THE LIMPING CHILDAN ORTHOPEDIC

PERSPECTIVE

Devin Peterson, MD, FRCSC, Dip Sport Med Associate Professor, McMaster University

McMaster University Medical Centre

David Braley Sport Medicine & Rehabilitation Centre

Faculty/Presenter Disclosure

• Faculty: Devin Peterson• Program: 51st Annual Scientific Assembly

• Relationships with commercial interests:• None

Disclosure of Commercial Support

• This program has received no financial support • This program has received no in-kind support

• Potential for conflict(s) of interest:– None

Mitigating Potential Bias

• N/A

OBJECTIVES

1. To assess and diagnose common causes of childhood limping

2. To understand the management principles of the limping child including timely referral

NORMAL GAIT

Smooth energy-efficient transfer of the body through space

Limp: “to walk with a halting or irregular step”

Funk & Wagnall's

PATHOLOGICAL GAITS

Antalgic Gait: body’s effort to compensate for pain or instability in the stance-phase limb by minimizing the duration and magnitude of loading

Trendelenburg Gait: leaning of the head and trunk toward the lower extremity affected by the pathologyPainWeakness in the hip muscles

COMMON CAUSES OF LIMPING SEEN IN EARLY CHILDHOOD

19 month old female referred because of limping

Fifth born Normal delivery/presentation

Walking at 14 monthsAlways limped

No pain

Healthy Negative Family history

Differential diagnosisTop three:

Hip dysplasiaNeuromuscular diseaseLeg length discrepancy

DEVELOPMENTAL DYSPLASIA OF THE HIP

(DDH)

Dislocated: the femoral head is not in contact with the

acetabulum

Dislocatable the femoral head is within the acetabulum but can be

forced out

Subluxed the femoral head is within the acetabulum but not in

its proper position

Subluxable the femoral head can be moved beyond its physiologic

limits within the acetabulum

Dysplastic although the femoral head is in the proper position the

acetabulum or head are abnormally developed

HistoryRisk Factors

FemaleFirstbornBreechLarge babyLow amniotic fluidFamily history

PhysicalAssociated

Conditionso Foot deformity,

Torticolliso Neuromuscular

disorderso SyndromesHip Examinationo Trendelenburg gaito Skin foldso Galeazzi signo Abductiono Provocative

maneuvers- Ortolani, Barlow

ImagingUltrasound

< 6 monthsX-ray

Treatment URGENT REFERRAL Pavlik Harness Closed Reduction

Safe Zone Open reduction

Extra-articular blocks Intra-articular blocks

Osteotomies Pelvic Femoral + Shortening

Most common cause of hip pain in childhood 3% childhood risk

Idiopathic Frequently associated with

concurrent or antecedent illness Right hip = left hip

NEVER BILATERAL 2:1 male:female

TRANSIENT SYNOVITIS

HistoryAge varies (9 months to

adolescence)Most between 3 and 8 years old

Unilateral hip painCan present with knee or thigh pain

Limp vs non-weight bearing

PhysicalMay have a low grade temperatureAntalgic or Trendelenburg gaitFlexed and externally rotated

positionDecreased ROM

Especially abduction and internal rotation

Laboratory testsNon-specific

ImagingRadiographs usually normalUltrasound may show effusion

Diagnosis of exclusion

TreatmentURGENT REFERRAL

Differential includes a septic jointSelf limiting disorder

May have symptoms for up to 10 days or longer

Bed rest until full ROM, no pain, limp freeCrutches for older patients

NSAIDSGradual return to activity

LEGG-CALVE-PERTHES DISEASE(PERTHES)

Self limiting hip disorder Caused by ischemia and subsequent

necrosis of the femoral head Usually 4 to 8 years of age Male to female ratio:

4-5 to 1 Usually unilateral (88%) Age and lateral head involvement are

the key to prognosis 8 years of age seems to be the

watershed <50% of lateral pillar involvement

better prognosis

DIFFERENTIAL DIAGNOSIS

Unilateral Perthes: septic arthritis sickle cell disease spondyloepiphyseal dysplasia

tarda Gaucher’s disease

Bilateral Perthes: Hypothyroidism Multiple epiphyseal dysplasia spondyloepiphyseal dysplasia

tarda sickle cell disease

HistoryMay be painless at first

present with a limp onlysymptoms occur with subchondral

collapse/fractureCan present with knee or thigh pain

Positive family history 1.6% – 20%1% - 3% of patients with transient

synovitis will develop Perthes

Physicalgait:

