The Limping ChildThe Limping Child

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Definition

Limp = Asymmetry• Joint - Range of motion• Bone - Deformity• Pain• Control

The Limping Child

•Diagnosis

•Mechanism

The Limping Child

• Pitfalls• Being misled by the parents’ analysis

• Always a leg length discrepancy

• Being misled by the patient’s complaint• Hip problems can cause knee pain

• Complaints of pain

AGE

NEWBORNINFANT

TODDLER

CHILD

PRE-TEEN

TEENAGER

ADULT

5

COMPLAINS

LIMPS

The Limping Child

Causes of limp• Joint - Range of motion• Bone - Deformity• Pain

• Hip• Control

-Physical exam-X-ray-‘Antalgic’ gait -Abductor lurch-Upper limb

Too much to cover

The Limping Child

Hip

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Age

The Limping Child

• Age 1 – 3 years

• Age 3 – 6 years

• Age 6 – 10 years

• Age 10 – 14 years

• DDH• Developmental Dysplasia of the Hip

• CDH• Congenital Dislocation of the Hip

Best Bet

The Limping Child:Age 1 – 3

1

The Limping Child: Age 1 – 3DDH

Physical findings• Girl• Asymmetrical skin folds• Limited abduction• Short leg• Pistoning• Ortolani’s sign• Barlow’s sign

X-ray findings• Delayed appearance of ossific nucleus• Small ossific nucleus• Dysplastic acetabulum• Proximal displacement of femur

The Limping Child: Age 1 – 3DDH

The Limping Child: Age 1 – 3DDH

Treatment• 0 – ½: Pavlik harness• ½ – 1½: Closed reduction, cast• 1 ½ - 5 or 8: Open reduction, pelvic osteotomy• Older: Leave dislocated

Pavlik Harness

• Check at 3 weeks to confirm reduction

• Adjust position every 6 – 12 weeks

• Continue until the hips are clincally and radiologically normal

• Transient synovitis

• Septic arthritis

Best Bet

The Limping Child:Age 3 – 6

s

• Flu

• Tonsillitis2

The Limping Child:Age 3 – 6

Transient synovitis• Child refuses to walk• Movement of hip is painful• May have fever• Moderately elevated WBC• Lasts a few days• Disappears without treatment

The Limping Child:Age 3 – 6

Septic arthritis• Child refuses to walk• Movement of hip is painful• May have fever• Elevated WBC• Progressively sicker• Progressive joint destruction

WIDENED JOINT SPACE

The Limping Child: Age 3 – 6Septic Arthritis

Bacteria

Enzymes

Destroy cartilage

Irreversable joint damage

White cells

Enzymes

The Worst Scenario

• Destruction of articular cartilage

• Destruction of femoral head

• Destruction of femoral neck

The Limping Child: Age 3 – 6Septic Arthritis

Treatment1. Kill the bacteria

• Antibiotics

2. Eliminate the white cells• Incision and drainage

3. Don’t delay• 48 hour window

The Limping Child: Age 3 – 6Septic Arthritis

• How to tell the difference?• Four predictors

• History of fever• Refusal to weight-bear• ESR > 40 mm/hr• WBC > 12,000

• If in doubt• Review in 12 hours• Do incision and drainage!

The Limping Child: Age 3 – 6Transient Synovitis vs. Septic Arthritis

Kocher, Kasser, et al.JBJS 86-A: 1629, 2004

Legg-Calvé-Perthes Disease

Best Bet

The Limping Child:Age 6 - 10

3

Physical findings• Boy• Limp• Antalgic gait• Pain with passive motion• Limited abduction• Positive Trendelenburg sign

