1. Approach to Limping Child

2. Points to be discussed…
Causes of limping in children:
Age distribution.
Differential diagnosis of a limp in children:
History
P/E
Investigations
Red flag presentations.
Hip :
Septic arthritis
Transient synovitis.

3. Approach to a limping child
Any deviation from the normal gait cycle is considered to be : a limp.
Different types of limping (gait) :
Antalgic.
Trendlenberg.
Tip toe.
Circumduction.
Stiff knee.

4. Approach to a limping child
Three major factors cause a child to limp:
Pain.
Weakness.
Structural or mechanical abnormalities of the spine, pelvis, and lower extremities.

5. Approach to a limping child
Limping is a common pediatric problem.
Presentations are variable :
Painful Vs Painless.
Acute Vs Chronic.
Isolated Vs Associated.
Age distribution …

6. Differential diagnosis
1-3 years
Painful
Painless
Trauma
Infection : septic arthritis/ osteomyelitis
Inflammatory
Neoplastic
Developmental hip dysplasia.
Neuromuscular problems: cerebral palsy
Leg length discrepancy : congenital lower limb deficiencies.

7. Differential diagnosis
4-10 years
Painful
Painless
Trauma
Infection : septic arthritis/ osteomyelitis/ synovitis
Inflammatory
Neoplastic
Hemtological
AVN ( Perthes disease )
Developmental hip dysplasia.
Neuromuscular problems: cerebral palsy
Leg length discrepancy : congenital lower limb deficiencies.

8. Differential diagnosis
11-18 years
Painful
Painless
Trauma
Infection : septic arthritis/ osteomyelitis/ synovitis
Inflammatory
Neoplastic
Hemtological
AVN ( Perthes disease )
Slipped capital femoral epiphysis (SCFE)
Developmental hip dysplasia.
Neuromuscular problems: cerebral palsy
Leg length discrepancy : congenital lower limb deficiencies.

9. Clinical evaluation HISTORY
Age
Onset:
Acute : trauma related
Gradual
Pain :
Painful limp (refusal to walk).
Painless limp
Associated sypmtoms:
Fever.
Stiffness.
Backach.
Abdominal pain.
Skin rash.

10. Clinical evaluation HISTORY
Night pain.
Developmental history.
Family history.
Nutritional history.
Raw milk ingestion.

11. Clinical evaluation HISTORY
Medical illnesses:
Hematological
Neurological.
Rheumatological.
Medication history:
antibiotics.
Steroids.
Growth hormone.

12. Clinical evaluation PHYSICAL EXAMINATIONS
General look:
Well looking
Ill looking
Dysmorphic features.
Body position.
Temp

13. Clinical evaluation PHYSICAL EXAMINATIONS
Type of gait.
Local examination : Look…… Feel …….. Move
Erythema, redness, swelling, skin abrasions
Local temp, localized tenderness, masses
Move the joints: active and passive.

14. Clinical evaluation INVESTIGATIONS
Laboratory:
CBC: WBC
ESR
CRP
Blood cultures.
Procalcitonin. RF
ANA
ASO titers
Brucella titers.

15. Clinical evaluation INVESTIGATIONS
Radiological :
X-rays.
US.
MRI
Invasive :
Joint aspiration.

16. RED FLAGS Limping (refusing to walk), ill looking, febrile child
Hip septic arthritis.
Significant night pain
Neoplasia.
Limping adolescent with/without trauma
SCFE.

17. Hip transient (toxic) synovitis

18. Hip transient (toxic) synovitis
It is the commonest cause of limping in toddlers and young children (3-10 years) .
Boys are affected more (2:1).
Idiopathic.
Benign condition with no consequences.
It is a diagnosis of EXCLUSION.

19. Hip transient (toxic) synovitis
The child presents with hip pain and a limp (mostly able to walk).
No associated symptoms.
No fever.
? H/O recent URTI.

20. Hip transient (toxic) synovitis
Looking well.
Restricted hip ROM (mainly internal rotation).
Normal or slightly elevated WBC.
Normal or slightly elevated ESR.
Normal CRP.
Low procalcitonin.
Negative blood culture.

21. Hip transient (toxic) synovitis
Normal X-ray.
US: positive for hip effusion.
MRI: may differentiate from septic arthritis.

22. Hip transient (toxic) synovitis
The most important step in working out this problem is to role hip septic arthritis .
Sometimes it is difficult to differentiate …… invasive hip aspiration.
Aspirate in transient synvitis: clear synovial fluid, low WBC count, negative culture, normal glucose level.

23. Hip transient (toxic) synovitis
If the diagnosis is turned to be transient synovitis, treatment will be :
Careful observation.
Analgesics.
Gradual return to normal activities.

