Approach to limping child
Case Scenario
• A 14 month old boy is brought to the office
because the parents noticed a limp this
morning when the child...
Pathophysiology
• Three major factors cause a child to limp:
pain, weakness, and structural or mechanical
abnormalities of...
Some Abnormal Gaits
•

An antalgic gait results from pain in one extremity that causes the patient to
shorten the stance p...
Differential Diagnosis
Age

1-3yr

Painful limp

1- Infection
Septic arthritis /
osteomyelitis/
cellulitis / transient
syn...
Differential Diagnosis
Age

Painful limp

4 - 10yr

1-Infection
2- inflammatory JRA, SLE
3- Trauma
4- Primary or metastati...
Differential Diagnosis
Age

Painful limp

11- 18yr

1-Infection
2- inflammatory :JRA, SLE
3- Trauma
4-Primary or metastati...
Approach
•
•
•
•

History
Examination
Investigation
Management
History
•
•
•
•
•
•
•

Age
Sex
Onset
Painful or painless? ( analysis…)
Acute or chronic
History of trauma
Association : Ni...
History
• Systemic review
– Recent illness : URTI
– Weight loss, anorexia
– Fever, chills
– Unexplained rash (SLE) or brui...
Examination
•
•
•
•
•

General inspection + Gait
Vital signs & anthropometric measurements
Musculoskeletal examination +Ba...
Investigations
•
•
•
•
•
•

FBC
ESR, CRP
TRO Infection
Blood culture
Coagulation profile
TRO Haematological
Peripheral Blo...
Investigations
• Imaging studies
– Plain x ray
– U/S
– CT
– MRI
– Radionuclide studies
– Bone scan
Investigations
• Synovial
fluid
aspiration

normal

traumatic

JRA

Septic
Arthritis

appearance

Clear to
yellow

Bloody ...
CASE SCENARIO
21 months old Malay Boy - NKMI
- p/w refuse to bear weight using
right LL x 2/7
- previously can walk since ...
PMH/PSHx: nil
FHx: no chronic illness running in
family
Developmental : able to walk at 1 y.o.
speak 2-3 words with
meanin...
O/E: Alert , playing with toys
Right hip joint:
- well flexed, abducted, externally rotated
- No skin changes, no bruises ...
Ix
• ESR not elevated
• CRP not elevated
• USG hip Joint:
- no psoas abscess seen bilaterally
- no hip effusion seen bilat...
Transient synovitis (irritable hip)
-Transient synovitis is the most common cause
of acute hip pain in children aged 3-10 ...
Symptoms
- Unilateral hip or groin pain is the most common
symptom.
- Limp.
- Recent history of an upper respiratory tract...
Signs
- Hip kept in flexion with slight abduction and
external rotation.
- some may have mild restriction of motion,
espec...
Causes
• No definitive cause of transient synovitis is known,
although the following have been suggested:
• Patients with ...
Differential diagnoses
Common
• Septic arthritis.
• Juvenile idiopathic arthritis.
• Juvenile rheumatoid
arthritis.
• Oste...
Investigations
• Usually to rule out other diagnoses.
• WBC, ESR and CRP are usually elevated in
septic arthritis.
• XRAYS...
Sign of effusion :
Widening of the
joint space. Note
that the space is
wider on the left
side. Discrepancies
greater than ...
Management
• Apply heat and massage .
• Advise bedrest for 7-10 days, allowing the patient
to rest in a position of comfor...
Prognosis
• Usually marked improvement within 24-48
hours.
• Two thirds to three fourths of patients have
complete resolut...
Complications
• 32.1% of patients develop coxa magna : an
overgrowth of the femoral head and
broadening of the femoral nec...
SEPTIC ARTHRITIS
IN CHILDREN
• Septic arthritis in children is monoarticular
more than 90% of the time.
• Knee and hip joi...
• After S. aureus, group B streptococcus and Gramnegative microorganisms are important pathogens in
the neonate and young ...
• Avascular necrosis of the femoral head is
unique to septic arthritis of the hip in children.
• Early surgical decompress...
Septic arthritis - Definition
• Hematogenous bacterial infection of the
hip, usually
• in infants or toddlers, with or wit...
• Hip - commonest septic joint
• condition during growth, reaching a distinct
peak in frequency during infancy.
• via hema...
Any OM changes, widening
of joint space
• Kocher criteria: (for child with painful hip)
- includes:
1) non-weight-bearing on affected side
2) ESR greater than 40 ...
Organisms
• epiphyseal plate prevents infection from
entering joint space in older children
• but apparently does not act as a barri...
• metaphysis of shoulder, hip, radial head, and
ankle remain intracapsular during early
childhood
• the hip joint seems es...
Examination
• Limp
• pain in groin area that occasionally radiates
down the medial side of thigh;
- progressive accompanie...
Differential diagnosis
• Acute osteomyelitis - tenderness and swelling
over the metaphysis
• Transient synovitis
• Tubercu...
Investigations
• Joint fluid aspiration analysis: AFB, Gram
stain, C&S, protein, glucose, wcc and crystal.
• FBC : leukocy...
Investigations

Investigations

Explaination

Full blood count

Elevated white blood cell count

ESR

> 40 mm/hr

CRP

> 2...
Synovial fluid analysis

Aseptic technique is used during aspiration of synovial fluid.
Avoid taken from infected site o...
Suspected
condition

Appearanc
e

Viscosity White
cells

Crystals

Biochemistry

Normal

Clear
yellow

High

Septic
arthri...
Imaging
X ray

 Early Stage – Normal
Look for soft tissue swelling, loss of tissue planes,
widening of joint space
 Lat...
Narrowing of joint space and irregularity of
subchondral bone.

