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The Limping Child By MedRx In most children, limping is caused by a mild, self-limiting event, such as a contusion, strain, or sprain. In some cases, however, a limp can be a sign of a serious or even life-threatening condition. Delays in diagnosis and treatment can result in significant morbidity and mortality. Examination of a limping any history of trauma, and any associated systemic symptoms.presence of pain, The presence of fever, night sweats, weight loss, and anorexia suggests the possibility of infection, inflammation, or malignancy. Physical examination should focus on identifying the type of limp and localizing the site of pathology by direct palpation and by examining the range of motion of individual joints. Contents Using this handout 1. The Limping Child 2. History The content in this handout is quite 3. Examination detailed. The most important aspects are the differential diagnosis, the 4. Investigations ‘essential advice’ and any writing in 5. Splitting the differential of The bold - prioritize these first! At the Limping Child same time, the content is not 6. Conditions causing a limp exhaustive and should not be seen as covering every detail but instead the a. Developmental Dysplasia most important ones. This handout is of the Hip for purely educational purposes and b. Transient Synovitis should not be used when treating c. Perthes Disease patients. The Limping Child What is a limp? A limp is any asymmetric gait that deviates from a normal age-appropriate pattern. An acute limp in a child is a common presentation to both primary and secondary care and can be due to a wide variety of causes. In 2016, 4 per 1000 visits in the paediatric emergency department where due to a limp. In most children, a limp is caused by a mild self-limiting issue, such as a strain or sprain, however there are less common but serious causes that must be identified. Differential diagnoses can be categorised by age group, yet many of these conditions can occur at any age. As with all interactions with children, it is important to always consider the possibility of non-accidental injury. The differential diagnosis for limping encompasses musculoskeletal, infectious, inflammatory, and neurological etiologies. A comprehensive assessment involves a meticulous exploration of the child's medical history, a thorough physical examination, and a systematic consideration of potential differential diagnoses. Taking a History Before starting out… • Always see the child with their carer • Involve the child in the history and examination • Make sure to take birth history and developmental history • Always take into account the age of the child HPC Onset and Duration: A detailed inquiry into the onset and duration of limping is crucial. Acute onset may suggest trauma or infection, while a chronic or gradual onset may indicate a more insidious, chronic condition, necessitating distinct diagnostic considerations. Trauma History: Gathering information regarding recent injuries, falls, or trauma is imperative. Traumatic incidents such as fractures, sprains, or soft tissue injuries are common causes of acute limping and require specific attention during the history-taking process. Pain Characteristics: Exploring the characteristics of the pain is paramount, including its location, intensity, and any exacerbating or alleviating factors. This information is instrumental in differentiating betweeninflammatory, infectious, or traumatic causes. Systemic Symptoms: Inquiring about the presence of systemic symptoms like fever, malaise, or weight loss is crucial. Such symptoms may point towards an infectious or systemic inflammatory condition affecting the child's overall health. PHM • Know your gross motor developmental milestones. • Make sure to ask about the birth history and developmental history • Were there any NIPE findings? • Presentation of the baby? • Vaginal or C-section? • Perinatal complications? • Also, useful to ask about: o Recent viral or bacterial infections (post-infectious arthritis) o Dysentery (reiters syndrome) o IM infections (muscle inflammation or abscesses) • As always, ask about previous trauma, surgery or illness DHx, SHx, FHx DHx: • Any allergies? • Glucocorticoid use? SHx: • Does the child play any sports/do any activities? Is the pain / limp affecting them in this? • Is the child safe at home? • NAI? FHx: • Any hereditary MSK conditions • Any family history of hip dysplasia?Red Flags! • Pain waking the child at night (potential malignancy) • Any redness, swelling, or stiffness in the joint or limb (potential infection or inflammatory joint disease) • Presence of weight loss, anorexia, fevers, night sweats, or fatigue (potential malignancy, infection, or inflammatory joint disease) • Unexplained rash or bruising (potential non-accidental injury) • Unable to bear weight or painful limitation of range of motion (potential trauma or infection) • Pain waking the child at night (potential malignancy) • Any redness, swelling, or stiffness in the joint or limb (potential infection or inflammatory joint disease) • Presence of weight loss, anorexia, fevers, night sweats, or fatigue (potential