Download Common conditions that can cause limping in a child

Approach to a Limping Child
• Comprehensive history
– Prenatal, perinatal and postnatal
– developmental milestones for posture,
locomotion, dexterity, social activities, and speech
previous procedures and significant medical
conditions
– pain or other symptoms
– family history may give clues to possible genetic
disorders such as congenital syndromes, muscular
dystrophy, skeletal dysplasias, and other disorders
affecting the musculoskeletal system
Characterization of Pain
Physical examination
• Examination of the musculoskeletal system
as well as a comprehensive neurologic
examination.
• Inspection, palpation, and evaluation of
motion, stability, and gait.
• Basic neurologic examination including
sensory examination, motor function, and
reflex evaluation
Inspection
Palpation
• Contractures
– loss of mobility of a joint
– periarticular soft-tissue fibrosis or involvement of muscles crossing the
joint
• Spasticity
– abnormal increase in tone associated with hyperreflexia and is
common in cerebral palsy.
• Deformity
– abnormal fixed shape or position
– +/- associated muscle spasm, local tenderness, or pain on motion.
– it an be defined as varus (away from midline) or valgus (apex toward
midline/coronal plane), or recurvatum or flexion deformity (sagittal
plane).
– In the axial skeleton, especially the spine, deformity can be defined as
scoliosis, kyphosis, hyperlordosis, and kyphoscoliosis
Range of Motion
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Abduction: Away from the midline
Adduction: Toward the midline
Flexion: Movement of bending from the starting position
Extension: Movement from bending to the starting position
Supination: Rotating the forearm to face the palm upward
Pronation: Rotating the forearm to face the palm
downward
Inversion: Turning the hindfoot inward
Eversion: Turning the hindfoot outward
Internal rotation: Turning inward toward the axis of the
body
External rotation: Turning outward away from the axis of
the body.
Gait Assessment
• Cadence: The number of steps taken per
minute
• Step length: The distance covered during one
step
• Step period: The time measured from an
event in one foot to the same event in the
opposite foot
• Stride period: The time from heel strike of one
foot to the next heel strike of the same foot
• Stride length: The total distance covered from
one heel strike to the same-foot heel strike.
LIMPING
Back Pain
• Most frequent causes of back pain in children
are trauma, spondylolysis, spondylolisthesis,
and infection
• Tumor and tumor-like lesions that cause back
pain in children are likely to be missed unless
a thorough clinical assessment and adequate
work-up are performed when required.
• Nonorthopedic causes of back pain include
urinary tract infections, nephrolithiasis, and
pneumonia.
Neurologic Evaluation
• Grade 0: No muscular contraction detected.
• Grade 1: Trace contraction, barely detectable
clinically.
• Grade 2: Active movement with gravity
eliminated.
• Grade 3: Active movement against gravity.
• Grade 4: Active movement against gravity and
some resistance.
• Grade 5: Active movement against full
resistance.
ASSESSMENT
• RADIOGRAPHIC ASSESSMENT.
– Plain radiographs
– Advanced imaging includes special procedures such as
nuclear bone scans, ultrasonography, CT, MRI, and positron
emission tomography (PET).
• PLAIN RADIOGRAPHS.
– Anteroposterior and lateral views of the involved area with
one joint above and below.
• NUCLEAR MEDICINE IMAGING.
– Bone scan - physiologic information rather than pure
anatomy
– emission of energy from the nucleotide injected into the
patient.
– Total body radionuclide scan (technetium-99) - identify
bony lesions and may also help in evaluation of biologic
activity of the primary bone lesion
ASSESSMENT
• ULTRASONOGRAPHY.
– No ionizing radiation, no contrast material to be
administered, and no biologically harmful effects and can
be repeated as often as necessary.
– Disadvantages: Bone is not penetrated, static images are
difficult to interpret, and the results are operator
dependent.
• MAGNETIC RESONANCE IMAGING.
– imaging modality of choice for further defining the exact
anatomic extent of most musculoskeletal lesions.
• MAGNETIC RESONANCE ANGIOGRAPHY (MRA).
– good visualization of peripheral vascular branches and
tumor neovascularity in patients with primary bone
tumors. MRA is helpful in demonstrating encroachment
onto and encasement of major vessels by the tumor mass
ASSESSMENT
• COMPUTED TOMOGRAPHY.
– Allows visualization of the detailed bone anatomy and the
relationship of bones to contiguous structures.