Joint space loss

subchondral erosions and
sclerosis of th...
Ultrasonography
• More reliable in revealing a joint effusion in early cases.
• Widening of space between capsule and bone...
Treatment
General supportive care
-Analgesics
-IV fluids
Splintage
- The joint must be rested either on a splint or in a w...
Surgical Management
 Surgical Drainage (serial needle aspiration + antibiotics)
 Arthroscopic debridement and copious ir...
Complications
• Bone destruction and dislocation of the joint (esp
Hip)
•Cartilage destruction
-may lead to either fibrosi...
Legg-Calvé-Perthes disease (LCPD)coxa plana
• Legg-Calvé-Perthes disease (LCPD) is the name given to
idiopathic osteonecro...
Pathogenesis
• Up to 4 years
Metaphyseal vessels,lateral epiphyseal
vessels,scanty vessels from ligamentum teres
Between 4...
*Lateral epiphyseal vessels situated in the
retinacula makes them susceptible to streching
and pressure from an effusion.T...
Pathology
Takes 2-4 years to complete.Involve 3 stages.
Stage 1:bone death
Episodes of ischemia leads to part of bony femo...
Clinical features
• Male
• 4-8 years old
• Hip pain, may be referred to the medial aspect of the ipsilateral
knee or to th...
Investigation
1)Plain radiograph
• hip radiographs, anteroposterior and frog-leg
lateral views of the pelvis to establish ...
Herring classification
The Herring classification addresses the integrity
of the lateral pillar of the femoral head.
• A: ...
Herring classification

Coxa magna

Coxa plana
Lateral Pillar Classification
• 3 groups:

– A) no lateral pillar
involvment
– B) >50% lat height
intact
– C) <50% lat hei...
• CT scan: allow early diagnosis of bone collapse
and also demonstrate subtle changes in the bone
trabecular pattern.
• Ul...
Treatment
• Skin traction as long as the hip is
painful(usually takes 3 weeks)
• Further treatment is taken by assessment ...
• Containment means keeping the femoral head
well seated within the acetabulum
• Can be achieved by:
1) holding the hips w...
Osteotomies
Slipped capital femoral
epiphysis (SCFE)
INTRODUCTION
The capital femoral epiphysis is
somewhat unique. It is one of the few
epiphyses in the body that is inside t...
SLIPPED CAPITAL FEMORAL EPIPHYSES
Slipped upper femoral epiphysis" term refer to slippage
of the overlying epiphysis of pr...
EPIDEMIOLOGY AND RISK FACTORS
 Most common in adolescent period with rapid growth plate
(boys aged 10-16 y, girls aged 12...
CLASSIFICATION
• Based on onset of symptoms-acute
-chronic
-acute on chronic
FUNCTIONAL CLASSIFICATION-stable
-Unstable
...
BASED ON SYMPTOMS -

SYMPTOMS
X-RAY

<2WKS

displaced epiphyses

>2WKS grdual
remodelling and

no remodelling
healing note...
FUNCTIONAL CLASSIFICATIONIt is important to determine ability of the patient to bear weight.
According to LODER1. "Stable"...
MORPHOLOGICAL CLASSIFICATION-Grading
Severity of SCFE according to AP and Lateral Xray views
PRESLIP-irregularity,widening...
ANTERIOR AND VALGUS SLIP

• the displacement is either superior and posterior (socalled valgus slip)or, even more rarely, ...
SYMPTOMS
1. Pain : in the groin and around the knee(d/t referred pain from the hip)
2. Limb looked shortened, held in exte...
INVESTIGATIONS
•
•
•
•
•
•
•
•
•

X-RAYS-AP VIEW-thretowan’s sign[kleins line]
-steel metaphysel blanch sign
-sham’s sign
...
A.P. VIEWinferior,
And medial translation of
epiphyses

LATERAL VIIEW-to
measure lateral
epiphyseal shaft
angle, anterior ...
TRETHOWAN’S SIGN-

• In normal hip a line drawn tangential to superior
femoral neck[klein’s line] intersects small portion...
METAPHYSEAL BLANCH SIGN• In AP VIEW-crescent-shaped area of increased
density overlying the
metaphysis adjacent to
the phy...
SHAM’S SIGN In the normal hip the inferiomedial femoral neck overlaps
the posterior wall of the acetabulum producing tria...
CAPENERS SIGN-

In pelvic AP view in the normal hip, the posterior acetabular margin
cuts across the medial corner of the ...
LATERAL VIEW
• Very early slips may appear to be normal in AP
VIEW but may be clearly noted in lateral view
• CHRONIC CASE...
USG-It has been useful in the detection of early slips -joint
effusion and a “step” between the femoral neck and the
epiph...
COMPLICATIONS
1. Avascular necrosis.
2. Chondrolysis.
3. Secondary Osteoarthritis.
4. Coxa vara (is a deformity of the hip...
IDEAL TREATMENT
•Prevent further slippage
•Stimulate early physeal closure
•Reduction of epiphyseal displacement
•Avoid co...
MANAGEMENT-

• Conservative management-rest and traction
- Rest for at least 12wks and traction can be an alternative to s...
Operative management
- ORIF: open reduction, limited osteotomy, and internal
fixation, if necessary, have been recommended...
Developmental Dysplasia of
Hip
A spectrum of disorder including :
Acetabular dysplasia without displacement
Subluxation
Di...
Epidermiology
Reported incidence is 5 – 20 per 1000 live births.
Re – examination 3 weeks after birth is only 1 or 2
per 1...
Aetiology
1- Genetic factors( families, even in entire populationgeneralized join laxity, shallow acetabulum)
2- Hormonal ...
Pathology
Femoral head dislocate posteriorly and later
lies superolateral to acetabulum
Cartilagenous socket is shallow an...
Clinical Features
Every newborn child should be examined for signs of
hip instability esp. in children with positive famil...
Ortolani’s Test
1. Baby’s thighs are held with the thumbs medially and
fingers resting on the greater trochanters
2. Hip a...
When test is positive, the dislocated femoral head will
fall back into acetabulum with palpable ‘clunk’ as the
hip abducte...
Barlow’s Test
• Thumb is placed in groin
• Grasping the upper thigh, an attempt is made to lever
the femoral head out of t...
Clinical Features
The infant
Limitation of abduction - < 50-60°

