Satheesh Krishna Jeyaraj

Khaldoun Koujok

Julie Hurteau

Kawan Rakhra

Adnan Sheikh

Neither I nor my immediate family members have a financial relationship with a commercial organization that may have a direct or indirect interest in the content.

By the end of this exhibit the participant will be able to:

Identify the role of the radiologist in diagnosing cause of limping in children

Identify spectrum of imaging findings (plain films, ultrasound, CT and MR) in children with limping

Evaluate the limping child with a comprehensive algorithmic imaging approach

• Incidence - 1.8 per 1,000 children < 14 years

• Male : female - 1.7 : 1

• Median - 4.4 years

• Painful limp - 80%

• Localised to hip - 34%

• Localised to knee- 19%

• Benign causes - 77%

• Most common - transient synovitis

Fischer SU, Beattie TF. The limping child: epidemiology, assessment and outcome. J Bone Joint Surg Br. 1999;81:1029-34

LimpCauses

Osseous

Developmental

Traumatic

Infection

Neoplasm

Joints

Traumatic

Infection

Inflammatory

Soft tissueInfection

Overuse injury

Intraabdominal

Incidence: 1.5 to 2 per 1000 births

Age: neonatal

Girls>boys

Features: USG < 6 months Alpha angle < 60 degrees

Beta angle > 77 degrees

Bony coverage 5 degrees

Plain radiographs Broken Shenton’s line

Femoral head in upper outer quadrant

‘Developmental dysplasia of hip’ in a 20-month-old girl since she started walking. Radiograph shows a broken Shenton’s line on right with femoral head in upper outer quadrant

Perkin

Shenton

Hilgenreiner

Upper Outer

LowerInner

Incidence: 6% of population

Age: 8 to 16 years

Boys > girls

Features

Calcaneonavicular

Anterior process

Anteater nose sign

Talocalcaneal

Middle facet

C-sign

Talar beak sign

‘Talocalcaneal coalition’

‘Calcaneonavicular coalition’

Incidence: 0.4 to 29.0 per 100,000 children <15 years

Age: 4-8 years; boys>girls

Early

Joint effusion

Smaller femoral epiphysis

Apparent increased density of femoral epiphysis

Blurring of physeal plate

Radiolucency of proximal metaphysis

‘Early Legg Calve Perthe’s’Subchondral lucent crescent andDecreased uptake on bone scintigraphy

Incidence: 0.4 to 29.0 per 100,000 children <15 years

Age: 4-8 years; boys>girls

Late

Femoral head deformity with widening and flattening

Coxa magna‘Advanced Legg Calve Perthe’s’Flattening and increased density of headand widening and shortening of femoral neck

Incidence: 5 to 15 cases per 100,000 children

Age: 8 to 15 years

Boys > girls, obesity

Preslip

Blurring of physeal edges

Demineralisation of metaphysis

‘Preslip left hip’Ill defined growth plate and radiolucencyand abnormal signal along growth plate

Incidence: 5 to 15 cases per 100,000 children

Age: 8 to 15 years

Boys > girls, obesity Acute slip – posteromedial

Better seen in frog-leg lateral view

Epiphysis appears smaller as it moves posteriorly

Trethowan’s sign

Loss of triangular sign of Capener

‘Acute slip right hip’Normal Klein’s line on the leftTrethowan’s sign on the right

Klein

Age: 14 to 25 years

IschialTuberosity

(hamstrings)

Symphysis Pubis and IPR

(adductors;gracilis)

Lesser Trochanter(iliopsoas)

Greater Trochanter

(hip rotators)

AIIS(rectus femoris)

ASIS(sartorius;

tensor fascia lata)

Iliac Crest(abdominal muscles)

‘Avulsion right ischium’Cortical irregularity and periostealreaction in a 11 year old competitive dancer

Incidence:

Age: 9 months to 3 years

Stress due to increasing ambulation

Features

Spiral fractures of tibia

Minimally or not displaced

Mild sclerosis and peritoneal reaction on follow up

NOT non-accidental injury !!!

Spiral femoral fracture = Non accidental injury

‘Toddler’s fracture’Subtle spiral fracture in the right tibiawith increased uptake on bone scan

Incidence:

Age:

4 to 5 weeks after starting a new exercise

Features

Linearly oriented sclerosis

Marked marrow edema

Cortical break

Periosteal reaction

‘Sacral stress fracture’Bone marrow edema withhypointense fracture line in this 15 year old boy

T1 T1 with gadolinium

T2 T2

Incidence: 1 in 500 to 5000

Age: 4 months to 5 years

Boys > girls

Features

Soft tissue swelling

Blurring of fat planes

Periosteal reaction

Endosteal scalloping

Cortical defect

Loss of architecture

T2

‘Acute osteomyelitis’Small effusion of the left hip with bone marrow edema in left femoral neck.Normal right hip for comparison.

Chronic

Sequestrum

Involucrum

Cloaca

MR

Bone marrow edema

Enhancement

Indium111 labelled WBC

Gallium67 scintigraphy

FDG-CT/PET‘Acute osteomyelitis’Left femoral neck show hypointensity on T1 andenhancement following contrast administration.Also note thin reactive synovial enhancement.