– Superior to MRI for assessment of bone involvement and
cortical destruction (even subtle changes), including
calcification or ossification and fracture.
• POSITRON EMISSION TOMOGRAPHY.
– Provides complementary metabolic information in many
oncology applications.
• LABORATORY STUDIES.
– May include a complete blood cell count; erythrocyte
sedimentation rate; C-reactive protein assay; Lyme titers;
and blood, wound, joint, periosteum, or bone cultures
– Rheumatoid factor, antinuclear antibodies, and human
leukocyte antigen B27
– Creatine kinase, aldolase, aspartate aminotransferase, and
dystrophin testing
COMMON CONDITIONS THAT CAN
CAUSE LIMPING IN A CHILD
Painful (Antalgic) Gait
Painless (Trendelenburg) Gait
Stance phase is shortened
Stance phase is equal
Trauma, infection, or
pathologic fracture
Underlying proximal muscle
weakness or hip instability
Child leans toward the
unaffected side
Child leans toward the
involved extremity
Common Causes of Limping
Age
Antalgic
Trendelenburg
Leg Length
Discrepancy
Toddler
(1-3)
Infection
(Septic arthritis, Osteomyelitis,
Diskitis)
Toddlers fracture
Neoplasia
Hip dislocation
Neuromuscular disease
Cerebral Palsy
Poliomyelitis
(-)
Childhood
(4-10)
Infection
(Septic arthritis, Osteomyelitis,
Diskitis, Transient Synovitis)
Legg-Calve-Perthes
Tarsal coalition
JRA
Trauma
Neoplasia
Hip dislocation
Neuromuscular disease
Cerebral Palsy
Poliomyelitis
(+)
Adolescent
(>10)
Slipped capital femoral
epiphysis
JRA
Trauma
Tarsal coalition
Neoplasia
(+)
Coronal Plane Deformities
• Genu Varum
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Bowleg
Usually secondary to normal in-utero positioning
Common during the 2nd year
May be secondary to metabolic bone disease,
asymmetric growth arrest, bone dysplasia and
congenital neuromuscular disorder
• Genu Valgum
– Knock-knees
– Common during 3-4yrs
– May be secondary to metabolic bone disease, skeletal
dysplasia, post-traumatic physical arrest, tumors and
infection
Osgood-Schlatter Disease
• Pain over the tibial tubercle in a growing child
• Traction apophysitis on the tibial tubercle
growth plate and the adjacent patellar tendon
• More common in males, athletes, 10-15 years
old
• Self-limited, resolves with skeletal maturity
• (+) fragmentary ossification of the tibial
tubercle, patella alta
• Tx: rest, restriction of activities, knee
immobilizer
Developmental Dysplasia of the Hip
• Hip subluxation
– partial contact between the femoral head and
acetabulum,
• Hip dislocation
– hip with no contact between the articulating
surfaces of the hip
• Two major groups
– Typical DDH occurs in otherwise normal
individuals or those without defined syndromes or
genetic conditions
– Teratologic hip dislocations usually have
identifiable causes and occur before birth
• ETIOLOGY, INCIDENCE, AND RISK FACTORS
– Actual dislocated or dislocatable hips are much less
frequent, being found in 1–1.5 of 1000 live births
– Etiology is multifactorial
• genetic and intrauterine environmental factors
• environmental factors, such as child-rearing practices
• RISK FACTORS FOR DDH
– positive family history
– more common among female patients
• greater susceptibility of females to maternal hormones such
as relaxin, which increases ligamentous laxity.
– tighter intrauterine space and, consequently, less
room for normal fetal motion
• oligohydramnios, large birth weight, and first pregnancy
• Left hip is the most commonly affected hip; in the most
common fetal position, this is the hip that is usually forced
into adduction against the mother's sacrum
• PATHOANATOMY
– If the hip is not dislocated at birth, all the specific
components of the hip joint, except for the
ligamentum teres and the hip capsule, usually
appear relatively normal.
– Teratologic dislocations frequently are
accompanied by a small, shallow acetabulum and
a stiff hip joint at birth.
– If untreated, deformity may occur
• hypertrophy of the lateral cartilage of the acetabulum
(neolimbus formation), hypertrophy of the ligamentum
teres, capsular laxity, hourglass constriction of the hip
capsule and hypertrophy of the transverse acetabular
ligament, and excess femoral anteversion.
DDH in a Neonate
• Barlow Provocative Maneuver
– assesses the potential for dislocation of a
nondisplaced hip
– Positive test
• Hip will be felt to slide out of the acetabulum.
