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Florence Bradshaw The Limping ChildCONTENTS 1. THE LIMPING CHILD 2. HISTORY AND EXAMINATION 3. INVESTIGATIONS 4. DIFFERENTIAL DIAGNOSIS 5. QUIZ NUMBER 1 6. CONDITIONS CAUSING A LIMP b. Transient Synovitisasia of the Hip c. Perthes Disease 7. QUIZ NUMBER 2CONTENTS 1. THE LIMPING CHILD 2. HISTORY AND EXAMINATION 3. INVESTIGATIONS 4. DIFFERENTIAL DIAGNOSIS 5. QUIZ NUMBER 1 6. CONDITIONS CAUSING A LIMP b. Transient Synovitisasia of the Hip c. Perthes Disease 7. QUIZ NUMBER 2A limping child... ● What is a limp? ● An uneven, jerky or laborious gait, usually caused by pain, weakness or deformity ● It is a common complaint in childhood, accounting for 4 per 1000 visits in the paediatric emergency department ● Can be caused by both benign and life-threatening conditions, of which will differ depending on age ● ! Non-accidental injury !A limping child... ● Three major factors to cause a child to limp: ● Pain ● Weakness ● Structural or mechanical abnormalitiesCONTENTS 1. THE LIMPING CHILD 2. HISTORY AND EXAMINATION 3. INVESTIGATIONS 4. DIFFERENTIAL DIAGNOSIS 5. QUIZ NUMBER 1 6. CONDITIONS CAUSING A LIMP b. Transient Synovitisasia of the Hip c. Perthes Disease 7. QUIZ NUMBER 2Taking a History – Key Points • Always see the child with their carer • Involve the chid • Birth history and developmental milestones • Age matters!HPC • Pain – site, severity, onset, nature, duration/chronicity, exacerbating/relieving factors, rest pain, radiation; • If child presents with knee pain, always ask about and examine the hips; • Swelling - site, size, onset, duration, exacerbating/relieving factors • Limp - refusing to weight bear limp +/- history of trauma or injury • Morning stiffness/start-up pain • Deformity - static/worsening or improving condition. • Associated systemic symptoms: • Loss of appetite/weightt sweats, flu-lie symptoms)PMH • Mostly includes birth and developmental history • NIPE? Hip exam findings Sitting 6 months • Vaginal or C-section? Crawling 10 months • Perinatal complications? Walking 18 months Also useful to ask about: • Recent viral or bacterial infections (post-infectious arthritis) • Dysentery (reiters syndrome) • IM infections (muscle inflammation or abscesses) • Endocrine dysfunction (slipped capital femoral epiphysis)DHX, SHX, FHX • DHx • Glucocorticoid use, any allergies? • SHx • Is the child safe at home? • NAI? • FHx • Heredity conditions e.g. hip dysplasiaRed 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) • ! Abdominal Pathology / Testicular Torsion !EXAMINATION • Tips: observe, leave in secure place, time, explain, distract, opportunistic • General inspection→ Height, weight, skin, gait • Skeletal alignment – spine, lower limb, feet • Flength discrepancywarmth, swelling, leg • Move – muscle tone, symmetric full joint range of movement, Ortolani and Barlow testsCONTENTS 1. THE LIMPING CHILD 2. HISTORY AND EXAMINATION 3. INVESTIGATIONS 4. DIFFERENTIAL DIAGNOSIS 5. QUIZ NUMBER 1 6. CONDITIONS CAUSING A LIMP b. Transient Synovitisasia of the Hip c. Perthes Disease 7. QUIZ NUMBER 2Investigations – Key Points • Almost any test available can be performed on children BUT • Children (especially) don’t like painful procedures • Do you need to know the answer (differential diagnosis)? • Will the answer change what you do?Investigations • Basic observations – TEMPERATURE! • Bloods: FBC, ESR (may be normal), CRP, blood cultures, blood film, rheumatoid factor (RF), antinuclear antibody (ANA) • Urine: dipstick + MSU. • X-rays: antero-posterior (AP), lateral plain X-ray of entire bone involved including joint above and below (e.g. if hip: AP pelvis and frog leg lateral views). • US scan: of muscle and bone. • MRI: very sensitive and specific—good for soft tissues and bone pathology.CONTENTS 1. THE LIMPING CHILD 2. HISTORY AND EXAMINATION 3. INVESTIGATIONS 4. DIFFERENTIAL DIAGNOSIS 5. QUIZ NUMBER 1 6. CONDITIONS CAUSING A LIMP b. Transient Synovitisasia of the Hip c. Perthes Disease 7. QUIZ NUMBER 2Splitting the Differential • A wide range of differentials for this presentation • Can split based on: • Age group • Surgical SieveSplitting the Differential - AgeSplitting the Differential – Sieve Cause Condition Developmental Developmental Dysplasia of the Hip Occult Trauma Toddler’s fracture, Slipped Upper Femoral Epiphysis, Stress Fracture, Puncture Wound, NAI Infectious Septic Arthritis, Osteomyelitis, Discitis Inflammatory Juvenile Idiopathic Arthritis, Transient Synovitis of Hip Neoplastic Leukaemia, Bone