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Prof Freih Abu Hassan البروفيسور فريح ابوحسان, profile picture
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العرج عند الاطفال - Limping child - البروفيسور فريح ابوحسان - استشاري جراحة العظام وعظام الاطفال

1) A 3-year-old male presented with right knee pain and inability to bear weight after being kicked. Initial x-rays were negative but symptoms persisted. 2) A 6-year-old girl presented with a 3-week history of right hip pain and fever 10 weeks prior. Exam found increased lumbar lordosis and hip tenderness. Tests found elevated ESR and CRP. MRI and biopsy revealed pelvic osteomyelitis. 3) A 5-year-old male reported right hip pain after falling down stairs, though he was able to play basketball with no pain initially. Exam found normal ROM but pain with movement of the right leg. Radiographs of the pelvis

Health & Medicine◦
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The Limping Child
Normal gait Stance Phase (weight-bearing phase) Heel-strike. Plantarflexion (foot flat) Toe-off Swing Phase begins with toe-off and ends with the heel-strike. +forward rotation and tilting of the pelvis, +stability of the lumbar spine
60% 40% Fully mature gait is attained by 4 years
1= Antalgic gait (anti-pain) Less time is spent in stance phase. 2= A Trendelenburg gait In swing-phase drop of the of the pelvis on the weak side. 3= Waddling gait Bilateral hip involvement or neurologic disease. 4= Stiff-legged gait Knee extension and circumduction with pelvic elevation on the affected side.
5-Toe walking = Habitual = Muscle contractures = Puncture wound in heel. = LLD. 6- Steppage gait Failed active dorsiflexion the foot, with exaggerated hip and knee flexion during the swing phase -- NM diseases. 7- Stooped gait - pelvic or abdominal pathology
The commonest site = Hip (34%) = Knee (19%) = Leg (18%) = Spine (fewer than 2%) . Pain from the spine may be referred to the thigh or the abdomen Hip pain is referred to the thigh or the knee.
Evaluation of the Child With a Limp If the right questions are asked a provisional DX can be made in most cases at the primary examination. = Proper hx and physical exam = Specific features of the disease = Proper investigation
50 causes of limping child
Causes as any pathology = Musculoskeletal Trauma = Inflammation = Infection = Developmental or Congenital = Neoplasm = Autoimmune = Osteochondrosis = Neurological
Musculoskeletal Trauma Physeal Fracture Toddler’s Fracture Stress Fracture Child Abuse Soft tissue injury
Physeal Fracture
Early stage of ossification Another variation of normal
Normal Fracture
Toddler’s Fractures Typical nondisplaced spiral fracture of tibia with no fibular fracture. Initial x-ray: often normal, diagnosis by F/U films with lucent line or periosteal reaction Or by ultrasound
• No specific injury notable most of the time • Any child refuses to bear weight on leg Examine (hip, thigh , knee , Leg and foot)
Fracture Fracture Callus
Fracture
Buckle fracture—bunk-bed fracture. 3-year-old male. Follow-up radiograph shows healing with sclerosis at the fracture site Fracture
Stress fracture Callus due to Fracture
Fracture Fracture edema
Child Abuse Fracture Fracture
Inflammation Transient Synovitis Juvenile Idiopathic Arthritis Viral Myositis
• Sudden hip pain or knee pain • Afebrile/low-grade fever (<38.5) • Able to ambulate with a limp –Antalgic gait • Hip: mildly decreased ROM
• Laboratory Evaluation –WBC count <12,000 –ESR (<40); CRP (<5mg/L) • X-Ray • Joint space widening • >2mm on affected side. • Ultrasound: • Joint effusion and/or synovial swelling Kocher, Etal JBJS -1999. JBJS -2006
3-year-old
R >2mm
Treatment – Self-limited after 2-7 days – Bed rest –Ibuprofen • Decreased pain by 2.5 days Vs Placebo • Mean duration of pain –ibuprofen: 2 days –placebo: 4.5 days Annals of Emergency Medicine 2002
Prognosis –?? association with increased risk of Perthes disease (1%) (Clinical Pediatrics, 1985) –Recurrance rate in 4-15%
Septic Arthritis Vs Transient Synovitis = No child with a temperature >38.5 was found to have transient synovitis = CRP > 5mg/dL was the only independent risk factor strongly associated with Septic arthritis +++++++++++++++++++++++++++++++++++++ – 86% of patients with ESR < 40 mm/hr had transient synovitis – 71% of patients with CRP < 5mg/ or WBC < 12,000/mm3 had transient synovitis J Bone Joint Surg. 2006 Orthop Clin N Am (2006)
Septic arthritis • Predicting of Septic arthritis –Fever >38.5 –Cannot weight bear –ESR >40 in 1st hr –WBCs >12 – CRP >5mg/L JBJS-Am. 1999.
Roll test The Dx of transient synovitis is more likely if an arc of 30 degrees or more of hip rotation is without pain.
Myositis = Viral myositis causing leg pain may be seen during influenza season = More common in older children
Infection Osteomyelitis Septic Arthritis Psoas abscess Discitis Children with septic arthritis or osteomylitis usually appear acutely ill than those with transient synovitis.
