Transcript THE CHILD WITH A LIMP

THE CHILD WITH A
LIMP
Madesa Espana, MD, FAAP
Pediatric Emergency Medicine
St. Joseph’s Regional Medical Center
Paterson, New Jersey
LIMP
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An uneven, jerky or laborious gait, usually
caused by pain, weakness or deformity.
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4/1000 visits in a pediatric ED
A CHILD WITH A LIMP
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Epidemiology
– Median age: 4 years old
– Male:female ratio: 2:1
– Most common diagnosis: Transient synovitis
– Pain is present in 80% of cases
– Localization: hip and knee
– Benign cause: 77%
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HISTORY
– Duration
– Trauma
– Fever
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HISTORY
– Location of the pain
– Pain characteristics
 Constant severe pain
 Intermittent mild to moderate pain
 Bilateral pain
 Modifying factors
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HISTORY
– Other symptoms
 Morning stiffness
 Incontinence, weakness or sciatica
 Recent viral or bacterial illness
 Recent medications
 Endocrine and other systemic diseases
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PHYSICAL EXAMINATION
– General appearance
 Ill or toxic appearing
 Fever
 Obvious discomfort/pain at rest
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PHYSICAL EXAMINATION
– Gait evaluation
 Phases of a gait
– Stance: time when the foot is in contact with the
surface
 Heel-strike to toe flat (contact)
 Foot-flat to heel-off (mid-stance)
 Heel-lift to toe off (propulsion)
– Swing: time from toe-off to heel strike
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PHYSICAL EXAMINATION
– Young child (<4 years) vs. adult gait
 Increased flexion of the hips, knees and
ankles
 Rotation of the feet externally, wider base of
support
 Faster cadence, slower velocity, shorter
stride length
 Smaller percentage of the gait cycle is spent
in single limb stance
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PYSICAL EXAMINATION
– Gait examination
 Expose the legs
 Bare feet or wearing only a pair of socks
 Listening to the gait
– Cadence
– Foot slap
– Scraping
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PHYSICAL EXAMINATION
– Gait examination
 Observe several gait cycles
 Includes jumping/hopping
Gait evaluation
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PHYSICAL EXAMINATION
– Musculoskeletal
 Muscle strength
 Muscular atrophy
 Bony tenderness
 Bony deformity
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PHYSCIAL EXAMINATON
– Musculoskeletal
 Active and passive ROM
 Joint swelling/tenderness
 Muscle tenderness
 Tenderness on the tendons, insertions sites
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PHYSICAL EXAMINATION
– Musculoskeletal
 Back and spine
 Hip
 Thigh
 Knee
 Leg
 Ankle
 Foot
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PHYSICAL EXAMINATION
– Musculoskeletal
 Limb length discrepancy
 Hip rotation
 Galeazzi test
 Trendelenburg test
 FABERE test
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PHYSICAL EXAMINATION
– Skin
 Bruises
 Rashes and other lesions
 Swelling
 Redness
 Tenderness
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PHYSICAL EXAMINATION
– Lymphatic
 Lymphadenopathy
– Localized vs. systemic
 Lymphadenitis
 Lymphangitis
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PHYSICAL EXAMINATION
– Neurologic
 Muscle strength
 Muscle tone
 DTR’s
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PHYSICAL EXAMINATION
– Gastroentestinal
 Abdominal tenderness
 Abdominal swelling
– Genitourinary
 Testicular or scrotal pain/swelling
 Inguinal swelling
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DIFFERENTIAL DIAGNOSES
– Age of the child
– Location of abnormal findings
– Duration of symptoms
– Type of gait abnormality
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DIFFERENTIAL DIAGNOSES
– OSSEOUS
 Fractures
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Salter-Harris or growth plate injuries
Toddler’s: tibia, calcaneous and cuboid
Stress
Incomplete: buckle, greenstick
Complete
Plastic or bowing deformity
Avulsion
Child abuse: bucket-handle fractures
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DIFFERENTIAL DIAGNOSES
– OSSEOUS
 Apophysitis
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Sinding-Larsen-Johnson disease
Kohler disease
Sever disease
Freiberg disease
Osgood-schlater disease
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DIFFERENTIAL DIAGNOSES
– OSSEOUS
 Vasoocclussive crisis of SCD
 Slipped capital femoral epiphysis
 Legg-Calve-Perthes disease
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DIFFERENTIAL DIAGNOSES
– TUMORS
 Leukemia
 Lymphoma
 Spinal cord tumor
 Osteogenic sarcoma
 Ewing’s sarcoma
 Osteoid sarcoma
 Metastatic neuroblastoma
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DIFFERENTIAL DIAGNOSES
– ARTICULAR
 Transient synovitis of the hip
 Septic arthritis
 Osteochondritis dessicans
 Acute rheumatic fever
 Juvenile rheumatoid arthritis
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DIFFERENTIAL DIAGNOSES
– ARTICULAR
 Serum sickness
 Discitis
 Developmental dysplasia of the hip
 Chondromalacia of the patella
 Hemarthrosis: traumatic, hemophilia
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DIFFERENTIAL DIAGNOSES