Shortening of the femur by Galeazzi
sign
placing both hip...
Clinical Features
Increase thigh folds on the
affected side than the normal
side
because of the foreshortened the
thigh.
Clinical Features
Walking children
Abnormal gait – due to shortened of the affected
leg
Trendelenburg gait
Waddling gait -...
Investigation
1. Ultrasonography
Neonate’s hip is composed primarily of cartilage –
difficult by using radiographic techni...
Investigation
2. Plain X-ray
In newborn the unstable hip may appear radiographically
normal, as the child reach 3 to 6 mon...
X- Ray
(A) Acetabulum : Shallow and sloping
(Acetabular roof angle < 30)

(B)Femoral head : Underdeveloped and out
Perkin’...
(C) Shenton’line is broken
(Inferior border of superior ramus
and inferior border of the neck)
(D) Von Rozen line = Hips a...
A

B

C
Management
0-6 months
+ve Ortolani
+ve Barlow
+ve US
Double napkins OR Abduction pillow for 6 weeks
Stable hip = follow-up...
Management

Von Rosen’s Splint
Management
Persistent dislocation: 6-18months
Failed early treatment or missed dislocation
Hip must be reduced by closed m...
Management
Operation
Indicated when concentric reduction failed
Psoas tendon is divided
Redundant tissue is removed
Hip is...
Management
18months-4 years
Closed reduction is less likely to succeed.
Traction: help to loosen the tissue and bring the ...
Management
Children >4 years
Up to 8 y/o; reduction and stabilization as above, risk of
AVN and hip stiffness (>25%)
Over ...
-THANK YOU-
Approach to limping child
Approach to limping child
Approach to limping child
Approach to limping child
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  • Age related changes in blood supply to EpiphysisAge &lt; 4Receives blood from the metaphyseal vesselsAge 4-8Blood from separate epiphyseal vessels as the physis is barrier to blood flowAge &gt; 8The ligamentumteres has increasing significance in supply (20%)Trueta suggested that did not supply until 3-4 years- See more at: http://www.orthofracs.com/basic-science/anatomy/blood-supply/blood-femoral-head.html#sthash.RNcjeoBT.dpuf
  • The lateral Epiphysial and both Metaphysial arteries usually arise from the medial femoral circumflex arteryThe medial Epiphysial is a continuation of the artery within the ligamentumteres which comes from the acetabular branch of the obturator artery
  • the loose hyperelastic capsule, elongated ligamentumteres, and slight eversion of the hypertrophied acetabular rim. The posterosuperior rim of the acetabulum has to have lost it sharp margin and become flattened and thicken in the area over which the femoral head slide. The femoral head normal in shape.
  • With hip abducted 45 degree, femoral shaft should point into acetabula.
  • Transcript of "Approach to limping child"

