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Evaluation of the Child with a Limp

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Evaluation of the Child with a Limp DD Aronsson University of Vermont Hx 2-year-old boy limps because of pain in the right thigh (antalgic) PE pain and ... – PowerPoint PPT presentation

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Title: Evaluation of the Child with a Limp


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 dont 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 _at_ 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
Subperiosteal aspiration
  • Aspiration is the key to the diagnosis
  • Dont wait for imaging

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
  • Genetic whites
  • Physiologic girls
  • Mechanical breech
  • Environmental swaddling

16
Barlow Provocative Test
  • Dislocates hip (exit)

Clunk
17
Ortolani Maneuver
  • Reduces dislocated hip (entry)

Abduction
Clunk
18
PE gt 3 Months
43º
57º
Limited abduction is key
19
PE gt 3 Months
  • Asymmetric thigh folds
  • Limb-length discrepancy

20
Radiographs
21
Ultrasound
  • Alpha gt 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 stage
Fragmentation stage
29
Reossification stage
Remodeling 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 gt 95th percentile weight

38
Hip Flexion Causes Abduction External Rotation
FABER
39
AP Pelvis Radiograph
Kleins line
  • Wide irregular physis
  • Epiphysis at or below Kleins line

40
Frog Pelvis Radiograph
  • Posterior slip
  • Wide, irregular physis

41
Preop AP pelvis
Preop frog pelvis
42
Postop AP pelvis
Postop frog pelvis
43
Limp
  • Think hips
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