Culture the Tumour Biopsy the Infection. Osteomylitis   Tumour
ANTIBIOTICS Guidelines  Central Line.  Large doses.  Drug level.  KFT. Duration 4-6 weeks * I.V : * Oral :
1- Afebrile for 24hr. 2- Known org. 3- Minimal symptoms 4- Reliable parents 5- ESR/CRP  Down.
Longer treatment required =Pelvis =Vertebrae =Diskitis =Calcaneum
Remember Tuberculosis is still around Arthroscopic drainge is dangerous
FABER test
Psoas Abscess Vs. Septic Arthritis Psoas sign. (Flexing the hip relieves the pain and allows painless IR+ER of the hip) Pain when the hip is passively extended or actively flexed against resistance. = Scoliosis, and Femoral N neuropathy Septic arthritis ROM is painfully limited in all directions. CT or MRI Diagnostic. American Family Physician-2009 Am J Orthop. 2008
Diskitis Vs. Vertebral osteomylitis Vertebral Osteomylitis. = Toxic appearance. = Radiographs :localized rarefaction of one vertebral body and bony destruction Diskitis: Lumbar disk space narrowing and destruction of adjacent vertebral end plates =MRI is the diagnostic study of choice. American Family Physician-2009
Don’t forget! Intra-abdominal pathology and testicular torsion may present simply as a limp – Examine abdomen and testicles in boys!!
Bony Deformities of the Hip DDH SCFE Perthes Disease Coxa Vara
R 2 years old
= Femoral neck displaces ant. producing an apparent varus, the head is posterior = Occurs through Zone of hypertrophy
It is important to determine 1. Stable Walking with or without crutches 2. Unstable Non walker
Hip flexion Ext rotation deformity
The goal of treatment for SCFE is to prevent further slippage and to stabilize the epiphysis Screw advancement until FIVE threads engage the epiphysis
Complications 1. Avascular necrosis. 2. Chondrolysis. 3. Osteoarthritis. 4. Coxa vara NSA less than 120 degrees. 5. Slipping of the opposite hip ≈ 20% of cases
Legg-Calvé-Perthes disease
Symptoms of Perthes usually have been present for weeks. • Hip, groin, thigh or knee pain • Limp :painless and intermittent. • Limitation of internal rotation.
* Slight widening of the left hip joint * Small joint effusion R
* Decrease epiphyseal hight R
R = The F.H smaller denser on the left = Joint widening can also be 2ry to hypertrophy of the cartilage.
Head-at-risk signs = Extrusion- subluxation (red arrow), = Metaphyseal reaction (yellow arrow), = Lateral rarifaction or Gage sign (white arrow)
Treatment Goals 1-Relief of symptoms 2-Restoration of ROM 3-Containment
Management according to Lat. Pillar (Skeletal Age) * Age < 6y at any stage - Conservative. * Group A any age - Conservative. ===================== * Group B 6>8Y --- Containment * Group C > 6Y --- Surgery.
=Bisphosphonates =Drilling of the head J Orthop Res 2005
10 Years Perthes
Perthes-11 years old
Developmental Coxa Vara Hilgenreiner’s Epiphyseal angle 200-250
Surgery is indicated in = H.E. angle > 45 degrees = NS angle < 90-100 degrees = Trendelenburg gait = Limping
Idiopathic Chondrolysis of the Hip Autoimmune response in susceptible patient !!! = Female > male 5:1 = Adolescent = Insidious onset of pain = Limp = Decreased ROM in all planes
Pathology = Thick fibrotic capsule = Dry joint = Thin synovium = Thin cartilage
Plain radiography N joint space 3.5-5 mm = < 3 mm joint space = Osteopenia
Pelvic tilt to right with medial hip joint space narrowing
Focus of abnormal signal intensity in middle one third of proximal femoral epiphysis.
Natural History = Acute phase: 6-16 months (inflammatory) = Chronic phase: # painful fibrous ankylosis # improvement 50-60 % have favourable long term outcome
Treatment = Physiotherapy = NSAIDS, = Protected weight bearing = Etanercept (TNF) Orthopedics. 2009
Osteochondroses Köhler Disease Freiberg Disease Sever Disease Sinding-Larsen- Johansson Syndrome Osgood-Schlatter Disease Osteochondritis Dessicans
Tumors Bone cyst Osteoid Osteoma Osteosarcoma Ewing’s Sarcoma Acute Lymphoblatic Leukemia
Bone cyst
Osteoid Osteoma
Osteoid Osteoma
Ewing’s Sarcoma
Lucent metaphyseal bands (arrows), a finding present in 90% of patients with leukemia.
Case-1 A 3-y-old male , C/O persistent pain around the knee and inability to bear weight on his right leg after a kick from an 11y old boy to his leg. There was no visible bruising on physical exam. X-ray of the lower extremities was negative for fracture --- immobilized in a splint. After 5 days returned to OPD with inability to bear full weight.
Upper tibial hyperextension fractures another occult toddler’s fracture. Pediatr Radiol , 1999 Emerg Radiol, 2011
Case-2 A 6y old girl C/O Right painful limping of 3w. Had fever 10 weeks earlier, treated by GP for 1week Augmentain and paracetamol , which were initially effective. On admission, = Increased Lumbar Lordosis . = Tenderness over the hip region = lower back was asymptomatic, = Hip movements were pain free apart from slight restriction of extension and IR.