malignancy, infection, or inflammatory joint disease) • Unexplained rash or bruising (potential non-accidental injury) • Unable to bear weight or painful limitation of range of motion (potential trauma or infection) Examination Examination should be of the whole child, not just the affected joint(s), including checking the child’s observations, height, and weight, and compare to previous if able. Examine the child in a secure place (e.g. the parents arms), distract the child whilst examining and do the examination in a opportunistic manner. The pGALS assessment (paediatric Gait, Arms, Legs, Spine) assessment is a useful musculoskeletal screening examination that can help give an overall assessment of the child, before performing a more focussed examination of the affected joint(s). Gait appears more adult like at the age of 7 years. Examination of the specific joint involved typically follows the “look, feel, move” approach of orthopedic examinations. The special tests to perform will depend on the joint being examined and clinical judgement as to potential differential diagnoses. Examining the Hips of a Newborn: This forms part of the NIPE exam and are crucial when testing for Developmental Dysplasia of the Hip. Two of the tests are the Ortolani and Barlow Tests. Ortolani Test: Is hip dislocated? If so, is it reducible? Ortolani’s test (O for out). Gently elevate (anteriorly) and abduct the dislocated hip to reduce it (clunk of reduction).Barlow Test: If not dislocated, can I dislocate it (i.e. dislocatable)? Barlow’s test. Gently adduct and depress (posteriorly) femur; vulnerable hip dislocates. N.B. these become unreliable after age 6–8wks… so look at gluteal folds and leg length discrepancies and how the child walks Investigations Almost any test available can be performed on children but remember children do not like painful procedures. So, before you perform any test, think if the answer from the test changes what you will do next. Always start with the most basic investigations – start with a basic set of observations including TEMPERATURE. Imaging Studies: X-rays: This is a fundamental initial investigation to evaluate for fractures, dislocations, or bony abnormalities. X-rays provide valuable information about the skeletal structure and are particularly useful in cases of trauma or suspected developmental issues. Ultrasonography: Useful for assessing soft tissue structures, ultrasonography is particularly relevant in evaluating the hip joint for conditions like developmental dysplasia. It can also help identify fluid collections indicative of joint effusions or infections. Magnetic Resonance Imaging (MRI): Employed for a detailed assessment of soft tissues, ligaments, and joints, MRI is invaluable in cases where X-rays may not provide a complete picture. It aids in the diagnosis of conditions such as Legg-Calvé-Perthes disease, osteomyelitis, or soft tissue injuries. Laboratory Tests: Complete Blood Count (CBC): Hematological abnormalities, such as an elevated white blood cell count, can signify infection, leukemia, or other systemic conditions contributing to limping. Inflammatory Markers (ESR, CRP): Elevated erythrocyte sedimentation rate (ESR) and C- reactive protein (CRP) levels are indicative of inflammation. These markers are valuable in assessing for conditions like juvenile idiopathic arthritis or infectious causes. Blood Cultures: In cases where septic arthritis or osteomyelitis is suspected, obtaining blood cultures is crucial for identifying the causative organism. Joint Aspiration: Aspiration of synovial fluid from an affected joint can aid in diagnosing septic arthritis or inflammatory joint conditions. Analysis of the synovial fluid, including cell count and culture, provides valuable insights into the nature of the pathology. Genetic Testing: In cases where there is a suspicion of hereditary musculoskeletal disorders or neuromuscular conditions, genetic testing may be warranted. This is particularly relevant in conditions like muscular dystrophy, where a genetic mutation is often the underlying cause.Neurological Studies: Electromyography (EMG) and Nerve Conduction Studies (NCS): These tests are valuable in assessing nerve and muscle function. They may be indicated when neuromuscular causes, such as peripheral neuropathies, are suspected. Rheumatological Evaluation: Antinuclear Antibody (ANA) Test: ANA testing is useful in the evaluation of autoimmune conditions such as systemic lupus erythematosus (SLE) or juvenile idiopathic arthritis. HLA-B27 Test: This test aids in the diagnosis of conditions like ankylosing spondylitis, which may present with musculoskeletal symptoms, including limping. Splitting the Differential Acute Painful Limp Chronic and Intermittent Limp 0-3 Years Infection – septic arthritis, Developmental dysplasia of the hip Old osteomyelitis of hip or spine (DDH), talipes Transient synovitis Neuromuscular, e.g. cerebral palsy Trauma – accidental/non-accidental Juvenile idiopathic arthritis (JIA) Malignant disease – leukaemia, neuroblastoma 3 – 10 Transient synovitis Perthes disease (chronic) Years Old Septic arthritis/osteomyelitis Neuromuscular disorders, e.g. Trauma and overuse injuries Duchenne