1. Evaluation of the Child with a Limp DD Aronsson University of Vermont

2. Hx – 2-year-old boy limps because of pain in the right thigh (antalgic) PE – pain and swelling just above the knee

3. Differential Diagnosis Bone infection (osteomyelitis) Joint infection (septic arthritis) Fracture Toxic synovitis

4. Bone & Joint Infections Hematogenous origin – Strep throat Implantation – Stepping on a nail

5. Osteomyelitis Metaphyseal origin Vessels don’t cross the growth plate

6. Septic Arthritis Infection can decompress into a joint Septic dislocation

7. Clinical Findings Systemically ill Irritable Refusal to bear weight Pseudoparalysis Pain & swelling @ the site

8. Laboratory Studies Elevated WBC,ESR, & CRP 50% Positive blood culture Infant – May be normal

9. Imaging Radiographs – Soft tissue swelling Bone scan – Increased uptake

10. Treatment Aspiration is the “key” to the diagnosis Don’t wait for imaging Subperiosteal aspiration

11. Treatment IV antibiotics – S aureus, gram-negative enteric, & Group B Streptococcus Surgical decompression – Hip & shoulder

12. Hx – 18 month-old girl limps on the left leg (no pain) PE – short left lower extremity is causing the limp

13. Differential Diagnosis Developmental dysplasia of the hip Limb-length discrepancy

14. DDH Instability Subluxation Dislocatable Reducible dislocation Irreducible dislocation

15. Etiology Unknown Multifactorial Geneticwhites Physiologicgirls Mechanicalbreech Environmentalswaddling

16. Barlow Provocative Test Dislocates hip (exit) Clunk

17. Ortolani Maneuver Reduces dislocated hip (entry) Abduction Clunk

18. PE > 3 Months 57º 43º Limited abduction is key

19. PE > 3 Months Asymmetric thigh folds – Limb-length discrepancy

20. Radiographs

21. Ultrasound Alpha > 60º – Slope of osseus acetabulum

22. Pavlik Harness Success Dysplasia 95% Dislocated 80%

23. Hx – 6-year-old boy limps on the right leg PE – limp with painful range-of-motion of the hip

24. Differential Diagnosis Infection Toxic synovitis Slipped capital femoral epiphysis (endocrine) Legg-Calv  -Perthes disease

25. Legg-Calv  -Perthes Loss of blood supply of the epiphysis

26. Legg-Calv  -Perthes History – Pain in the groin or knee – Limp – Aggravated by exercise

27. Legg-Calv  -Perthes Physical examination – Decreased internal rotation – Decreased abduction – Irritable hip

28. Necrotic stageFragmentation stage

29. Reossification stageRemodeling stage

30. Treatment Containment – Physical therapy ROM exercises – Orthosis Abduction & internal rotation – Osteotomy

31. Toxic synovitis History – sudden onset – Pain in groin or thigh – Painful limp – URI 2 weeks ago

32. Physical Examination Limp Irritable hip with guarding Mimic septic hip

33. Treatment Activity modification Expect improvement Question diagnosis if not responding

34. Hx – 14-year-old obese boy has pain in the right knee and limps PE – no swelling and full ROM of the knee but decreased internal rotation of the hip

35. Differential Diagnosis Infection Osgood-Schlatter disease Anterior knee pain Slipped capital femoral epiphysis

36. Slipped Capital Femoral Epiphysis (SCFE) Most common hip disorder in adolescents Age – Boys 14 y/o – Girls 12 y/o

37. Etiology Endocrine – Hypothyroid – Growth hormone treatment Mechanical – 63% > 95th percentile weight

38. Hip Flexion Causes Abduction & External Rotation FABER

39. AP Pelvis Radiograph Wide & irregular physis Epiphysis at or below Klein’s line Klein’s line

40. Frog Pelvis Radiograph Posterior slip Wide, irregular physis

41. Preop AP pelvisPreop frog pelvis

42. Postop AP pelvisPostop frog pelvis

43. Limp Think hips