1. Presentation with a Limp

2. Limping is a common and often challenging problem in children and adolescents.
A limp is defined as asymmetric deviation from a normal gait pattern.
Most common cause is trauma, awareness of other potential causes is important
Main concern is not to miss serious pathology
Age relevant differential diagnosis
History, physical examination, appropriate investigations and follow-up

3. Limping child- History and Exam
Duration of and progression of limp
Recent trauma and mechanism, be aware of limited paediatric history, unintentional trauma
Associated pain and characteristics
Accompanying weakness
Time of day when limp is worse
Has limp interfered with normal activities
Presence of systemic symptoms like fever and weight loss
Medical history, family history
Can the child walk/weight bear- ideally observe child barefoot with minimal clothing
Palpate for tenderness and warmth
All joints should be taken through normal ROM actively and passively
History of limp that appears worse in morning suggests a rheumatologic process
Night pain, especially pain that wakes child from sleep may be an indicator of a malignancy
Growing pains- leg pain is bilateral, pain occurs only at night, pt has no pain, limp, symptoms during day
Recent URTI could be instigating event of septic process, pyrexia suggests infection or inflammatory process

4. A 4yr old child presents with a 24 hr history of right sided limp Normally fit and well, recent coryzal episode No history of trauma All observations within normal parameters OE can pinpoint pain to rt hip

5. Transient synovitis/ Irritable hip
Most common cause of acute hip pain or limp in children
Incidence of 1-4:1000
Age group 3-8 yrs
Male: female 2:1
Formation of effusion within hip joint
In approx 30% cases pain may originate in knee/thigh
Aetiology unknown- viral infection, minor trauma, allergy have been implicated
Sudden onset of pain in hip, or limp, as a result of intra-articular pressure caused by effusion
Reduced ROM
Hip held flexed and externally rotated to relieve pain
Signs of sepsis absent

6. Irritable hip
X ray- may be NAD, or slight widening of joint space from effusion
USS- small effusion may be detected
Simple analgesia and bed rest
TS rarely lasts longer than few days or weeks
Effusion in affected hip

7. Septic arthritis Usually affects children under 10 years
Sudden onset of significant groin/hip pain, may radiate down medial aspect of thigh
Child looks toxic and has a fever
All movements of joint exquisitely painful, leg often held in flexed abduction
Child will resist all attempts to move hip

8. Xray- may reveal increased joint space ( secondary to infection)
Inflammatory markers raised
May have positive blood cultures for organism (20%)
Joint fluid aspiration (80%)
Admit
Surgical irrigation of joint
IV antibiotics

9. Leukaemia
Leukaemia is the most common malignancy of childhood ( 400 new cases per yr in UK)
Peak incidence at 2-5yrs
Incidence higher in boys, and white population
Massive proliferation of malignant blast cells in medullary canal- mass effect producing bone and joint pain- often manifested as limp, refusal to weight bear
Mild pyrexia, lymphadenopathy, raised ESR, anaemia, thrombocytopaenia etc!
Presentation may mimic other orthopaedic disorders
Almost 40% in study had musculoskeletal problems 12.3% had limp

10. Metaphyseal band sign can indicate
Lead Poisoning
Normal variant
Infection
Malignancy
Healing stages of rickets, leukaemia and scurvy

11. 6 year old boy presents with a 4 day history of limp
No significant trauma
Normally fit and well
Differentials at this age group before you start examination?

12. Perthe’s disease
Avascular necrosis of the femoral head, collapse, fragmentation and progressive deformity of hip joint
Unknown aetiology
Affects ages years (peak incidence between 6 and 9 years
Male:female, 4:1
History of persistent hip pain( limp can be painless) referred knee pain common
O/E loss of internal rotation, loss of abduction, overall decreased ROM
May be ‘wasting’ of affected leg
Necrosis,fragmentation,healing, remodelling

13. Perthe’s Good prognosis- age<6yrs at diagnosis
< 50% head involved
no stiffness or shortening O/E
Poor prognosis-
age > 7 yrs at diagnosis
> 50% head involvement
significant stiffness and shortening

15. Containment
Corrective Osteotomy

16. Kohler’s disease Avascular necrosis of navicular Typically 2-10 yrs
Boys: girls 4:1
May have history of minimal trauma
Disease is usually unilateral
POP has demonstrated reduction in duration of symptoms
Navicular is last bone to ossify ( approx 3 yrs) ? Makes it more vulnerable to trauma

17. Slipped upper femoral epiphysis
Slow, chronic
Late childhood, adolescence
Male:female 2:1
Child may be obese
Stress fracture through femoral epiphysis, resulting in progressive slip of femoral neck over femoral head
Limping or non weight bearing, referred pain to thigh or knee
Bilateral disease in 30%
Pain, exacerbated by activity
Trendelenburg gait
Preserve blood supply
May require surgery

18. 2 views – seen clearly on lateral
Clinical signs

19. SUFE

20. Osteomyleitis Can affect any age, peak incidence under 10 years
50% in pre school aged children( rich vascular supply in bones)
Male:female 2:1
Caused by spread of infection ( septic arthritis), puncture wound, compound fracture
Organisms age-dependant (>4 yrs 80% staph)
Severe constant pain, aggravated by movement
Fever, unwell child
May have localized redness, swelling, and warmth
Raised inflammatory markers
Initial X-ray NAD
Rapid spread of infection
Severe case may have abscesses to skin surface
Bone aspiration to identify pathogen
IV antibiotics ( normally 4 weeks)

22. References
Fischer,S. Beattie,T.(1999) The limping child:epidemiology, assessment, and outcome British Journal of Bone & Joint Surgery 81,6 pp
Goldsworthy,L. (revised 2008) Paediatric Emergency Department Handbook, Bristol Children’s Hospital
Hoary et al (2007) Kohler Disease: Diagnoses and Assessment by Bone Scintigraphy Clinical Nuclear Medicine 32, 3 pp
Leet,A. Skaggs,D. (2000) Evaluation of the Acutely Limping Child American Family Physician 61,4.
Paediatrics A Clinical Guide for Nurse Practitioners (2003) d Katie Barnes Elsevier Science Limited, London
Roew et al (2006) Outcome of Cheilectomy in Legg-Calve-Perthes Disease Minimum 25-Year Follow-Up of Five Patients Journal of Paediatric Orthopaedics 26 pp
Sinigaglia et al (2008) Musculoskeletal Manifestations in Pediatric Acute Leukemia Journal of Paediatric Orthopaedics 28, 1 pp 20-28