1. Approach to the Limping child
DR FATMA AL TAMIMI.
PEDIATRIC RHEUMATOLOGY CONSULTANT.

2. Objectives Definition. Causes. Differential diagnosis.
Common disorder of limping.

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

4. 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%

5. THE CHILD WITH A LIMP 1- History 2- Physical examination.
3- Differential diagnosis.

6. HISTORY Duration Trauma Fever Location of the pain
Pain characteristics
Constant severe pain
Intermittent mild to moderate pain
Bilateral pain
Modifying factors

7. Other symptoms Morning stiffness Incontinence, weakness or sciatica
Recent viral or bacterial illness
Recent medications
Endocrine and other systemic diseases

8. PHYSICAL EXAMNATION General appearance Ill or toxic appearing Fever
Obvious discomfort/pain at rest

9. PHYSICAL EXAMNATION 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
Observe several gait cycles.
Includes jumping/hopping.

10. Gait evaluation

11. Gait examination Expose the legs
Bare feet or wearing only a pair of socks
Listening to the gait
Cadence
Foot slap
Scraping

12. 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

13. PHYSICAL EXAMNATION Musculoskeletal Muscle strength Muscular atrophy
Bony tenderness
Bony deformity
Active and passive ROM
Joint swelling/tenderness
Muscle tenderness
Tenderness on the tendons, insertions sites

14. PHYSICAL EXAMNATION Skin Lymphatic Neurologic Bruises
Rashes and other lesions
Swelling
Redness
Tenderness
Lymphatic
Lymphadenopathy
Neurologic
Muscle strength
Muscle tone
DTR’s

15. PHYSICAL EXAMNATION Gastroentestinal Genitourinary
Abdominal tenderness
Abdominal swelling
Genitourinary
Testicular or scrotal pain/swelling
Inguinal swelling

16. DIFFERENTIAL DIAGNOSES
ACCORDING TO AGE.

17. DIFFERENTIAL DIAGNOSES Acute or chronic?!
Contusion
Foreign body
Fracture
Osteomyelitis
Reactive arthritis
Septic arthritis
Transient synovitis
Lyme arthritis
Poor shoe fit
Rheumatic disease
JRA
Acute rheumatic fever
SLE
Inflammatory bowel disease

18. Septic Arthritis Hot, swelled, acute tender joint.
More difficult to identify at hip.
Raised ESR,CRP,WCC.
Need urgent aspiration and IV AB.
Usually S.areus.

19. TODDLERS FRACTUR Typically age<3 years. Pain, unwilling to wt bear.
May be minimal trauma, often twisting injury.
Tender swelling lower leg.
Spiral, distal third of tibia.
Long leg cat for 4 weeks.

21. PERTHES DISAES
*Avascular necrosis of femoral head. *Boys:Girls>>5:1. *Age4-8 years. *limp+/- pain. *reduced abduction in internal rotation.

23. TRANSIENT SYNOVITIS
Most common cause of hip pain in children. Usually after viral UPTI. Limp, reduce ROM, pain. Diagnosis by exclusion. Normal WCC,ESR,CRP and Xray. Self limiting usually after7-10 day. Analgesia and rest.

24. 2-year-old girl with transient synovitis of left hip
2-year-old girl with transient synovitis of left hip. shows lower signal intensity of left femoral head than of right femoral head (arrow). Synovial thickening appears as thicker enhancing rim of synovium (arrowheads).

25. SLIPPED UPPER FEMORAL EPIPHYSIS
During adolescence growth spout.
Posterior slipping or femoral head epiphysis.
Increase incidence of obese.
25%bilateraly.
Limp. Hip/thigh/knee pain.
Risk of osteomylitis and AVN.
Surgical fixed.

26. X-Ray showing a left sided SUFE

27. Osteomylitis
Infection of the metaphysis of long bones(distal femur, proximal tibia).
Due to haematogenous spread of pathogen.
Swollen over infected wound.
S.aureus, streptococcus and H.influnzae.
It can end with SA.

28. Thank you