The Limping Child

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The Limping Child

• AAPA

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Definition

• Limp Asymmetry
• Joint - Range of motion
• Bone - Deformity
• Pain
• Control

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The Limping Child

• Diagnosis
• Mechanism

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The Limping Child

• Pitfalls
• Being misled by the parents analysis
• Always a leg length discrepancy
• Being misled by the patients complaint
• Hip problems can cause knee pain
• Complaints of pain

COMPLAINS
LIMPS
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The Limping Child

• Causes of limp
• Joint - Range of motion
• Bone - Deformity
• Pain
• Hip
• Control

-Physical exam -X-ray -Antalgic gait
-Abductor lurch -Upper limb
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The Limping Child
Too much to cover

• Hip

Best Bets
Age
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The Limping Child

• Age 1 3 years
• Age 3 6 years
• Age 6 10 years
• Age 10 14 years

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The Limping ChildAge 1 3
1
Best Bet

• DDH
• Developmental Dysplasia of the Hip
• CDH
• Congenital Dislocation of the Hip

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The Limping Child Age 1 3DDH

• Physical findings
• Girl
• Asymmetrical skin folds
• Limited abduction
• Short leg
• Pistoning
• Ortolanis sign
• Barlows sign

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The Limping Child Age 1 3DDH

• X-ray findings
• Delayed appearance of ossific nucleus
• Small ossific nucleus
• Dysplastic acetabulum
• Proximal displacement of femur

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The Limping Child Age 1 3DDH

• Pavlik Harness
• Check at 3 weeks to confirm reduction
• Adjust position every 6 12 weeks
• Continue until the hips are clincally and
  radiologically normal

• Treatment
• 0 ½ Pavlik harness
• ½ 1½ Closed reduction, cast
• 1 ½ - 5 or 8 Open reduction, pelvic osteotomy
• Older Leave dislocated

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The Limping ChildAge 3 6
2
s
Best Bet

• Transient synovitis
• Septic arthritis

• Flu
• Tonsillitis

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The Limping ChildAge 3 6

• Transient synovitis
• Child refuses to walk
• Movement of hip is painful
• May have fever
• Moderately elevated WBC
• Lasts a few days
• Disappears without treatment

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The Limping ChildAge 3 6

• Septic arthritis
• Child refuses to walk
• Movement of hip is painful
• May have fever
• Elevated WBC
• Progressively sicker
• Progressive joint destruction

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The Limping Child Age 3 6Septic Arthritis
Bacteria
White cells
Enzymes
Enzymes
Destroy cartilage
Irreversable joint damage
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The Limping Child Age 3 6Septic Arthritis

• The Worst Scenario
• Destruction of articular cartilage
• Destruction of femoral head
• Destruction of femoral neck

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The Limping Child Age 3 6Septic Arthritis

• Treatment
• Kill the bacteria
• Antibiotics
• Eliminate the white cells
• Incision and drainage
• Dont delay
• 48 hour window

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The Limping Child Age 3 6Transient Synovitis
vs. Septic Arthritis

• How to tell the difference?
• Four predictors
• History of fever
• Refusal to weight-bear
• ESR gt 40 mm/hr
• WBC gt 12,000
• If in doubt
• Review in 12 hours
• Do incision and drainage!

Kocher, Kasser, et al.JBJS 86-A 1629, 2004
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The Limping ChildAge 6 - 10
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Best Bet

• Legg-Calvé-Perthes Disease

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The Limping Child Age 6 10Perthes Disease

• Physical findings
• Boy
• Limp
• Antalgic gait
• Pain with passive motion
• Limited abduction
• Positive Trendelenburg sign

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The Limping Child Age 6 10Perthes Disease

• X-ray findings
• Perhaps nothing
• MRI
• Irregular consistency
• Flattening
• Lateral bump/ridge
• Lateral hinging

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The Limping Child Age 6 10Perthes Disease
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The Limping Child Age 6 10Perthes Disease

• Treatment
• Maintain range of motion
• Physical therapy
• Anti-inflammatory medication
• Containment
• Bracing in abduction
• Femoral osteotomy
• Pelvic osteotomy

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The Limping Child Age 6 10Perthes Disease
50 need a Total Hip by age 50
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The Limping ChildAge 10 14
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Best Bet

• Slipped Capital Femoral Epiphysis(SCFE skiffey)

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The Limping Child Age 10 14SCFE
Always get a frog lateral view
Always check the other side
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The Limping Child Age 10 14SCFE

• Pediatric orthopaedic surgeons
• See 6 per year
• General orthopaedic surgeons
• See 1 every 6 years
• Same as fixing a fracture

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The Limping Child Age 10 14SCFE

• Classification
• Acute or chronic
• Stable or unstable
• Severity of displacement
• Slip angle
• Bilaterality
• 10 15 at presentation

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Useful Classification

• Stable
• Walks in
• Unstable
• Wheels in

• Bone in one piece
• Slow plastic deformation of the growth
  plate

• Bone in two pieces
• Physeal fracture

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Unstable SCFE
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Xray Findings

• Displacement of neck on head
• Mainly anterior
• Somewhat superior
• Decreased projected femoral head height
• Chronicity
• Inferior new bone
• Superior rounding off of metaphysis
• Curved neck

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CastroAP
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Silva Chronic Slip
Degree of slip??
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Castro Right Lateral
Slip angle
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Concept

• Displacement of head on neck

Gradual change in shape
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Starting Point Severe Slips
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Correct Path
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Controlling Depth

• Approach Withdraw
• Rotate hip through full range
• Observe projected distance of pin tip from
  subchondral bone
• Watch for change in direction
• That moment presents the critical view

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3D Geometry
The Critical View
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Approach-Withdraw 1
1
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Approach-Withdraw 2
2
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Approach-Withdraw 3

3
43
Approach-Withdraw 4
4
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Approach-Withdraw 5
5
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Approach-Withdraw 6
6
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Approach-Withdraw 8
7
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Approach-Withdraw 7
8
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Approach-Withdraw 5
The Critical View
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The Contralateral Hip

• Out of 100 patients
• 10 are bilateral at presentation
• 10 will slip on the other side later
• 5 will have painless slips on the other side

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Follow-up for Bilaterality

• Follow radiologically
• Every three months
• For 18 months

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The Limping Child

• Age 1 3 years - DDH
• Age 3 6 years - Septic arthritis
• Age 6 10 years - Perthes Disease
• Age 10 14 years - SCFE

Best Bets
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The Limping Child

• AAPA