24. Hip transient (toxic) synovitis
Prognosis :
Usually benign with no consequences.
Weak evidence correlating transient synovitis with future Perthes disease (AVN)

25. HIP SEPTIC ARTHRITIS

26. HIP SEPTIC ARTHRITIS
Hip septic arthritis in kids is a catastrophic event if lift untreated.
It is caused by inclusion of the invding organism into the hip joint and its synovial tissues.

27. HIP SEPTIC ARTHRITIS
The offending bacterial organism is usually spread to the hip joint by the mean of hematological spread.
Incidence is correlated to age, and as the child grows the probability is reduced.
Boys are affected twice as girls.

28. HIP SEPTIC ARTHRITIS
The proteolytic enzymes secreted by the inflammatory cells and the offending organisms destroy the immature cartilage.
The increased pressure of the intra-articular fluids will :
Destruct the joint ligaments.
Obstruct the tenacious blood supply to the femoral head causing avascular necrosis, and destruction of the femoral head.

29. Early recognition and Prompt treatment
HIP SEPTIC ARTHRITIS
The key in successfully treating hip septic arthritis in kids:
Early recognition and Prompt treatment

30. HIP SEPTIC ARTHRITIS
The hip joint is one of the deep joints in the body, making early recognition of septic arthritis is a challenging task.
In neonates and infants , the challenge is overwhelming, and it requires very high index of suspicion to point a finger to this tragedy.
Unfortunately, this age group usually have the worst outcomes.

31. HIP SEPTIC ARTHRITIS CLINICAL EVALUATION
Hip pain, limping, and fever are the hallmark of clinical presentation.
The child is ill looking, irritable, splinting the involved extremity in FABER position.
Inability to walk.
High grade temp (> 38.5)

32. HIP SEPTIC ARTHRITIS CLINICAL EVALUATION
Elevated WBC.
High ESR.
High CRP.
High Procalcitonin.
Level of 0.4 ng/ml, is very sensitive and specific for infection.
Positive blood culture.
Karthikeyan et al. Journal of Orthopaedic Surgery and Research 2013Level of 0.4 ng/ml, is very sensitive and specific for infection.
, 8:19

33. HIP SEPTIC ARTHRITIS CLINICAL EVALUATION
The prediction probability of :
History of fever
inability to walk
ESR > 40 mm
WBC > 12,000
0 variable >> 0.2%
1 variable >> 3%
2 variables >> 40%
3 variables >> 93.1%
4 variables >> 99.6 %
Kokher et al. JBJS. 1999, 81(12):

34. HIP SEPTIC ARTHRITIS CLINICAL EVALUATION
Pelvis X-ray: ??? NAD
To rule out bony lesions
2mm lateralization, is indicative of joint effusion >>> septic arthritis .
Hip US: positive for joint effusion
S.T. Jung et al. JPO. 2003, 23(3):

35. Diagnosis was reached ….
HIP SEPTIC ARTHRITIS
Diagnosis was reached ….
What is next ??

36. Management Goals of Treatment Control and eradicate the infection.
Prevent complications:
Cartilage damage.
Damage to growth plate.
Joint dislocation.
Avascular necrosis

37. How to achieve the treatment goals ?
Management
How to achieve the treatment goals ?

38. Urgent Management Joint decompression. Antibiotic therapy.
Joint immobilization.

39. Joint aspiration Management Technique:
Either infero-medial , lateral, or supero-lateral entry sites.
C-arm guided.
Arthrography confirmed.

40. Arthrotomy With Joint Drainage
Management
Arthrotomy With Joint Drainage
After positive aspiration, joint arthrotomy and drainage is elemental in the management of septic hip.
Utilizing anterior approach, the joint capsule is incised, and the joint is thoroughly irrigated.

41. Arthrotomy With Joint Drainage
Management
Arthrotomy With Joint Drainage
Further fluids should be sent with tissues for culture and histopathology.
Through irrigation should be done to evacuate the chondrolytic enzymes, followed by drain insertion.
Joint stability should be assessed, and if in doubt consider skin traction, abduction bracing, or even Spica cast.

42. Management Arthrotomy With Joint Drainage Pediatric J.O.I.N.T.S
Hip Spetic Arthritis : Pediatric J.O.I.N.T.S Thamer Alhussainan, M.D.
10/26/15

43. Management Arthrotomy With Joint Drainage Pediatric J.O.I.N.T.S
Hip Spetic Arthritis : Pediatric J.O.I.N.T.S Thamer Alhussainan, M.D.
10/26/15

45. Management Antibiotic therapy …
Start with broad spectrum covering the common pathogen, then convert to the C/S guided. (staph aureus, strept pyogen, Gp A strept, H-influenzae, kingella kingae, CAMRSA)
Start with IV rout, and monitor the clinical and laboratory response.
Antibiotic therapy will be stopped when CRP is normalized and the clinical recovery is almost complete.

46. Management Antibiotic treatment is dependent on :
Severity of infection.
Virulance of the organism.
Host response .

47. Management Follow up needs to be continued till :
Avascular necrosis and proximal femur growth disturbance is ruled out .