Trendelenburgdecreased

abduction/ internal hip rotation

thigh, calf, and buttock atrophy

LLD

ImagingX-ray, bone scan,

MRI

TreatmentTIMELY REFERRALPrinciples of treatment are

maintenance of ROM & containment (good coverage of the head by the acetabulum) of the femoral head through the evolution of healing

May be obtained by non-operative means

o relative restopain controlophysiotherapyo tractionoabduction splinting at night

OPERATIVE TREATMENTS

Containable Hipadductor releaseFemoral

varus/pelvic osteotomies

Non-Containable HipHip/Late-presenting

patient with deformity

Hinge abduction Chiari/lateral shelf Cheilectomy Femoral

abduction/extension osteotomy

OCD, non-operative, revascularization, removal, ORIF

DISCOID MENISCUS First description: Young 1889 3-5% in general population have a

larger than normal meniscus Almost all in lateral, but reported in

medial 20% bilateral and 10% associated

with OCD of lateral femoral condyle

ANATOMY

THREE SEGMENTS• Anterior horn• Body• Posterior horn

Attached to tibial plateau, primarily through Coronary Ligament

Attached to the capsule except at popliteal hiatus

DIAGNOSIS

Clinical PresentationHistory:

Asymptomatic“Snapping knee syndrome”Meniscal tear symptoms

Physical: Snapping knee with gaitMeniscal signs

X-rayWidened lateral joint

space, squaring of lateral femoral condyle, cupping of lateral tibial plateau

MRIVerify diagnosis and

assess damage

TREATMENT OPTIONS Asymptomatic: observe Symptomatic:

TIMELY REFERRAL UNLESS LOCKED KNEE THEN URGENT

Non-operative: restricted activity, bracing, physiotherapy

Operative:Partial meniscal “saucerization” Repair of tear

COMMON CAUSES OF LIMPING SEEN IN LATE CHILDHOOD

APOPHYSEAL CONDITIONS

Apophysitis of the Hip and Pelvis Sinding-Larsen-Johansson: inferior

pole of patella Osgood-Schlatter Disease: tibial

tuberosity disturbance Sever Disease: calcaneal apophysitis Iselin Disease: apophysitis of the

fifth metatarsal

OSGOOD SCHLATTER DISEASE

Tibial tuberosity disturbancePartial avulsion (microscopic

fractures) of the ossification center and overlying hyaline cartilage

Epidemiology10 – 15 years oldBoys > girls> 10% of teenagers

HistoryPain localized to tubercleWorse with direct blows to the are

and activity

PhysicalAntalgic gait may be presentProminent tubercle + local swellingTenderness localized to tubercle

Lovell and Winter’s Pediatric Orthopaedics 5th edition

TreatmentSpontaneous resolution at maturity

20% may have pain with kneelingsurgery for loose ossicles

ReassuranceSymptomatic treatment/activity

modificationNSAIDS, stretching, knee

pads/braces, foot orthosis, castsTIMELY REFERRAL

OSTEOCHONDRITIS DISSECANS(OCD)

INTRODUCTION

Acquired potentially reversible lesion of subchondral bone resulting in delamination and sequestration with or without articular cartilage involvement and instability

Juvenile and Adult formsAdult form is typically progressive

and unremittingMay occur in almost any joint in

upper or lower extremityVery common in the knee

EPIDEMIOLOGY

15-29 per 100,000May be bilateral in 25% of casesMale: female ratio

5:3>70% are in the classical area

Posterolateral aspect of the medial femoral condyle

ETIOLOGY

IdiopathicTheories include:

Genetics Inflammation IschemiaOssificationRepetitive trauma (stress reaction

causing a stress fracture in the underlying subchondral bone)

CLINICAL PRESENTATION

History Juvenile

Poorly localized pain Exacerbated by

exercise May present with

symptoms of instability (swelling, stiffness, catching, locking)