muscular dystrophy Perthes disease (acute) Juvenile idiopathic arthritis (JIA) Juvenile idiopathic arthritis (JIA) Tarsal coalition Malignant disease, e.g. leukaemia Complex regional pain syndrome 11 – 16 Mechanical – trauma, overuse injuries, Slipped capital femoral epiphysis Years Old sport injuries (chronic) Slipped capital femoral epiphysis Juvenile idiopathic arthritis (JIA) (acute) Tarsal coalition Avascular necrosis of the femoral head Reactive arthritis Juvenile idiopathic arthritis (JIA) Septic arthritis/osteomyelitis Osteochondritis dissecans of the knee Bone tumours and malignancy Complex regional pain syndrome Developmental Dysplasia of the Hip (DDH) Developmental Dysplasia of the Hip (DDH) is a condition that affects the hip joint in infants and young children. Formerly known as congenital hip dislocation, DDH involves abnormal development of the hip socket, which can lead to instability and potential long-term issues if not addressed early. This condition ranges from mild hip joint laxity to complete dislocation, and its prevalence varies globally. Early detection and intervention are crucial for successful management and optimal outcomes. Presentation: DDH manifests across a spectrum of severity, ranging from subtle hip joint laxity to complete dislocation. Clinical presentation varies with age, necessitating vigilance during infancy and early childhood. In newborns, signs may include hip instability, asymmetrical skin folds, and limited hip abduction. As the child grows, observable gait abnormalities, limb length discrepancies, or a waddling gait may become apparent. In older children, hip pain and functional limitations may emerge. The cornerstone of early detection lies in a thorough physical examination, incorporating maneuvers such as the Ortolani and Barlow tests, alongside vigilant monitoring of risk factors like breech presentation during birth. Investigations: Ultrasound Imaging: Ultrasound stands out as a non-invasive and reliable diagnostic tool, particularly in neonates. It allows for the assessment of dynamic components of hip instability, aiding in the identification of subtle abnormalities. X-ray Imaging: While not as commonly used in the neonatal period due to the immaturity of the bony structures, X-rays become valuable in assessing older infants and children. They provide detailed images of the bony components of the hip joint, aiding in determining the severity of dysplasia. MRI (Magnetic Resonance Imaging): In cases where ultrasound and X-ray results are inconclusive or require further clarification, MRI becomes a valuable adjunct. It offers detailed visualization of soft tissues surrounding the hip joint, aiding in a comprehensive understanding of the condition. Management: Non-surgical Interventions: Early intervention is paramount in DDH management. For milder cases, the application of the Pavlik harness proves effective in maintaining hip stability. This non-surgical approach encourages natural development by holding the hip joint in a corrected position. Surgical Options: In more severe cases, where non-surgical interventions prove insufficient, surgical options become necessary. Closed reduction, involving repositioning the hip joint without an incision, may be considered. Open reduction, accompanied by spica casting to maintain the corrected position, is reserved for cases requiring a more invasive approach. Long-term Follow-up: Continuous monitoring and follow-up are essential components of DDH management. Regular assessments throughout childhood ensure that any emerging issues are identified and addressed promptly. Physical therapy plays a crucial role in rehabilitation, fostering proper muscle development and preventing complications. Transient Synovitis Two conditions that share common symptoms but differ significantly in their implications are Transient Synovitis (TS) and Septic Arthritis (SA). Clinical Presentation: Transient Synovitis: Transient Synovitis, also known as irritable hip, is a benign, self-limiting condition predominantly affecting young children. Typically, it manifests with acute hip pain, limited range of motion, and sometimes a limp. The onset is often rapid, and while the exact cause remains elusive, viral infections or post-viral inflammatory responses are suspected triggers. The affected joint may exhibit mild swelling and warmth, and the child may appear otherwise healthy. Septic Arthritis: On the other hand, Septic Arthritis is a more serious condition characterized by the invasion of the joint by infectious agents, commonly bacteria. Children with Septic Arthritis may present with similar symptoms as Transient Synovitis, such as joint pain, limited mobility, and systemic signs of illness, but the severity is notably higher. Septic Arthritis demands prompt intervention to prevent long-term joint damage and systemic complications. Investigations: Transient Synovitis: Diagnosing Transient Synovitis relies on a combination of clinical assessment and exclusion of other more severe conditions. Blood tests may reveal an elevated white blood cell count and inflammatory markers, but these findings are nonspecific. Imaging studies, particularly ultrasound and sometimes MRI, can