    1. 1. Approach to limping child
    2. 2. Case Scenario • A 14 month old boy is brought to the office because the parents noticed a limp this morning when the child got out of bed…
    3. 3. Pathophysiology • Three major factors cause a child to limp: pain, weakness, and structural or mechanical abnormalities of the spine, pelvis, and lower extremities (Clark, 1997; deBoeck & Vorlat, 2003; Lawrence, 1998). • A normal gait is composed of symmetrical, alternating, rhythmical motions involving two phases: stance and swing. The stance phase normally encompasses 60% of the gait cycle. The type of gait may be helpful in identifying the etiology of the limp
    4. 4. Some Abnormal Gaits • An antalgic gait results from pain in one extremity that causes the patient to shorten the stance phase on that side with a resultant increase in the swing phase. The most common causes of an antalgic gait are trauma or infection • A Trendelenburg gait is a downward pelvic tilt away from the affected hip during the swing phase as a result of weakness of the contralateral gluteus medius muscle .The gait disturbance is commonly observed in children with developmental dysplasia of the hip, Legg-Calves-Perthes disease, or slipped capital femoral epiphysis. If the involvement is bilateral, a waddling gait results • A steppage (equinus) gait is a result of the inability to actively dorsiflex the foot, with exaggerated hip and knee flexion during the swing phase. A steppage gait is seen in children with neuromuscular diseases (eg, cerebral palsy) that cause impairment of dorsiflexion of the ankle. • A vaulting gait occurs when the knee is hyperextended and locked at the end of the stance phase and the child vaults over the extremity .A vaulting gait is seen in children with limb length discrepancy or abnormal knee mobility. • A stooped gait is characterized by walking with bilaterally increased hip flexion A stooped gait is common in children with pelvic or lower abdominal pain.
    5. 5. Differential Diagnosis Age 1-3yr Painful limp 1- Infection Septic arthritis / osteomyelitis/ cellulitis / transient synovitis 2- Trauma 3- Primary or metastatic neoplasm Painless limp 1- Developmental dyplasia of the hip 2- Neuromuscular disease -Cerebral palsy -Muscular dystrophy 3- lower limb length discrepancy
    6. 6. Differential Diagnosis Age Painful limp 4 - 10yr 1-Infection 2- inflammatory JRA, SLE 3- Trauma 4- Primary or metastatic tumor 5- hematological disease Hemophilia, leukemia 6-Legg-Calve-Perthes Disease (AVN of femoral head) Painless limp 1-Developmental dyplasia of the hip 2- Neuromuscular disease: Cerebral palsy Muscular dystrophy 3- Lower limb length discrepancy
    7. 7. Differential Diagnosis Age Painful limp 11- 18yr 1-Infection 2- inflammatory :JRA, SLE 3- Trauma 4-Primary or metastatic tumor 5-hematological disease Hemophilia, leukemia 6-Legg-Calve-Perthes Disease (AVN of femoral head) 7-acute slipped upper femoral epiphysis* Painless limp 1- Developmental dyplasia of the hip 2- Neuromuscular disease Cerebral palsy Muscular dystrophy 3- lower limb length discrepancy 4- chronic slipped upper femoral epiphysis *very tall and/or obese. Limp and pain in the hip. Leg is held in an extemal rotation position. Often painful on internal rotation of the hip. Association with hypothyroidism
    8. 8. Approach • • • • History Examination Investigation Management
    9. 9. History • • • • • • • Age Sex Onset Painful or painless? ( analysis…) Acute or chronic History of trauma Association : Night pain (ALL), arthralgia, swelling, morning stiffness(JRA), backache (malignancy or rheumatologic disease)
    10. 10. History • Systemic review – Recent illness : URTI – Weight loss, anorexia – Fever, chills – Unexplained rash (SLE) or bruising (haematology ds) – Voiding problem (neuromuscular ds)
    11. 11. Examination • • • • • General inspection + Gait Vital signs & anthropometric measurements Musculoskeletal examination +Back exam Neurological examination Evaluate leg lengths- anterior iliac spine to medial mallelous
    12. 12. Investigations • • • • • • FBC ESR, CRP TRO Infection Blood culture Coagulation profile TRO Haematological Peripheral Blood Film disorder Immunological : RF, ANA TRO Rheumatological disorder
    13. 13. Investigations • Imaging studies – Plain x ray – U/S – CT – MRI – Radionuclide studies – Bone scan
    14. 14. Investigations • Synovial fluid aspiration normal traumatic JRA Septic Arthritis appearance Clear to yellow Bloody to straw colored Cloudy yellow Purulent WBC <200 <5,000 5,000- 80,000 50,000200,000 Polymorphs <25% <25% 50-75% 75-100% other High RBC count Bacterial culture positive Low glucose High protien
    15. 15. CASE SCENARIO 21 months old Malay Boy - NKMI - p/w refuse to bear weight using right LL x 2/7 - previously can walk since 1 y.o. and can run and suddenly refuse standing on right LL - right knee joint not warm or swollen - no h/o fall / trauma before - Afebrile , No URTI sx
    16. 16. PMH/PSHx: nil FHx: no chronic illness running in family Developmental : able to walk at 1 y.o. speak 2-3 words with meaning
    17. 17. O/E: Alert , playing with toys Right hip joint: - well flexed, abducted, externally rotated - No skin changes, no bruises seen - not warm , not swollen Right knee joint : - Able to flex , not warm or swollen, non-tender Right ankle joint: - Able to move , not warm or swollen . Non-tender IMP : transient synovitis of right hip joint
    18. 18. Ix • ESR not elevated • CRP not elevated • USG hip Joint: - no psoas abscess seen bilaterally - no hip effusion seen bilaterally
    19. 19. Transient synovitis (irritable hip) -Transient synovitis is the most common cause of acute hip pain in children aged 3-10 years. -The disease causes arthralgia and arthritis secondary to a transient inflammation of the synovium of the hip. -affects boys twice as often as girls. - Usually it is a diagnosis of exclusion, once trauma and infection are excluded
    20. 20. Symptoms - Unilateral hip or groin pain is the most common symptom. - Limp. - Recent history of an upper respiratory tract infection in 50% of patients. - Usually afebrile or have a mildly elevated temperature. - Very young children with transient synovitis may have no symptoms other than crying at night.