– ARTICULAR
 Henoch-Schonlein purpura
 Lyme disease
 SLE
 Patellar dislocation
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DIFFERENTIAL DIAGNOSES
– SOFT TISSUE
 Contusion
 Muscle strain
 Sprain
 Tendonitis
 Viral myositis
 Foreign body
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DIFFERENTIAL DIAGNOSES
– SOFT TISSUE
 Cellulitis
 Abscess
 Pyomyositis
 IM vaccination
 Insect envenomation
 Plantar warts
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DIFFERENTIAL DIAGNOSES
– SOFT TISSUE
 Bunion
 Ingrown toenail
 Baker’s cyst rupture
 Myositis ossificans
 Bursitis
 Benign hypermobility syndrome
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DIFFERENTIAL DIAGNOSES
– NEUROLOGICAL
 Meningitis/Intracranial abscess
 Cerebral palsy
 Peripheral neuropathy
 Epidural abscess
 Spinal cord tumor
 Complex regional pain syndrome (reflex
sympathetic dystrophy)
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DIFFERENTIAL DIAGNOSES
– INTRA-ABDOMINAL
 Appendicitis
 PID
 Pelvic abscess
 Psoas abscess
 Perirectal abscess
 Iliac adenitis
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DIFFERENTIAL DIAGNOSES
– GENITO-URINARY
 Incarcerated inguinal hernia
 Testicular torsion
 STD’s
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DIFFERENTIAL DIAGNOSES
– PSYCHIATRIC
 Conversion disorder
 Malingering
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DIFFERENTIAL DIAGNOSES
– DERMATOLOGIC
 Erythema multiforme
– VASCULAR
 Henoch-schonlein purpura
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DIFFERENTIAL DIAGNOSES
LIFE OR LIMB-THREATENING CAUSES OF
LIMP IN CHILDREN
Septic arthritis
SCFE
Osteomyelitis
Fracture
Tumors
Appendicitis
Testicular torsion
Discitis
Meningitis
Epidural abscess
Developmental dysplasia of the hip
CAUSES OF LIMP IN CHILDREN
OF ALL AGES
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ACUTE
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Contusion
Foreign body
Fracture
Osteomyelitis
Reactive arthritis
Septic arthritis
Transient synovitis
Lyme arthritis
Poor shoe fit
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CHRONIC
– Rheumatic disease
 JRA
 Acute rheumatic
fever
 SLE
 Inflammatory bowel
disease
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SEPTIC ATHRITIS
– Clinical signs/symptoms
 Fever
 Pain
 Decreased ROM
 Minor trauma
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SEPTIC ARTHRITIS
– Clinical signs/symptoms
 Toxic or ill appearance
 Painful ROM
 Joint effusion
 Warmth/erythema
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SEPTIC ARTHRITIS
– Laboratory findings
 Elevated WBC count with left shift
 Elevated ESR
 Elevated CRP
 Positive blood culture
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SEPTIC ARTHRITIS
– Laboratory findings
 Synovial fluid analysis
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Volume > 3.5 ml
Clarity: opaque
Color: yellow to green
WBC: > 100,000/mm3, >75% PMN’s
Gram stain/Culture: positive
Total protein: 3 – 5 g/dl
Glucose: <25 mg/dl
LDH: variable compared to blood level
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SEPTIC ARTHRITIS
– Common organisms
 Staphylococcus aureus
 Beta hemolytic streptococcus
 Group A strep
 Hemophilus influenzae
 Neisseria gonorrhea
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SEPTIC ARTHRITIS
– Radiologic findings
 Plain films:
– Soft tissue swelling
– Widened joint space
– Periosteal reaction of the adjacent bone,
suggestive of osteomyelitis
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SEPTIC ARTHRITIS
– Radiologic findings
 Ultrasonography
– Increased joint space and amount of joint fluid
– Increased vascularity
 CT scan
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Joint effusion
Increased vascularity
Erosion of the cartillage
Periosteal reaction or osteomyelitis
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SEPTIC ARTHRITIS
– Radiologic findings
 MRI
 Radionuclide studies
CAUSES OF LIMP IN PRESCHOOL CHILDREN
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ACUTE
– Fractures
 Abusive injuries
 Toddler’s fracture
 Salter I fractures
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Hemarthrosis
HSP
Septic hip
IM shots
Toxic synovitis
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CHRONIC
– Blount disease
– Cerebral palsy
– Developmental
dysplasia of the hip
– Discitis
– Kohler disease
– Leg length
discrepancy
– Vertical talus
CAUSES OF LIMP IN SCHOOLAGE CHILDREN
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ACUTE
– Fractures
– Myositis
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CHRONIC
– Legg-calve-Perthes
disease
– Baker cyst
– Kohler disease
– Leukemia
– Spinal dysraphism
(tethered cord)
– Tarsal coalition
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LEGG-CALVE-PERTHES DISEASE
– Idiopathic vascular necrosis of the femoral
head
– More common in boys
– Common in 5 – 9 years old, may affect 2 – 11
years old
– Transitional stage of development of the
vascular anatomy of the femur
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LEGG-CALVE-PERTHES DISEASE
– Preceding history of minor trauma
– Predisposing factors
 SCD
 Steroid use
 Hip dysplasia
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LEGG-CALVE-PERTHES DISEASE
– Radiologic studies
 Plain films
 Radioisotope studies
 MRI