• As the examiner relaxes the proximal push, the hip can
be felt to slip back into the acetabulum
• Ortolani Test
– examiner attempts to reduce a dislocated hip
– Positive
• femoral head will slip into the socket with a delicate
“clunk” that is palpable but usually not audible
DDH in an Infant
• Signs of DDH usually appear on the 2nd-3rd month
of life
• Shortening of the thigh, the Galeazzi sign, is best
appreciated by placing both hips in 90 degrees of
flexion and comparing the height of the knees,
looking for asymmetry
• Asymmetry of thigh and gluteal skin folds is
suggestive of DDH.
• Klisic test, in which the examiner places the 3rd
finger over the greater trochanter and the index
finger of the same hand on the anterior superior
iliac spine. In the dislocated hip, the trochanter is
elevated, and the line projects halfway between
the umbilicus and the pubis.
DDH in a Walking Child
• limp, a waddling gait, or a leg-length discrepancy
• affected side appears shorter than the normal
extremity, and the child will toe-walk on the
affected side
• Trendelenburg sign is positive in these children,
and a Trendelenburg gait is usually observed
• (+) limited abduction on the affected side and the
knees are at different levels when the hips are
flexed (the Galeazzi sign)
• Excessive lordosis, which develops secondary to
altered hip mechanics, is common and is often
the presenting complaint.
Radiographic Findings
• UTZ
– provides dynamic assessment about the stability of the hip joint
• RADIOGRAPHY.
– recommended for an infant once the proximal femoral epiphysis
ossifies, usually by 4–6 mo.
– Hilgenreiner line - horizontal line drawn through the top of both
triradiate cartilages
– Perkins line - vertical line through the most lateral ossified margin of
the roof of the acetabulum, perpendicular to the Hilgenreiner line
– Shenton line - curved line drawn from the medial aspect of the femoral
neck to the lower border of the superior pubic ramus
– Acetabular index - angle formed between the Hilgenreiner line and a
line drawn from the depth of the acetabular socket to the most lateral
ossified margin of the roof of the acetabulum.
– Center-edge angle is a useful measure of hip position
– In children 6–13 yr old, an angle >19 degrees has been reported as
normal, while in children 14 yr and older, an angle >25 degrees is
considered normal
Treatment
• NB to <6 months
– Pavlik Harness
• 6 months – 2 years
– Closed reduction
– Open reduction (12 wks after closed reduction)
– Traction
• >2 years
– Open reduction
– Concomita t acetabular procedure
DDH – Sequelae/Complications
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Avascular necrosis of the CFE
Redislocation
residual subluxation
acetabular dysplasia
postoperative complications
– wound infections
Legg-Calve-Perthes
• femoral head disorder of unknown etiology
• temporary interruption of the blood supply to the bony
nucleus of the proximal femoral epiphysis
• impairment of the epiphyseal growth and femoral head
deformity
• Pathogenesis (4)
– growth disturbance in CFE and physis
– the asymmetric repair process and the applied stresses on
the femoral head
– superficial layers of articular cartilage continue to
“overgrow” as they are nourished by the synovial fluid. The
deeper layers are, however, devitalized by the disease
process, leading to epiphyseal trabecular collapse and
deformity.
– iatrogenic - trying to contain, either nonsurgically or
surgically, a noncontainable femoral head.
Legg-Calve-Perthes
• CLINICAL PRESENTATION
– Limp of varying duration
– Pain - activity related and may be localized in the groin or
referred to the anteromedial thigh or knee region
• RADIOGRAPHIC FINDINGS
– Routine plain radiographs are the primary imaging tool for
LCPD. Anteroposterior and Lauenstein (frog) lateral views
are used to diagnose, stage, provide prognosis, follow the
course of the disease, and assess results
– radionuclide bone scanning with technetium-99m may
reveal the avascularity of the CFE
– MRI is sensitive in detecting infarction but cannot
accurately portray the stages of healing.
– Arthrography may demonstrate any flattening of the
femoral head and the hinge abduction phenomenon with
abduction of the leg.
Legg-Calve-Perthes
• Classification
Legg-Calve-Perthes
• TREATMENT
– NONOPERATIVE TREATMENT - mainstay of
treatment is nonoperative, specifically activity
limitation and physical therapy to maintain hip
range of motion
– OPERATIVE TREATMENT
• Varus osteotomy - most common procedure.