    21. 21. Signs - Hip kept in flexion with slight abduction and external rotation. - some may have mild restriction of motion, especially to abduction and internal rotation - The hip may be painful with passive movement and tender to palpation. - The most sensitive test for transient synovitis is the log roll, in which the patient lies supine and the examiner gently rolls the involved limb from side to side. This may detect involuntary muscle guarding of one side when compared to the other side.
    22. 22. Causes • No definitive cause of transient synovitis is known, although the following have been suggested: • Patients with transient synovitis often have histories of trauma, which may be a cause or predisposing factor. • One study found an increase in viral antibody titers in 67 of 80 patients with transient synovitis. • Postvaccine or drug-mediated reactions and an allergic disposition have been cited as possible causes.
    23. 23. Differential diagnoses Common • Septic arthritis. • Juvenile idiopathic arthritis. • Juvenile rheumatoid arthritis. • Osteomyelitis. Less common • Avascular necrosis (Perthe’s disease). • Fracture. • Gonococcal arthritis. • Lyme’s arthritis. • Soft tissue injuries. • Tumor or malignancy.
    24. 24. Investigations • Usually to rule out other diagnoses. • WBC, ESR and CRP are usually elevated in septic arthritis. • XRAYS: can exclude bony lesions. • Ultrasound guided aspiration of the effusion.
    25. 25. Sign of effusion : Widening of the joint space. Note that the space is wider on the left side. Discrepancies greater than 1 mm indicate the presence of fluid.
    26. 26. Management • Apply heat and massage . • Advise bedrest for 7-10 days, allowing the patient to rest in a position of comfort. • Advise the patient with transient synovitis not to bear weight on the affected limb. • Advise the patient with transient synovitis to avoid full unrestricted activity until the limp and pain have resolved. • Non-steroidal anti-inflammatory drugs (NSAIDs).
    27. 27. Prognosis • Usually marked improvement within 24-48 hours. • Two thirds to three fourths of patients have complete resolution within 2 weeks. • The remainder may have less severe symptoms for several weeks. • The recurrence rate is 4-17%; most recurrences develop within 6 months.
    28. 28. Complications • 32.1% of patients develop coxa magna : an overgrowth of the femoral head and broadening of the femoral neck. It leads to dysplasia of the acetabular roof and subluxation. • 1-3 % develop perthe’s disease.
    29. 29. SEPTIC ARTHRITIS IN CHILDREN • Septic arthritis in children is monoarticular more than 90% of the time. • Knee and hip joints account for about two thirds of all cases. • Children less than 2 years old are more susceptible to septic arthritis than older children.
    30. 30. • After S. aureus, group B streptococcus and Gramnegative microorganisms are important pathogens in the neonate and young infant. • Candida and Gram-negative bacilli are usually acquired in the hospital or in another health care setting. • Septic arthritis and osteomyelitis can coexist or complicate each other in the very young child because the metaphyseal and epiphyseal blood vessels communicate and the metaphyses of some long bones are within the joint capsule. (eg hip joint)
    31. 31. • Avascular necrosis of the femoral head is unique to septic arthritis of the hip in children. • Early surgical decompression to reduce the high intra-articular pressure will restore blood flow to the femoral head. • Leg length discrepancy, limitation of joint mobility, and secondary degenerative joint disease are late sequelae in 25% of cases.
    32. 32. Septic arthritis - Definition • Hematogenous bacterial infection of the hip, usually • in infants or toddlers, with or without involvement of • the proximal femoral metaphysis. • Synonym: Septic coxitis
    33. 33. • Hip - commonest septic joint • condition during growth, reaching a distinct peak in frequency during infancy. • via hematogenous transmission, resulting in colonization of the joint with bacteria • in infants - occur from propagation of adjacent proximal femoral osteomyelitis
    34. 34. Any OM changes, widening of joint space
    35. 35. • Kocher criteria: (for child with painful hip) - includes: 1) non-weight-bearing on affected side 2) ESR greater than 40 mm/hr 3)Fever 4)WBC count of >12,000 mm3 • when 4/4 criteria are met, there is a 99% chance that the child has septic arthritis • when 3/4 criteria are met, there is a 93% chance of septic arthritis • when 2/4 criteria are met, there is a 40% chance of septic arthritis • when 1/4 criteria are met, there is a 3% chance of septic arthritis
    36. 36. Organisms
    37. 37. • epiphyseal plate prevents infection from entering joint space in older children • but apparently does not act as a barrier in infants • synovial membrane inserting distally to epiphysis, • allowing bacteria to spread directly from the metaphysis to joint space;
    38. 38. • metaphysis of shoulder, hip, radial head, and ankle remain intracapsular during early childhood • the hip joint seems especially prone to sepsis from adjacent osteomyelitis • synovial reflections over the metaphyseal bone decrease with age;
    39. 39. Examination • Limp • pain in groin area that occasionally radiates down the medial side of thigh; - progressive accompanied by spasm of the hip muscles - hip in flexion and external rotation & decreased internal rotation compared to the normal hip - patient resists all attempts to move hip; - palpate the SI joint for local tenderness;
    40. 40. Differential diagnosis • Acute osteomyelitis - tenderness and swelling over the metaphysis • Transient synovitis • Tuberculosis • Acute rheumatic fever • Haemarthrosis
    41. 41. Investigations • Joint fluid aspiration analysis: AFB, Gram stain, C&S, protein, glucose, wcc and crystal. • FBC : leukocytosis • Blood C&S • C-reactive protein • ESR • X-ray • Ultrasound
    42. 42. Investigations Investigations Explaination Full blood count Elevated white blood cell count ESR > 40 mm/hr CRP > 20 mg/dL Blood culture May be positive
    43. 43. Synovial fluid analysis Aseptic technique is used during aspiration of synovial fluid. Avoid taken from infected site of skin. The fluid is then analyzed by gross and microscopic examination and culture. Gross examinations include appearance, volume, viscosity, mucin clotting (amount of proteoglycans). Microscopic examinations include leucocyte count, staining of smears, serum glucose ratio, protein. Finally, culture and sensitivity for definitive diagnosis and treatment.