Heterogenousspectrum of conditions

Age: Mostly in second decade

Limp by pain, fracture or limitation of motion

Features Small zone of

transition

Benign type of periosteal reaction

‘Osteoid osteoma’

‘Aneurysmal bone cyst’

Incidence: 6% of all childhood malignancies

Age: 10 to 20 years

Features Wide zone of

transition

Aggressive periostealreaction

Cortical destruction

Extraosseous soft tissue component

‘Ewings sarcoma’ withLytic destruction,and periosteal reaction

soft tissue component

‘Osteosarcoma’ withLytic destruction,and periosteal reaction

soft tissue component

Incidence: 1/3 of all childhood malignancies

Age: 2 to 8 years

Boys > girls

Features

Metaphyseal lucency

Osteolytic lesions

Osteopenia

Vertebral fractures

Periosteal reaction

Altered bone marrow signal

T1 T2

‘Acute lymphoid leukemia’Metaphyseal lucent bandsand replaced bone marrow

Incidence: 5 to 37 per 100,000 children

Age: any age; most common <3 years

Boys>girls

Features Joint effusion

Juxta-articular osteoporosis

Bone erosions

Fat fluid level

Synovial enhancement

Perisynovial edema‘Septic arthritis’ Right hip effusion. Note mild secondary inflammation of bone and muscles.Right hip effusion.

Incidence: 76.2 per 100,000 children <15 years

Age: 3-8 years

Self limiting condition

Features

Symptomatic hip effusion

Synovial thickening

Synovial enhancement

Altered signal in surrounding tissue

No altered signal in bone marrow !!!

‘Transient synovitis’ Subtle synovial enhancement of the left hip. No bone marrow edema.

Incidence: 1-4% in tropical countries

30% in patients with HIV

Age: 2 to 5 years

Features

Muscle edema

Muscle enlargement

Intramuscular abscess

Gas within the abscess or muscle planes

‘Pyomyositis’ - 15 year old boy with fever and pain on internal rotation showsedema and inflammation of muscleand intramuscular abscess

Incidence

Age: 10 to 14 years

Children with cerebral palsy

Features

Thickening of proximal patellar tendon

Heterogeneity of posterior fibers

Abnormal signal in inferior pole of patella ‘Sinding Larsen Johansson disease’

High signal in the proximal patellar tendon,inferior patella on either side of the synchondrosis

Incidence: 13-21% in athletic adolescents

Age: 12 to 15 years

Boys > girls

Features Thickening and edema of

inferior patellar tendon

Soft tissue swelling

Loss of sharp inferior angle of Hoffa’s fat pad

Infrapatellar bursitis

Fragmentation of tibial tuberosity

‘Osgood Schlatter disease’ High signal seen in the distal patellar tendon,and tibial tuberosity

antero inferior Hoffa’s fat pad

Thrombophlebitis Appendicitis

Pelvic teratoma Pelvic abscess

Emergencies UrgenciesSeptic arthritis Open fractures

Neurovascular compromise Stable slipped capitalfemoral epiphysis

Compartment syndrome

Unstable slipped capital femoral epiphysis

Age

Type of gait

Toddler (1-3)

Occult Fracture

Transient Synovitis

Infection:

• Septic arthritis

• Osteomyelitis

• Pyomyositis

Neoplasm (neuroblastoma mets, leukemia)

Child (4-10)

Perthe’s disease

Transient synovitis

Infection:

• Septic arthritis

• Osteomyelitis

• Pyomyositis

JRA

AVN/Sickle cell pain

Neoplasm/Leukemia

Adolescent (11-16)

Slipped Capital Femoral Epiphysis

Infection:

• Septic arthritis

• Osteomyelitis

• Pyomyositis

JRA

AVN/Sickle cell pain

Neoplasm/Leukemia

Traumatic:

• Avulsion injuries

• Muscular tear

Non-antalgiclimp

Steppage gaitNeurologic condition

with loss of dorsiflexion

Trendelenburg gait

DDHabnormality in

adductor mechanism

Perthe’s

SUFE

Circumduction gait

Positive GaleazziLimb-length discrepancy

Neurologic or mechanical condition

leading to ankle or knee stiffness

Equinus gait

CTEVCerebral palsy

Idiopathic tight Achilles tendon

Calcaneal fractureForeign body in foot

Sever’s disease

Stooping gait

Appendicitis

Pelvic inflammatory disease

Psoas abscess

NOT SICK

< 2 yearsX ray of lower leg

for Toddler’s fracture

If negative hip

radiograph / US

2 to 10 years

No imaging or US to confirm transient

synovitis

Hip radiograph and ultrasound

> 10 years Hip radiograph

SICK Ultrasound

Effusion = septic arthritis

No effusion – Radiograph / bone scan / MR for

osteomyelitis

<5 days

>5 days

Persistent unexplained symptoms or

high suspicion

with negative radiography

MRI

Kocher criteria1. Non weight bearing2. Temp > 38.5oC 3. ESR > 40mm/h4. WBC > 12,000/mm3

Step 1

• Radiograph of hip (AP and frog leg)

• In toddler, radiograph of leg

Step 2

• Ultrasound hip in sick patients

• Ultrasound abdomen

Step 3

• MRI in negative cases with high index of suspicion

8 year old girl

Ischiopubic synchondrosis

9 year old girl

Normal or abnormal?

Normal irregularity of iliac crest

Normal apophysisin teenager Lucencies from

bowel gas.Rarely seen over the lateral half of the iliac crest.Always ask your self: “could these be a lytic bone lesion?”

Normal irregularitiesof the acetabular roofseen between 7 and 12 years old

15 year old

Limp is caused by myriad of trivial to life threatening causes with management varying from reassurance to major surgery depending upon the diagnosis.

The age of the child and clinical presentation has major bearing on the differentials to be considered.

An algorithmic imaging approach enables us to ‘walk towards the correct diagnosis’ to institute prompt management.

Satheesh Krishna Jeyaraj

Fellow in Emergency Radiology,

The Ottawa Hospital,

501, Smyth Road,

Ottawa,

K1H 8L6

Email: dr.satheeshkrishna@gmail.com