The Limping Child: The good, bad and do not miss KELLY CROWN, PA-C PEDIATRIC ORTHOPEDIC SURGERY Disclosures I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation Objectives 1. Learn to recognize which pediatric limps are concerning and require urgent/emergent care. Ultimately: When should you be concerned 2.
Review the most common and the most concerning etiologies of pediatric limp 3. Learn how clinical, radiographic and lab values can help you differentiate between these various etiologies What is a Limp? Asymmetric Results When gait in decreased time in the Stance Phase its painful = Antalgic Gait Painless: Typically Trendelenburg Gait seen BIGGEST TAKE AWAY When a child says they have knee pain..
Teen (13-18) SCFE Dysplasia Tarsal Coalition Osgood-Schlatter Disease Septic Arthritis #1 thing you MUST rule this out in all limping Serious kids Delay bacterial infection within the joint in treatment cartilage damage, AVN, osteomyelitis Hematogenus Neonates: Infants: spread Group B Strep, Gram Negative Bacteria MSSA, H. Influenza
Children: MSSA, Salmonella Adolescents: MSSA, Gonorrhea Can affect any body part and kids of any age but 50% are under the age of 2 0-2 y/o Hips 50% 3+ Knees 50%, Hip 20% SURGICAL Septic Arthritis Symptoms Physical Exam
Refuse to bear weight or limp Febrile or low grade fever Knee or hip pain Toxic/sick looking Fever NO injury No improvement with NSAIDs/Motrin Challenge
SEVERE pain with passive ROM. Positive Log Roll (hips) Asymmetry in motion Very hesitant to let you examine them Neonates less likely to be toxic Hip held in flexion and ER Can have TTP, erythema and when severe, visible effusion Kocher Criteria Used to identify septic hip arthritis vs. transient synovitis # 1. Refusal to bear Criteria weight Met
2. Fever >38.5C 1 (101.3F) 2 3. WBC >12,000 cells/uL 3 **CRP4. >20 mg/L or ESR >40 mm/h >2mg/dL ** (not part of original criteria, but shown to be most reliable indicator) Percentage chance of having Septic Arthritis 3% 40% 93% 4 Joint Surg. Am. 99% (J. Bone 1999;81:1662-70)
Septic Arthritis Tests CBC, CRP, ESR Treatment *Kocher Criteria Xray: Pelvis AP/Frog View Normal doesnt mean something isnt wrong. Late sign is narrowing, edema and ANV/collapse of the femoral head
Ultrasound if 2+ Kocher Criteria MRI more sensitive but can delay treatment Aspiration >50,000 cells/mm3, >75% segmented neutrophils Positive gram stain EITHER SURGERY EMERGENT SURGERY for I&D Sometimes, repease I&Ds are nessesary continue to follow the CRP
If its increasing, take back to surgery 6 weeks IV antibiotics Transient (Toxic) Synovitis * No. 1 Cause of limp/hip pain in children age 2-8 Self-limited inflammatory joint condition Most commonly affects the hip Most commonly complain of Knee/Thigh Pain Males 2:1 Diagnosis of Exclusion
MUST RULE OUT SEPTIC ARTHRITIS No single laboratory or imaging study will be definitive to confirm or exclude transient synovitis. Transient (Toxic) Synovitis Symptoms Physical Exam Limp or refuse to bear weight Afebrile or low grade fever Knee or hip pain Not toxic/sick looking
REMOTE history of an ILLNESS Passive ROM: Asymmetry +/- guarding and pain 1 to 5 weeks ago Viral or bacterial NO injury Typically worse in the morning AFEBRILE or low grade fever (99-101)
Limp improves with NSAIDs Hips: decreased Abduction and Internal Rotation (+Impingement) Knee: lack full flexion +/- lack terminal extension No TTP, No erythema, No visible effusion Transient (Toxic) Synovitis Tests Treatment CBC, CRP, *ESR Xray: Pelvis AP/Frog View
Normal Normal vs slight widening Ultrasound 0.43 0.49 Self limiting Symptoms can resolve in a week or as long as 4-5 weeks The faster the patient is put on Motrin, TID, the faster their pain/symptoms resolve Toddlers Fractures