    44. 44. Suspected condition Appearanc e Viscosity White cells Crystals Biochemistry Normal Clear yellow High Septic arthritis Purulent Tuberculous arthritis Few - As for plasma - Low + - Glucose low + Turbid Low + - Glucose low + Rheumatoid arthritis Cloudy Low ++ - - - Gout Cloudy Normal ++ Urate - - Pseudogout Cloudy Normal + Pyropho sphate - - Osteoarthrit is Clear yellow High Often + - - few Bacteriology
    45. 45. Imaging X ray  Early Stage – Normal Look for soft tissue swelling, loss of tissue planes, widening of joint space  Late stage – Narrowing and irregularity of joint space  Plain film findings of superimposed osteomyelitis may develop (periosteal reaction, bone destruction, sequestrum formation).
    46. 46. Narrowing of joint space and irregularity of subchondral bone. Joint space loss subchondral erosions and sclerosis of the femoral head osteonecrosis and complete collapse of the femoral head
    47. 47. Ultrasonography • More reliable in revealing a joint effusion in early cases. • Widening of space between capsule and bone of > 2mm indicates effusion. • Echo-free  transient synovitis • Positively echogenic  septic arthritis
    48. 48. Treatment General supportive care -Analgesics -IV fluids Splintage - The joint must be rested either on a splint or in a widely split plaster -In neonates and infants, with hip infection the joint is held abducted and 30 degree flexed, on traction to prevent dislocation. Antibiotics Treatment is started once the blood and samples are obtained without waiting for the detail results. Choice of antibiotic depends on the most likely pathogen
    49. 49. Surgical Management  Surgical Drainage (serial needle aspiration + antibiotics)  Arthroscopic debridement and copious irrigation with normal saline (Arthrotomy washout) Indications for Arthrotomy washout • Joint does not respond to serial aspirations • No improvement in 48hrs of tx • Frank pus is aspirated • Loculations noted on MRI or U/S
    50. 50. Complications • Bone destruction and dislocation of the joint (esp Hip) •Cartilage destruction -may lead to either fibrosis or bony ankylosis - secondary osteoarthritis •Growth disturbance - presenting as either localised deformity or shortening of the bone
    51. 51. Legg-Calvé-Perthes disease (LCPD)coxa plana • Legg-Calvé-Perthes disease (LCPD) is the name given to idiopathic osteonecrosis of the capital femoral epiphysis in a child. • • • • • Usually ages 4-8yo As early as 2yo, as late as teens Boys:Girls= 4-5:1 Bilateral 10-12% No evidence of inheritance
    52. 52. Pathogenesis • Up to 4 years Metaphyseal vessels,lateral epiphyseal vessels,scanty vessels from ligamentum teres Between 4-7 years,femoral head depends entirely on the lateral epiphysael vessels. • 7 years old Vessels of ligamentum teres has developed
    53. 53. *Lateral epiphyseal vessels situated in the retinacula makes them susceptible to streching and pressure from an effusion.The precipitating cause is an effusion into the hip joint following: Etiology 1)idiopathic 2) slipped capital femoral epiphysis 3) Trauma 4)steroid use 5)sickle-cell crisis 6)Synovitis 7) congenital dislocation of the hip.
    54. 54. Pathology Takes 2-4 years to complete.Involve 3 stages. Stage 1:bone death Episodes of ischemia leads to part of bony femoral head dies,x-ray looks normal bt it stops enlarging. Stage 2:revascularization and repair New blood vessels enter the necrotic area and new bone is laid down on the dead trabeculae,x-ray-increased in density.If only part of the epiphysis is involved & the repair is rapid bony architecture is completely restored. Stage 3:distortion and remodelling If large part of the bony epiphysis is damaged & the repair process is slow,epiphysis may collapse and growth of the head and neck will be distorted Epiphysis ends up flattened(coxa plana),flat and enlarged(coxa magna) and the femoral head will be incompletely covered by the acetabulum.
    55. 55. Clinical features • Male • 4-8 years old • Hip pain, may be referred to the medial aspect of the ipsilateral knee or to the lateral thigh. • All ROM are limited • The quadriceps muscles and thigh soft tissues may undergo atrophy • the hip may develop adduction flexion contracture • The patient may have an antalgic gait with limited hip motion. • passive range of motion are limited, especially internal rotation and abduction. • Children can have a Trendelenburg gait resulting from pain in the gluteus medius muscle.
    56. 56. Investigation 1)Plain radiograph • hip radiographs, anteroposterior and frog-leg lateral views of the pelvis to establish the diagnosis. • Initial radiographs can be normal, • Early changes-increased density of the bony epiphysis and widening of the joint space. • Late changes-flattening,fragmentation and lateral displacement of the epiphysis with rarefraction at the metaphysis.
    57. 57. Herring classification The Herring classification addresses the integrity of the lateral pillar of the femoral head. • A: there is no loss of height in the lateral one third of the head and there is little density change. • B: there is a lucency and less than 50% loss of lateral height. • C: there is a more than 50% loss of lateral height.
    58. 58. Herring classification Coxa magna Coxa plana
    59. 59. Lateral Pillar Classification • 3 groups: – A) no lateral pillar involvment – B) >50% lat height intact – C) <50% lat height intact
    60. 60. • CT scan: allow early diagnosis of bone collapse and also demonstrate subtle changes in the bone trabecular pattern. • Ultrasonography :preliminary diagnosis of transient synovitis of the hip and the onset of CP.Hip effusion with capsular distension is well depicted on sonographic images. • MRI: allows more precise localization of the femoral head.
    61. 61. Treatment • Skin traction as long as the hip is painful(usually takes 3 weeks) • Further treatment is taken by assessment of the prognostic value: Good prognosis 1)Onset under age 6 2)Partial involvement of femoral head 3)Absence of metaphyseal involvement 4)Normal femoral head shape No active Tx needed Poor prognosis 1)Age over 6 years old 2)Involve the whole femoral head 3)Severe metaphyseal rarefraction 4)Lateral displacement of femoral head containment