help rule out other joint abnormalities and contribute to the diagnosis of TS. Septic Arthritis: In contrast, Septic Arthritis demands urgent and thorough investigation. Aspirating the joint for analysis is a critical step in confirming the diagnosis. The synovial fluid is examined for cell count, culture, and sensitivity to identify the causative organism. Blood cultures and imaging studies, such as X-rays and MRI, are essential to evaluate the extent of joint involvement. Management: Transient Synovitis: Management of Transient Synovitis is primarily supportive and focused on relieving symptoms. Nonsteroidal anti-inflammatory drugs (NSAIDs) are often prescribed for pain management. Bed rest may be recommended initially, followed by a gradual return to normal activities as symptoms subside. The condition typically resolves within a few days to weeks without long-term consequences. Septic Arthritis: Septic Arthritis requires prompt hospitalization, intravenous antibiotics, and joint drainage to eradicate the infectious source. Delayed or inadequate treatment can lead to irreversible joint damage and systemic complications. Close monitoring and follow-up are crucial to assess the response to treatment and adjust the management plan accordingly.Kocher Criteria: The Kocher criteria, established by Dr. Lawrence L. Kocher, provide a valuable tool for clinicians in distinguishing between Transient Synovitis and Septic Arthritis. The criteria include: • Fever: Presence of a fever (>38.5°C or 101.3°F). • Non-weight bearing status: Refusal to bear weight on the affected limb. • Elevated white blood cell count: White blood cell count exceeding 12,000 cells/mm³. • ESR (Erythrocyte Sedimentation Rate): ESR greater than 40 mm/hour. A child presenting with a hip effusion and meeting three or four of these criteria is more likely to have Septic Arthritis. The Kocher criteria aid in making timely and accurate diagnostic and management decisions, reducing the risk of long-term joint complications. Perthes Disease Perthes Disease, also known as Legg-Calvé-Perthes Disease, is a pediatric orthopedic condition that affects the hip joint. Named after the physicians who first described it, Arthur Legg, Jacques Calvé, and Georg Perthes, this disorder primarily occurs in children between the ages of 4 and 10 years. Perthes Disease involves a disruption of blood supply to the femoral head, leading to necrosis and subsequent deformity. Clinical Presentation: The clinical presentation of Perthes Disease is characterized by a progressive avascular necrosis of the femoral head, resulting in impaired blood flow and subsequent deformity. The early stages may be asymptomatic, making early detection challenging. As the condition advances, children may experience pain in the hip or groin, limited range of motion, and a noticeable limp. Over time, muscle atrophy may occur, and the affected leg may appear shorter than the unaffected one. The disease typically follows a self-limiting course, with phases of necrosis, fragmentation, revascularization, and remodeling, ultimately leading to the restoration of the femoral head's shape. Investigations: X-rays are essential for diagnosing Perthes Disease and assessing the extent of femoral head involvement. Changes in the shape and structure of the femoral head, joint space widening, and signs of healing can be observed. Magnetic Resonance Imaging (MRI) may be employed for a more detailed evaluation of the blood supply to the femoral head and to detect early changes not visible on X-rays. Bone Scans: Technetium-99 bone scans can help identify areas of decreased blood flow and aid in differentiating between active and inactive stages of the disease. Management: Non-surgical Management: Rest and activity modification are crucial in the early stages to minimize stress on the affected hip. Physical therapy is employed to maintain joint mobility and prevent muscle contractures. Bracing may be utilized to optimize femoral head containment within the acetabulum during the healing process. Surgical Interventions: In some cases, especially when non-surgical measures prove insufficient, surgical interventions may beconsidered. Femoral or pelvic osteotomies aim to improve femoral head coverage and overall joint congruity, mitigating the risk of long-term joint damage. Follow-up and Monitoring: Long-term follow-up is essential to monitor the progression of Perthes Disease and assess the effectiveness of interventions. Periodic imaging studies, including X-rays and MRI, help track the healing process and guide ongoing management decisions. Perthes Disease requires a tailored approach to management, considering the child's age, the stage of the disease, and the severity of symptoms. The goal is to promote optimal femoral head containment, preserve joint function, and prevent long-term complications. References 1. http://gooeybrains.com/2017/04/18/motor-development/ 2. https://teachmesurgery.com/orthopaedic/paediatrics/the-limping-child/ 3. https://www.rcemlearning.co.uk/foamed/the-limping-child/ 4. https://www.grepmed.com/images/5368/peds-diagnosis-joint-pediatrics-septic 5. https://ypeda.com/attachments/fil/Illustrated%20Textbook%20o.pdf