• Pelvic osteotomies - acetabular rotational
osteotomies, shelf procedures, and medial
displacement or Chiari osteotomies
Osteomyelitis
• Etiology
– Staphylococcus aureus is the most common infecting
organism in all age groups, including newborns
– After 6 yr of age, most cases of osteomyelitis are caused by
S. aureus, streptococcus, or Pseudomonas aeruginosa
– Salmonella species and S. aureus are the two most
common causes of osteomyelitis in children with sickle cell
anemia
• Fungal infections usually occur as part of multisystem
disseminated disease
• Primary viral infection of bones is exceedingly rare.
• A microbial etiology is confirmed in about 75% of cases
of osteomyelitis. Prior antibiotic therapy and the
inhibitory effect of pus on microbial growth may
explain the low bacterial yield.
Osteomyelitis
• PATHOGENESIS.
• The unique anatomy and circulation of the ends
of long bones result in the predilection for
localization of blood-borne bacteria
• Blood flow in this area is sluggish and provides an
ideal environment for bacterial seeding.
• Phagocytes migrate to the site and produce an
inflammatory exudate (metaphyseal abscess).
The generation of proteolytic enzymes, toxic
oxygen radicals, and cytokines results in
decreased oxygen tension, decreased pH,
osteolysis, and tissue destruction.
Osteomyelitis
• TREATMENT
• Neonates
– Anti-staphylococcal Penicillin
• Nafcillin or Oxacillin
• Cefotaxime
– Older Infants and Children
• Cefazolin or Nafcillin
Osteomyelitis
• DIAGNOSIS
– Blood culture
– Aspiration for Gram stain and culture
– No specific laboratory tests for osteomyelitis
• RADIOGRAPHIC EVALUATION
– Within 72 hrs of onset of symptoms
– Displacement of the deep muscle planes from the
adjacent metaphysis caused by deep-tissue edema
– Lytic bone changes are not visible on radiographs until
30–50% of the bony matrix is destroyed.
– Tubular long bones do not show lytic changes for 7–14
days after onset of infection. Flat and irregular bones
can take longer.
Septic Arthritis
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May cause permanent disability
More frequent in infants and children
Most common: Staphylococcus aureus
May also be caused by Gonococcus in sexually
active adolescents
• Usually hematogenous in origin
• Neonates may present with subtle signs and
symptoms, while older infants and chidren
usually manifest with pain, fever, limp or
difficulty in ambulation
Septic Arthritis
• Diagnosis
– Definitive Dx: Gram stain and culture
– Blood culture
– Radiographic findings
• Widening of joint capsule
• Soft tissue edema
• Obliteration ofnormal fat lines
– UTZ is sensitive in detecting joint effusion
– CT and MRI can confirm the presence of joint fluid
Septic Arthritis
• Treatment usually lasts for 10-14 days
– Neonates: Nafcillin/Oxacillin + Cefotaxime
– Children: Nafcillin or Cefazolin
– MRSA : Clindamycin + Vancomycin
– Immunocompromised: Vancomycin and
Ceftazidime or extended-spectrum penicillins and
B-lactamase inhibitors, + aminoglycoside
– Dexamethasone for 4 days
Achondroplasia
• Autosomal dominant
• At birth, nepnates present with short limbs, a
long and narrow trunk, large head with midfacial hypoplasia and a prominent forehead
• Proximal segments of the limbs are usually
short and fingers display a trident
configuration
• Most joints are hyperextensible
• Normal intelligence
Achondroplasia
• Diagnosis
– Radiographic Findings
• Large calvarial bones
• Small cranial base and facial bones
• Short vertebral pedicles, decrease interpedicular
distance, 1st to 5th lumbar vertebra
• Fibula longer than tibia
• Treatment
– Surgical correction may be done for severe spinal
canal stenosis
Osteogenesis Imperfecta
• Autosomal dominant
• Triad
– Fragile bones
– Blue sclerae
– Early deafness
• Most common genetic cause of osteoporosis
• Connective tissue disorder
• Defective type I collagen
– Primary component of the ECM of bone and skin
Osteogenesis Imperfecta
• Diagnosis
– Collagen biochemical studies or sequencing of
cDNA
– UTZ as early as 16wks AOG may detect sever OI
• Treatment
– None
– Supportive:
• Severe nonlethal type: active physical rehabilitation
while the patient is young
• Severely affected individuals: wheelchair ambulation
• Orthopedic management: treatment of fractures and
correction of deformity
• Cause of death: Cardiopulmonary