    62. 62. • Containment means keeping the femoral head well seated within the acetabulum • Can be achieved by: 1) holding the hips widely abducted in plaster or removable splint.(at least will take a year). 2) Varus osteotomy of the femur or innominate osteotomy of the pelvis.
    63. 63. Osteotomies
    64. 64. Slipped capital femoral epiphysis (SCFE)
    65. 65. INTRODUCTION The capital femoral epiphysis is somewhat unique. It is one of the few epiphyses in the body that is inside the joint capsule. (The joint capsule is the tissue that surrounds the joint.)
    66. 66. SLIPPED CAPITAL FEMORAL EPIPHYSES Slipped upper femoral epiphysis" term refer to slippage of the overlying epiphysis of proximal femur posteriorly and inferiorly due to weakness of the growth plate in relation to metaphysis. Most often, it develops during periods of accelerated growth, shortly after the onset of puberty. The femoral epiphyses maintains its relation with acetabulum ,it’s the femoral neck and shaft upward and anterior movement on epiphyses thus epiphyses displaces relatively posterior
    67. 67. EPIDEMIOLOGY AND RISK FACTORS  Most common in adolescent period with rapid growth plate (boys aged 10-16 y, girls aged 12-14 y).  Obesity is a risk factor because it places more shear forces around the proximal growth plate in the hip at risk.  Bilateral slippage is common of which 2nd slip is about 12-18mths later to 1st (left hip is more common than right).  Etiology: 1. Local trauma 2. obesity 3. Endocrine disorders (e.g primary or secondary hypothyroidism, adiposogenital dystrophy(hypogonadal male), 4. Deficiency or increase of androgens. 5. Growth hormone deficiency  Slipping of the upper femoral epiphysis occurs predominantly in obese children with underdeveloped sexual characteristics and less commonly, in tall, thin children.
    68. 68. CLASSIFICATION • Based on onset of symptoms-acute -chronic -acute on chronic FUNCTIONAL CLASSIFICATION-stable -Unstable MORPHOLOGICAL CLASSIFICATION-mild -moderate -severe
    69. 69. BASED ON SYMPTOMS - SYMPTOMS X-RAY <2WKS displaced epiphyses >2WKS grdual remodelling and no remodelling healing noted ACUTE ON CHRONIC SLIPS-Symptoms lasting longer than 1mth and recent sudden exacerbation pain after trivial trauma
    70. 70. FUNCTIONAL CLASSIFICATIONIt is important to determine ability of the patient to bear weight. According to LODER1. "Stable" SCFEs allow the patient to (walk) with or without crutches (walking aids). 2. "Unstable" SCFEs do not allow the patient to ambulate at all regardles of duration of symptoms; these cases carry a higher rate of complication, particularly of AVN.
    71. 71. MORPHOLOGICAL CLASSIFICATION-Grading Severity of SCFE according to AP and Lateral Xray views PRESLIP-irregularity,widening,and indistinctness of physes Grade-1 Grade-II Grade-III
    72. 72. ANTERIOR AND VALGUS SLIP • the displacement is either superior and posterior (socalled valgus slip)or, even more rarely, anterior. • In valgus slips there is a restriction of adduction as well as of flexion. • In anterior slips there is a limitation of extension and external rotation—exactly the opposite of what is found in typical slips. • X-RAY of valgus slip show -superior or lateral displacement of the capital epiphysis on the femoral neck on the AP projection -posterior displacement on the lateral projection.  Anterior slips may appear little different from typical slips on the AP projection, but the anterior displacement of the capital epiphysis is identified on the lateral projection.
    73. 73. SYMPTOMS 1. Pain : in the groin and around the knee(d/t referred pain from the hip) 2. Limb looked shortened, held in external rotation 3. Flexion, abduction, medial rotation are limited 4. External rotation, adduction are increased. 5.Axis deviation – pathognomonic – when hip is flexed, the limb goes into external rotation
    74. 74. INVESTIGATIONS • • • • • • • • • X-RAYS-AP VIEW-thretowan’s sign[kleins line] -steel metaphysel blanch sign -sham’s sign -capner’s sign -widening of growth plate -decrease of epiphyseal height X-RAY -frog-leg [lowenstein]lateral view CT-SCAN MRI SCAN
    75. 75. A.P. VIEWinferior, And medial translation of epiphyses LATERAL VIIEW-to measure lateral epiphyseal shaft angle, anterior or posterior translation
    76. 76. TRETHOWAN’S SIGN- • In normal hip a line drawn tangential to superior femoral neck[klein’s line] intersects small portion of lateral capital epiphyseal. • In posterior displacement of epiphyses the line doesn’t intersect.
    77. 77. METAPHYSEAL BLANCH SIGN• In AP VIEW-crescent-shaped area of increased density overlying the metaphysis adjacent to the physis • This increased density is due to the overlapping of the femoral neck and the posteriorly displaced capital epiphysis
    78. 78. SHAM’S SIGN In the normal hip the inferiomedial femoral neck overlaps the posterior wall of the acetabulum producing triangular radiographic density • With displacement of capital epiphysis this dense triangle is lost because this portion of the femoral neck is located lateral to the acetabulum.
    79. 79. CAPENERS SIGN- In pelvic AP view in the normal hip, the posterior acetabular margin cuts across the medial corner of the upper femoral metaphysis With slipping, the entire metaphysis is lateral to the posterior acetabular margin
    80. 80. LATERAL VIEW • Very early slips may appear to be normal in AP VIEW but may be clearly noted in lateral view • CHRONIC CASE OF SCFE X-RAY• Reactive bone formation along superolateral aspect of neck • Bone remodelling and broadening of neck resulting in PISTOL GRIP like appearance[hordons hump]
    81. 81. USG-It has been useful in the detection of early slips -joint effusion and a “step” between the femoral neck and the epiphysis created by slipping. • Absolute displacement of 6 mm, >2 mm is diagnostic of a slipped epiphysis. • CT-useful in documenting presence of decreased upper femoral neck anteversion or true retroversion. • it’s more accurate measure head–neck angle. • CT is useful in the management of slips. • First, CT of the hip can be very helpful in demonstrating whether penetration of the hip joint by fixation devices has occurred (Fig. 18-9). • CT is also used to confirm closure of the proximal femoral physis and also when reconstructive osteotomy is being considered. • MRI-useful to assess AVN