Limp

PhysicalAntalgic gaitEffusionCrepitusPainful ROMQuads atrophyMaximum tenderness

usually anteromedial knee

Wilson sign Pain with internal

tibial rotation

DIAGNOSTIC STUDIES

X-raysAPLateralNotch

MRI + gadoliniumLesion sizeStatus of the cartilage and subchondral boneBone edema and high signal zone beneath

fragmentLoose bodies

Technetium bone scan

MANAGEMENTNonoperative

Open physis = good prognosis?Activity modification

Immobilization?RehabilitationLocal and systemic pain

managementReview every 3-6 months or sooner if

symptoms worseningRepeat MRI every 6 months?TIMELY REFERRAL if no improvement

or worsening, URGENT IF LOCKED KNEE

Operative Indications

Lesions not responding to nonoperative management

Unstable lesions?Detached lesions

THE PAINFUL FLATFOOT:TARSAL COALITION

HISTORY

Tarsal coalition is an abnormal connection between some of the tarsal bones May be painful Can be associated with increased

ankle sprains

PHYSICAL

GaitAntalgic

FlexibilityToe standingSitting/supine

Subtalar ROM

Flexible Flatfoot Arch returns with

sitting or tiptoe standing

Normal subtalar and midtarsal motion

Tarsal Coalition Arch may not

return with sitting or tiptoe standing

May be painful to move or palpate subtalar joint or other tarsal bones

Subtalar motion often decreased

IMAGING

Normal in flexible flatfoot

Oblique views and Harris view may help view a coalition

May need an MRI or CT to make diagnosis

TREATMENT Tarsal Coalition

TIMELY REFERRALRest/activity modificationAntiinflammatoriesPhysiotherapy?OrthoticsCastsSurgery: resection or fusion

SLIPPED CAPITAL FEMORAL EPIPHYSIS(SCFE)

The slip normally occurs during adolescent growth phase

Mechanical or systemic factors may be presentCommonly obeseEndocrinopathies

(eg. 1o & 2o hypothyroidism, panhypopituitarism, GH, hypogonadal conditions, & renal osteodystrophy

Male > female

Left > right

Bilateral involvement may occurSecond slip presents within 18 months

in 88%

HistoryChronic and/or acute

Limp

May present with knee or thigh pain instead of hip/groin pain

PhysicalGait: TrendelenburgShortened/external rotationDecreased abduction/internal hip

rotationPassive flexion leads to thigh

abduction and external rotation

ImagingX-ray, CT, MRI

X-rays Physeal plate

widening & irregularity Decrease in

epiphyseal height Blanch sign of Steel

Crescent-shaped area of increased density in the proximal femoral neck

Femoral metaphysis appears laterally displaced Klein’s line

Southwick angles

Imaging

Frog-leg lateral avoid in acute

situationCross-table lateral

Treatment - Acute EMERGENT REFERRAL Immediate bed rest Insertion of one or

more screws in situ fixation

Designed to fuse the epiphysis on the metaphysis to prevent further slipping

Prophylactic Pinning

Known metabolic/endocrine disorders?

Inability to follow-up

STRESS FRACTURES

STRESS FRACTURES

Stress Fractures in Skeletally Immature Patients

Walker et. al.: JPO 1996

34 stress fractures Tibia (47%), fibula, femur, radius,

humerus, MT

HistoryPain often associated with an

increase in activityBe wary of female triad

PhysicalAntalgic gait may be presentTenderness localized

RadiographsRapid bony response

may be present Bone Scan

Helpful in questionable situations

Treatment (depends on causative factors)URGENT REFERRALModification of activitiesImmobilization

COMMON CAUSES OF LIMPING SEEN AT VARIOUS AGES

BONE AND SOFT TISSUE TUMORS

BONE AND SOFT TISSUE TUMORS History

PainNight painHistory of trauma may delay

diagnosisOsteoid Osteoma pain relieved by

NSAIDsConstitutional Symptoms

Fever, night sweats, anorexia, weight losseg. Ewing sarcoma

Soft tissue mass may not be symptomatic

Physical ExamGait disturbanceMuscle atrophyNeurovascular examRange of motionMass

Size, tenderness, pulsation, mobility, bruits, tenderness, erythema, consistency

Lymph nodes

InvestigationsBloodwork

CBC, ESR, CRP, serum alkaline phosphatase, serum and urine calcium & phosphorus, LDH

ImagingX-rayBone ScanCT/MRI

ManagementReferral

Urgency dependent on tumor type

SEPTIC JOINTS

HistoryPain

Refusal to bear weightLimping

Recent illnessDecreased immunity

eg. chickenpoxTrauma

Physical ExamTemperatureAntalgic gaitDisuse of a partErythema/swellingTendernessDecreased ROM

Laboratory tests CBC

WBCCRPESRBlood culturesAspirates (Gram

stain, Culture)

ImagingX-raysUltrasoundBone ScanCTMRI

TreatmentEMERGENT REFERRALStop tissue destruction ASAP

Decrease bacterial load and irrigation of the joint

Identify the OrganismSelect appropriate antibiotic