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KOHLER DISEASE
– Affects more boys than girls
– Most common in 5 – 10 years old, as early as
2 years old
– Impaired perfusion to the navicular bone of
the talus
– Inflammatory changes over the navicular
bone
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KOHLER DISEASE
– Treatment
 Weight bearing with below the knee cast
followed by arch support
CAUSES OF LIMP IN
ADOLESCENTS
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ACUTE
– Sprain
– Strain
– Tendonitis
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CHRONIC
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Arthritis
Herniated disc
SCFE
Scoliosis
Spinal dysraphism
Spondylolisthesis
Chondromalacia
RSD
Osgood-Schlatter
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OSGOOD-SCHLATTER DISEASE
– Over use injury affecting the insertion site of
the patellar tendon on the anterior tibial
tubercle
– Inflammatory changes over the tubercle
– Treatment goal: decrease the stress on the
tubercle
 Rest
 Cast
 Excision of an ossicle
Surface Anatomy of the Knee
Saggital view of the knee
Osgood-Schlatter Disease
radiographs
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SINDING-JOHANSSON-LARSEN DISEASE
– Traction tendinitis of the proximal attachment
of the patellar tendon (inferior pole of the
patella)
– Boys more than girls
– Age of presentation: 10 –16 years old
– Overuse injury, athletes
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SINDING-JOHANSSON-LARSEN DISEASE
– Radiologic findings
 Irregular calcification of the inferior pole of
the patella
– Treatment
 Rest
 Cast
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SLIPPED CAPITAL FEMORAL EPIPYSIS
(SCFE)
– Epiphyseal dislocation in superolateral
displacement and external rotation of the
femoral metaphysis, Salter I injury
– Causes kinking of the epiphyseal vessels that
leads to compromised blood to the epiphysis
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SCFE
– Incidence
 10/100000
– Boys: 13.5, Girls 8.5/100000
 Regional and seasonal variation
 Initial presentation 20% bilateral hip
– 20 – 40% eventually develop bilateral
involvement within 18 months of initial
presentation
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SCFE
– Radiologic classification
 I: < 33%
 II: 33 – 50%
 III: > 50%
 Displacement in relation to the femoral neck
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Treatment
– Depends on the onset of symptoms and grade
– Internal fixation with single cannulated screw
– Prophylactic fixation of the unaffected hip
– Osteomy of the proximal femur
SCFE radiographs
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LABORATORY STUDIES
– Blood tests
 CBC, differential
 ESR
 CRProtein
 Blood culture
 Lyme studies
 ANA
 ASO
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LABORATORY STUDIES
– Normal synovial fluid characteristics
 Highly viscous
 Clear
 Essentially acellular
 Protein concentration is 1/3 of plasma
protein
 Glucose concentration is similar to plasma
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LABORATORY STUDIES
– Components of synovial fluid analysis
 Clarity
 Color
 Viscosity
 Glucose content
 Protein content
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LABORATORY STUDIES
– Components of synovial fluid analysis
 Microscopic examination
– WBC count
– Crystal search
– Gram satin
 Culture
– Routine bacterial culture
– GC culture
– Unusual organisms
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RADIOLOGIC TESTS
– Plain radiographs
 Affected site
 Comparison views
 Skeletal survey
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RADIOLOGIC TESTS
– MRI
– Radionuclide studies
– Ultrasonography
– CT scan
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DISPOSITION
– In-patient
 IV antibiotics
 Diagnostic work-up
 Surgical intervention
– Out-patient
 Observation with close follow up
 NSAID’s
 Sub-specialty referrals
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DISPOSITION
– Consultation
 Orthopedic
– Joint aspiration
– Surgical intervention
 Hematology-Oncology
– Bone marrow aspiration
– Chemotherapy
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DISPOSITION
– Consultation
 Gynecologic
– Pelvic examination
– Surgical intervention
 Urology
– Surgical intervention
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DISPOSITION
– Consultation
 Neurosurgery
 Pediatric or general surgery
– Surgical intervention
 Infectious disease
– Choice of antibiotics
– Length of treatment
THE CHILD WITH A LIMP
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DISPOSITION
– Consultation
 Rheumatology
 Pain specialist
 Psychiatry
 Physiatry
– Physical/occupational therapy
– Orthotics
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DISPOSITION
– Diagnoses that require immediate intervention
 Septic arthritis
 Osteomyelitis
 Meningitis
 Epidural abscess
THE CHILD WITH A LIMP
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DISPOSITION
– Diagnoses that require immediate intervention
 Fractures
 Dislocated patella
 SCFE
 Developmental dysplasia of the hip
THE CHILD WITH A LIMP
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DISPOSITION
– Diagnoses that require immediate intervention
 Neoplasms/tumors
 Testicular torsion
 Appendicitis
 PID with tuboovarian abscess
 Discitis