1. Prof. Mamoun Kremli AlMaarefa College
The limping child
Prof. Mamoun Kremli
AlMaarefa College

2. Introduction Limping is a common presentation in children
Seen by orthopedic surgeons, pediatricians, primary care physicians
Need to take a proper
History
physical examination
Investigations
Some diseases related to specific age groups

3. History Duration, when first noticed Pain History of trauma
Associated systemic symptoms
Fever, night sweating, anorexia, weight loss

4. Limping Painful Painless History of trauma often reported in all cases
Antalgic gait – short stance phase of gait cycle
Child may not complain of pain
Painless
History of trauma often reported in all cases
Relevant
Irrelevant

5. Types of gait High steppage: Trendelenburgh: Circumduction: Tip-toe
Foot drop – neurologic disease
Trendelenburgh:
DDH, weak hip abductors, could not abduct
Circumduction:
Stiff hip, neurologic disaese
Tip-toe
Tight achilles tendon, CTEV, Cerebral Palsy, habitual, compensating length discrepency
Lurching:
Short length

6. Types of gait Wide-base: Scissoring Hemiplegic gait Ataxic
To gain balance – neurologic disease
Scissoring
Tight hip adductors – Cerebral Palsy
Hemiplegic gait
Cerebral palsy - neurologic
Ataxic
Neurologic disease
Foot inversion / eversion
Foot deformity / avoiding pain

7. Types of gait Stiff-knee Hand-knee Knee disease / arthrogryposis
Weak quadriceps femoris muscle

8. Causes of painful limping
Trauma
Major musculoskeletal
Splinter into foot
Infection
Acute OM, Septic arthritis
Malignant bone tumor
Rheumatic disease
Acute slipped capital femoral epiphysis
Perthes disease (Avascula necrosis)

9. Causes of painless limping
Benign bone tumors
Congenital
DDH, club foot, congenitally short femur, short tibia
Post injury deformity / length discrepancy
AVN – Perthe’s disease
Slipped capital femoral epiphysis (chronic)
Deformity and leg length discrepancy

10. History
Sudden onset:
Trauma
Gradual onset:
Disease

11. Pitfalls Misled by parents’ history Misled by patients’ complaint
History of trauma
Always a leg length inequality
Misled by patients’ complaint
Hip problems may present with knee pain
Children below 5 years do not complain of pain

12. Many causes
Different diseases occur more commonly at specific age groups

13. Age 1-4 years CDH – DDH History: at risk groups Physical findings:
Asymmetrical folds
Limited abduction
Hamstring stretch sign
Ortolani / Barlow
Shortening
Trendelenburgh

14. Age 3 – 6 years Transient synovitis Septic arthritis
Limping, painful to move, ?WBC, ? Fever, ? ESR
Resolves in days
Disappears without treatment
Septic arthritis
Limping-refuses to walk
Fever >38.5
WBC >12,000
ESR >40 mm
If in doubt: Aspiration

15. Age 5 – 10 years Legg-Calve-Perthes disease Boy, antalgic gait
Pain and muscle spasm with passive motion
Limitation of rotation and abduction
Positive Trendelenburgh

16. Legg-Calve-Perthes Age usually: 4-8 years, Boys= 4X girls
Idiopathic avascular necrosis of femoral head
Blood supply of femoral head:
Neonates: metaphyseal,lateral epiphyseal, and scanty ligamentum teres vessels
4 years: no epiphyseal vessels
7 years: ligamentum teres vessels developed well
4 – 7 years: dependent on lateral epiphyseal vessels
If trauma or synovitis, pressure occludes blood supply

17. Legg-Calve-Perthes Stages: Bone death: may still look normal on x-ray
Revascularization and Repair:
Increased density and fragmentationon x-ray
Distortion and Remodelling
Distortion, falttening (coxa plana), and enlargement (coxa magna), with partial uncoverage

18. Legg-Calve-Perthes Clinical picture: Limping (painful / painless)
May present with knee/thigh pain
Early: limitation of all movements
Later: limitation of abduction and internal rotation

19. Apley’s System of Orthopedics and Fractures
Legg-Calve-Perthes
Apley’s System of Orthopedics and Fractures

20. Apley’s System of Orthopedics and Fractures
Legg-Calve-Perthes
Apley’s System of Orthopedics and Fractures

21. Legg-Calve-Perthes Different stages of Perthes in a patient
Sclerosis Collapse Fragmentation Remodelling

22. Legg-Calve-Perthes Treatment: Rest Physiotherapy: abduction
Containment by splint
Surgery:
Containment, improved cover
Later: for aftermath

23. Age 10 – 15 years Slipped Capital Femoral Epiphysis (SCFE)
Acute Vs. chronic
Boys, overweight, ?hypogonadism
Limited internal rotation
Hip externally rotates when flexed
X-ray: AP and Frog lateral
Really is an antero-lateral slippage of the metaphysis
www2.massgeneral.org/ortho/SCFE.htm

24. Apley’s System of Orthopedics and Fractures
SCFE
Around puberty
? Hormonal imbalance between gonadal and growth hormones
Tall, or obese, gonads underdevelopment
Presents with limping
May present with thigh/knee pain
Acute slip Vs. chronic slip
Apley’s System of Orthopedics and Fractures

25. Apley’s System of Orthopedics and Fractures
SCFE
Externally rotated hip
Loss of internal rotation
External rotation on flexion
Slippage of other hip
in one third of patients
Apley’s System of Orthopedics and Fractures

26. Apley’s System of Orthopedics and Fractures
SCFE
X-rays diagnosis:
Apley’s System of Orthopedics and Fractures

27. SCFE

28. SCFE Treatment Complications:
Manipulation to try to reduce the slip may cause AVN
Fixation in situ
? Fix the other hip
Complications:
Avascular Necrosis
Coxa vara
Slippage of opposite hip
Secondary osteoarthritis

29. 3 – 12 years Acute osteomyelitis: Constitutional symptoms
WBC, CRP, ESR
X-ray may initially be normal
MRI

30. 5 – 18 years Trauma – place related to age Household - early
Playground - childhood
School and Sports 0 older child - teenager
RTA – teenager
A prick or a splinter in sole of foot

31. Time algorithm years Infection Trauma SCFE Perthes DDH 1 2 3 4 5 6 7 89 10 11 12 13 14 15
years