Low energy injury i.e.) Trip and fall over a toy Classic: going down a slide Age < 3y/o Walking toddlers: low likelihood of child abuse If not walking, suspect abuse STABLE fractures: commonly spiral/oblique fracture of the tibia Other common locations
1st Metatarsal Tibia +/- Fibula Femur (higher suspicion for abuse) Toddlers Fractures Symptoms Limp or refuse to bear weight Physical Exam Afebrile, Nontoxic Crawling: tibia, fibula fx BONY TTP and/or pain with rotation
Not walking: tibia or femur fx Walk on lateral aspect of foot or on their heel: Metatarsal fx Passive ROM: Asymmetry +/- guarding and pain Injury AFEBRILE Pain with hip ROM: femur
Pain with knee ROM: distal femur or proximal tibia Pain with ankle ROM: distal tibia/fibula Toddlers Fractures Tests Xray: nondisplaced subtle fracture Treatment Self limiting Cast vs observation Sometimes a clinical diagnosis
Might not be visible for a week Heal in 2-4 weeks Late finding is new periosteal reaction Limp up to 6 weeks Typically no long term sequela Proximal Tibia (Cozen Fracture) slight risk of developing Cozen Deformity (Valgus deformity of the knee 1-2 years after) Leg-Calve-Perthes aka Perthes
Unknown etiology Avascular Necrosis of the Femoral Head Can cause permanent deformity of the femoral head Earlier treatment, minimizes this risk of permanent deformity Boys 5:1 more likely Age typically 4-7 Age <6 better prognosis Age > 8 worse prognosis Leg-Calve-Perthes Symptoms
PAINLESS LIMP (first symptom) +/- Hip, thigh or Knee NO injury Afebrile Symptoms Wax and Wane Physical Exam Antalgic gait Trendelenburg gait late finding once
femoral head collapses Decreased hip ROM Loss of Abduction and Internal Rotation Hip flexion contracture Worse during or after activities Limp Length Discrepancy (late finding) Improve with rest and NSAIDs Hip contracture can exacerbate this Leg-Calve-Perthes Tests Xray Treatment **type of treatment recommended is based on patients age, stage of disease, and radiographic class** Normal first 3-6mo
Early signs is medial joint space narrowing, sclerosis and MAIN GOALS flattening of the femoral head Symptomatic relief: NSAIDs MRI is the gold standard for diagnosis Follow with serial xrays Protected weight bearing through the acute phase with crutches +/abduction brace Can take 18mo to 2 years to fully subside SCFE (Slipped Capital Femoral Femoral head Slips off the Femoral neck
Most common adolescent hip disorder Epiphysis) Ice cream falling off the cone During rapid growth Males: 13.4 y/o (12-16) Females 12.2 y/o (10-14) Younger: Hypothyroid **Obesity** Male (2 to 1.5 ratio)
Unilateral (40% BL) SURGICAL EMERGENCY Jorge Muniz, PA-C, Medcomic.com SCFE Symptoms PAINFUL LIMP Acute or chronic Hip pain (L>R)
Physical Exam Commonly get referred thigh or Gait Antalgic gait = Stable SCFE NWB = Unstable SCFE Decreased hip ROM knee pain Loss of Internal Rotation +/- minor injury Obligatory ER with hip flexion
Afebrile Guarding Limp Length Discrepancy (unstable) Short and Externally rotated SCFE Tests Xray Pelvis Frog-leg best at subtle SCFE MRI if nl Xray: can dx pre-slip AP & Frog-leg Lateral
Treatment Physeal edema or widening Percutaneous Screw Fixation URGENT Contralateral Pinning? Correct the deformity after it heals Minimal displacement: hip arthroscopy with chondroplasty (FAI surgery) Displaced: Varus Derotational Osteotomy (VDRO)
