systemic symptoms? Any recent infection or chronic illness?

54. The Limping Child Observe the child at rest –Position of protection? Assess passive range of motion –Work toward the affected leg to gain assurance Test weight-bearing, gait, running –Make it fun, involve others –Look for consistency

55. Workup for a Limping Child Xrays – Can you localize the limp? CBC with differential – How does the child look overall? CRP, ESR – Can help rule out “badness”. Joint ultrasound – Is there effusion? Bone scan – Are things just not adding up? CT/MRI – What is going on??

56. Indicators for X-rays Localized tenderness over bone Inability to bear weight Possible growth plate injury –Opposite side radiographs for comparison Limited passive range of motion Joint effusion

57. The “Basics…” History/PhysicalEvaluation Red flags?Localizable? Infection/illness?Overall appearance (sick/well)? Position of protection?“Badness”? Passive range of motion?Effusion? Active range of motion?Lost?