The Limping Child: Age 6 – 10Perthes Disease

The Limping Child: Age 6 – 10Perthes Disease

• X-ray findings• Perhaps nothing

• MRI

• Irregular consistency• Flattening• Lateral bump/ridge• Lateral hinging

The Limping Child: Age 6 – 10Perthes Disease

Treatment1. Maintain range of motion

• Physical therapy

• Anti-inflammatory medication

2. “Containment”• Bracing in abduction

• Femoral osteotomy

• Pelvic osteotomy

The Limping Child: Age 6 – 10Perthes Disease

The Limping Child: Age 6 – 10Perthes Disease

50% need a Total Hip by age 50

Slipped Capital Femoral Epiphysis(SCFE – skiffey)

Best Bet

The Limping Child:Age 10 – 14

4

The Limping Child: Age 10 – 14SCFE

Always get a frog lateral view

Always check the other side

• Pediatric orthopaedic surgeons• See 6 per year

• General orthopaedic surgeons• See 1 every 6 years• Same as fixing a fracture

The Limping Child: Age 10 – 14SCFE

• ClassificationClassification• Acute or chronicAcute or chronic• Stable or unstableStable or unstable• Severity of displacementSeverity of displacement• Slip angleSlip angle

• BilateralityBilaterality• 10 – 15% at presentation10 – 15% at presentation

The Limping Child: Age 10 – 14SCFE

Useful ClassificationUseful Classification

• StableStable• Walks inWalks in

• UnstableUnstable• Wheels inWheels in

• Bone in one pieceBone in one piece • Slow plastic Slow plastic deformationdeformation of the growth plate of the growth plate

•Bone in two piecesBone in two pieces• Physeal fracturePhyseal fracture

No reductionNo reductionOne screwOne screw

Closed reductionClosed reductionTwo screwsTwo screws

Unstable SCFEUnstable SCFE

Xray FindingsXray Findings

• Displacement of neck on headDisplacement of neck on head• Mainly anteriorMainly anterior• Somewhat superiorSomewhat superior

• Decreased projected femoral head heightDecreased projected femoral head height• ChronicityChronicity

• Inferior new boneInferior new bone• Superior rounding off of metaphysisSuperior rounding off of metaphysis• Curved neckCurved neck

CastroAPCastroAP

Silva Chronic SlipSilva Chronic SlipDegree of slip??

Castro Right LateralCastro Right Lateral

Slip angle

ConceptConcept

Displacement of head on neckDisplacement of head on neck

Gradual change in shapeGradual change in shape

The femoral neck “curves” posteriorlyThe femoral neck “curves” posteriorly

Starting Point – Severe Slips

Correct PathCorrect Path

Controlling DepthControlling Depth

• Approach WithdrawApproach Withdraw• Rotate hip through full rangeRotate hip through full range• Observe projected distance of pin tip from Observe projected distance of pin tip from

subchondral bonesubchondral bone• Watch for change in directionWatch for change in direction• That moment presents the critical viewThat moment presents the critical view

BLIND SPOT

3–D Geometry3–D Geometry

The Critical ViewThe Critical View

Approach-Withdraw 1Approach-Withdraw 1

1

Approach-Withdraw 2Approach-Withdraw 2

2

Approach-Withdraw 3Approach-Withdraw 3

3

Approach-Withdraw 4Approach-Withdraw 4

4

Approach-Withdraw 5Approach-Withdraw 5

5

Approach-Withdraw 6Approach-Withdraw 6

6

Approach-Withdraw 8Approach-Withdraw 8

7

Approach-Withdraw 7Approach-Withdraw 7

8

Approach-Withdraw 5Approach-Withdraw 5

5The Critical View

The Contralateral HipThe Contralateral Hip

• Out of 100 patients:• 10 are bilateral at presentation• 10 will slip on the other side later• 5 will have painless slips on the other side

Follow-up for BilateralityFollow-up for Bilaterality

• Follow radiologicallyFollow radiologically

• Every three monthsEvery three months• For 18 monthsFor 18 months

The Limping Child

• Age 1 – 3 years - DDH• Age 3 – 6 years - Septic arthritis• Age 6 – 10 years - Perthes Disease• Age 10 – 14 years - SCFE

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The Limping ChildThe Limping Child

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