Case 1: Left leg pain x 13 days. Hasnt walked in 12 days 7 y/o Female No PMH 2 weeks ago fell from a seated position off a rocking chair. Walked and had no pain after the fall. Next morning woke up with left knee pain and wouldnt walk 2 days later, had a tactile fever. Taken to local ER, Temp 100.4. Hip Xray Slight Narrowing. Positive for StrepA and put on Amoxicillin Day 7 of her ABX develops a rash, back to urgent care. Still not walking! Temp 99. Thought to be a drug rash. Stopped the Amoxicillin and put on Ceftin. CBC: elevated WBC (13.6), Anemic, Hgb 10.5, Hct 31.1, Platelets 724 Case 1 Sees PCP the AM before coming to the ortho clinic, order labs CBC: nl WBC (10), worsening anemia Hgb 9.1, Hct 28, Platelets 671
Sed Rate 95 DAY 13: Sees me HASNT WALKED IN 12 DAYS. Parents still say that tactilely she is still febrile (dont have a thermometer) No improvement in pain with Motrin or Tylenol. Any small movement, she cries in pain. Case 1 Vitals Temp 98.2 F (took motrin 2 hrs prior)
Unable to get height and weight because she refuses to stand PE Sitting in a baby stroller Looks sick SEVERE pain with even minor left hip ROM Hip flexion contracture with obligatory ER Full knee ROM without pain TTP at Psoas
Day 4 Day 13 Case 1 Admitted to Fairfax ED for STAT MRI with aspiration Labs WBC 14.12 Hgb Hematocrit 29.0
Platelets CRP 6.3 ESR 99 9.5 681 4.80 - 13.00 x10 3/uL 11.5 - 14.5 g/dL 33.0 - 43.0 % 140 - 400 x10 3/uL 0.0 - 0.8 mg/dL 0 - 20 mm/Hr Kocher Criteria Used to identify septic hip arthritis vs. transient synovitis # 1. Refusal to bear Criteria
weight Met 2. Fever >38.5C 1 (101.3F) 2 3. WBC >12,000 cells/uL 3 **CRP4. >20 mg/L or ESR >40 mm/h >2mg/dL ** (not part of original criteria, but shown to be most reliable indicator) Percentage chance of having Septic Arthritis 3% 40% 93% 4 Joint Surg. Am. 99%
(J. Bone 1999;81:1662-70) Case 1 MRI URGENT I&D Septic arthritis with Psoas Abscess Cartilage of her hip was gone, underlying osteomyelitis 6 weeks IV ABX 3 months post-op Still has pain and limited hip ROM 1 year post op Case 2: Left hip pain x 2 weeks
11 y.o. female No PMH Left hip pain x 2 weeks after a fall jumping over hurdles at camp and landed on her LLE "awkwardly." Pain= sharp, non-radiating, worse with movement Able to walk PE: Vitals 53 130lbs Afebrile AAO x 3, NAD Slightly antalgic gait but FWB TTP at the groin Pain and Limited IR
Case 2 URGENT Percutaneous Screw Fixation 7 weeks post-op Pain free FWB Only lacked 10 degrees IR Full abduction CLEARED FOR ALL ACTIVITIES Case 3: 1 year of left knee pain
16 y/o M with no PMH here for 2nd opinion Left knee pain x 1 year after a twisting injury during soccer Didnt get treatment for 2 months Was seen by an outside ortho group for concern for meniscus tear MRI showed small lateral meniscus tear Tx included rest, NSAIDs, corticosteroid injection and months of physical therapy Physical Therapist noted that he had minimal hip ROM
Has had no hip pain x 2 months Case 3 Vitals 57 187lbs Afebrile IR of the Right was 40, Left was 0 and with mild pain Obligate ER of the left Full knee ROM, negative McMurry Gait: Significant Trendelenburg and External Foot progression of the left
PE Case 3 TREATMENT Option 1: Percutaneous Screw Fixation POSITVE: would stop further Slippage, minor surgery, WBAT after NEGATIVE: wouldnt correct the deformity, likely need a second surgery Option 2: VDRO (Valgus Derotational Osteotomy) POSITIVE: Would correct the deformity and regain his motion NEGATIVE: Major surgery, would be NWB for 4-6 week and not able to run for 12 weeks
They choose option 2 10 weeks post-op -now FWB -knee pain -recently started PT to help with his hip ROM and strength now that the osteotomy is healed BIGGEST TAKE AWAY When a child says they have knee pain.. ALWAYS EXAMINE THE HIPS Thank you! Questions?
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