Tumours Osteochondroses Perthes Disease Non-MSK Appendicitis, Testicular Torsion, Psoas AbscessCONTENTS 1. THE LIMPING CHILD 2. HISTORY AND EXAMINATION 3. INVESTIGATIONS 4. DIFFERENTIAL DIAGNOSIS 5. QUIZ NUMBER 1 6. CONDITIONS CAUSING A LIMP b. Transient Synovitisasia of the Hip c. Perthes Disease 7. QUIZ NUMBER 21. An 18-month-old girl is brought to an urgent GP appointment with an acute limp. She is coryzal but apyrexial. There is no history of trauma. She is able to weight bear. What is the correct management? a. Routine Paediatric referral b. Urgent X-ray c. Urgent Hip USS d. Urgent specialist assessment e. Watchful waiting with safety netting advice2. What does a positive Ortolani sign indicate a. Septic Arthritis b. Dislocated patella c. Dislocated hip d. Arthritis e. Perthes Disease3. When should a child start to crawl? a. 6 months b. 8 months c. 10 months d. 12 months e. 16 monthsCONTENTS 1. THE LIMPING CHILD 2. HISTORY AND EXAMINATION 3. INVESTIGATIONS 4. DIFFERENTIAL DIAGNOSIS 5. QUIZ NUMBER 1 6. CONDITIONS CAUSING A LIMP b. Transient Synovitisasia of the Hip c. Perthes Disease 7. QUIZ NUMBER 2Developmental Dysplasia of the Hip (DD of the H)DD of the Hip • Hip instability, dislocation of femoral head and/or acetabular dysplasia in a developing hip joint. • More common in left hip, ~20% bilateral. • Risk Factors: • Breech presentation - US if breech at 36 weeks/ first degree relative/ multiple pregnancy • Female - 6 times greater risk • Oligohydramnios • Family history • High birth weightPresentation • Presentation will depend on age • Screening tests can be done at birth • Galeazzi – tests for apparent leg length discrepancy due to a unilateral dislocated hip • Barlow – aims to dislocate an unstable hip by adduction and depression • Ortolani – aims to relocate a dislocated hip by elevation and abductionInvestigations • Routine screening at NIPE and 6 week check on examination. • US for high-risk infants, and to confirm if suspected. • If >4.5 months then X-ray first-lineManagment • Spontaneously by 3-6 weeks • Pavlik harness <4.5 months • Surgery for olderTransient SynovitisTransient Synovitis • Or irritable hip • Acute hip pain following recent viral infection • Common age group: 3-8 yearsPresentation • limp/refusal to weight bear • groin or hip pain • a low-grade fever is present in a minority of patients • high fever should raise the suspicion of other causes such as septic arthritis • fever is a red flag, indicating the need for urgent specialist assessmentInvestigationsManagment • Once septic arthritis is ruled out… • Conservative management • Simple analgesia • Resolved spontaneously within 7 – 10 daysPerthes DiseasePerthes Disease • Idiopathic avascular necrosis to the upper femoral epiphysis • More common in boysars old • Aetiology unknownPresentation • Pain • Limping • Limited ROM • Leg length discrepancy • Muscle atrophy • Gait abnormalities • Delayed skeletal maturationInvestigations • XR – primary investigation • MRI • Bone scintigraphyManagment • Depends on age and severity • Conservative management: • Pain management • Physical therapy • Surgical management: • Femoral or pelvic osteotomies • Hip arthroplastyCONTENTS 1. THE LIMPING CHILD 2. HISTORY AND EXAMINATION 3. INVESTIGATIONS 4. DIFFERENTIAL DIAGNOSIS 5. QUIZ NUMBER 1 6. CONDITIONS CAUSING A LIMP b. Transient Synovitisasia of the Hip c. Perthes Disease 7. QUIZ NUMBER 24. A 2-year-old child comes to the emergency department with a 2 day history of right hip pain and irritability. She had recently recovered from a viral respiratory tract infection and is apyrexial and asymptomatic now. On examination, the joint is painful to move but not hot or erythematous, with full ROM and she is able to weight bear. Blood results show the following: WCC - 11.5x10^9 (4.0-11.0) CRP 29 (<5) ESR 32 (0-10) Kocher’s criteria a. Septic arthritis Non-weight bearing - 1 pt Fever > 38.5 - 1 pt b. Transient synovitis WCC > 12 - 1 pt c. Juvenile idiopathic arthritis ESR > 40 - 1pt d. Psoriatic arthritis e. Osteochondritis dissecans5. What staging can be used for Perthes’ disease a. Catterall b. Kocher c. Salter-Harris d. Benes e. Silverman6. Which of the following is NOT a risk factor for DDH? a. Breech presentation b. Firstborn c. Birth weight > 5kg d. C-section e. FemaleTHANK YOU!REFERENCES 1. https://teachmesurgery.com/orthopaedic/paediatrics/the-limping-child/ 2. https://www.rcemlearning.co.uk/foamed/the-limping-child/ 3. https://www.grepmed.com/images/5368/peds-diagnosis-joint-pediatrics-septic