    82. 82. COMPLICATIONS 1. Avascular necrosis. 2. Chondrolysis. 3. Secondary Osteoarthritis. 4. Coxa vara (is a deformity of the hip, whereby the angle between the ball and the shaft of the femur is reduced to less than 120 degrees). 5. Slipping of the opposite hip ≈ 20% to 80% of cases
    83. 83. IDEAL TREATMENT •Prevent further slippage •Stimulate early physeal closure •Reduction of epiphyseal displacement •Avoid complications like osteonecrosis , chondrolysis and osteoarthritis •Any child with SCFE and open epiphyses needs treatment ,without stabilisation it progresses. •In a patient with closed physes, the only surgical treatment in the absence of severe degenerative changes is proximal femoral osteotomy. Indications are functional limitations, unacceptable gait, or cosmetic deformity
    84. 84. MANAGEMENT- • Conservative management-rest and traction - Rest for at least 12wks and traction can be an alternative to surgical treatment - Indicated in – temporary measure before operative mx or slip due to hypothyroidism • Closed manipulative reduction - High risk of ischemic necrosis of head. - So, manipulate only acute severe slips that may be technically difficult or impossible to pin in situ. • Only for acute and acute on chronic severe slips • Within 24 hours of slip • Operative management - In situ pinning • 1 cannulated screw for both stable and unstable hip
    85. 85. Operative management - ORIF: open reduction, limited osteotomy, and internal fixation, if necessary, have been recommended if a severe acute or chronic slip which cannot be reduced by closed methods - Osteotomy: moderately or severely displaced chronic slips produce permanent irregularities in the femoral head and acetabulum, some form of realignment procedure often is indicated to restore the normal relationship of the femoral head and neck and possibly delay the onset of degenerative joint disease
    86. 86. Developmental Dysplasia of Hip A spectrum of disorder including : Acetabular dysplasia without displacement Subluxation Dislocation
    87. 87. Epidermiology Reported incidence is 5 – 20 per 1000 live births. Re – examination 3 weeks after birth is only 1 or 2 per 1000 infants. ( i.e spontaneous correction) Girls are more common with ratio 7:1 Left hip is more often affected, 1 in 5 cases is bilateral.
    88. 88. Aetiology 1- Genetic factors( families, even in entire populationgeneralized join laxity, shallow acetabulum) 2- Hormonal changes in late pregnancy→ lig. laxity 3- Intrauterine malposition( breech + extended legs) 4- Postnatal factors( swaddling- simultaneous hip and knee extension may lead to hip dislocation during early development)
    89. 89. Pathology Femoral head dislocate posteriorly and later lies superolateral to acetabulum Cartilagenous socket is shallow and anterverted Capsule is stretched Ligamentum teres is elongated and hypertrophied
    90. 90. Clinical Features Every newborn child should be examined for signs of hip instability esp. in children with positive family history or with breech presentation Methods in testing instability: Ortolani’s test (reducible) Barlow’s test (dislocatable)
    91. 91. Ortolani’s Test 1. Baby’s thighs are held with the thumbs medially and fingers resting on the greater trochanters 2. Hip are flexed to 90°and gently abducted 3. Normally, there is smooth abduction to almost 90°but in congenital dislocation the movement usually impede 4. If pressure is applied to greater trochanter there is soft ‘clunk’ as the dislocation reduce (the jerk of entry) 5. If abduction stops halfway and there is no jerk of entry, they may be an irreducible dislocation
    92. 92. When test is positive, the dislocated femoral head will fall back into acetabulum with palpable ‘clunk’ as the hip abducted. When hip is adducted, the examiner will feel the head dislocate posteriorly.
    93. 93. Barlow’s Test • Thumb is placed in groin • Grasping the upper thigh, an attempt is made to lever the femoral head out of the acetabulum by fully adduct hips and push posteriorly • Indicate unstable hip When the test is positive, the examiner will feel the femoral head make a small jump out of acetabulum. When the pressure is release, the head is felt to slip back into place.
    94. 94. Clinical Features The infant Limitation of abduction - < 50-60° Shortening of the femur by Galeazzi sign placing both hip in 90° of flexion and comparing the height of knee and look for asymmetry
    95. 95. Clinical Features Increase thigh folds on the affected side than the normal side because of the foreshortened the thigh.
    96. 96. Clinical Features Walking children Abnormal gait – due to shortened of the affected leg Trendelenburg gait Waddling gait - if bilateral hip affected (walk with short steps and a clumsy swaying motion) Excessive lordosis – secondary to hip flexion contracture
    97. 97. Investigation 1. Ultrasonography Neonate’s hip is composed primarily of cartilage – difficult by using radiographic techniques Shows the shape of cartilaginous socket Position of femoral head
    98. 98. Investigation 2. Plain X-ray In newborn the unstable hip may appear radiographically normal, as the child reach 3 to 6 month of age the dislocated hip will be evident radiographically.
    99. 99. X- Ray (A) Acetabulum : Shallow and sloping (Acetabular roof angle < 30) (B)Femoral head : Underdeveloped and out Perkin’s lines = Vertical line at the outer edge of acetabulum Hilgenreiner’ line = Horizontal line through the triradiate cartilages. Normally the head is medial to vertical and below the horizontal
    100. 100. (C) Shenton’line is broken (Inferior border of superior ramus and inferior border of the neck) (D) Von Rozen line = Hips abducted 45 Femoral shaft should point into the acetabulum
    101. 101. A B C
    102. 102. Management 0-6 months +ve Ortolani +ve Barlow +ve US Double napkins OR Abduction pillow for 6 weeks Stable hip = follow-up for 6 months Persistent instability = Splint for 3-6 months (Pavlic harness) Splintage Hold the hips flexed and abducted 3 Golden Rules for splintage: Hip must be properly reduced before splintage Avoid extreme position Hips should be able to move Types: Von Rosen’s Splint (easy to apply) Pavlik Harness (difficult to apply but more freedom to move)
    103. 103. Management Von Rosen’s Splint
    104. 104. Management Persistent dislocation: 6-18months Failed early treatment or missed dislocation Hip must be reduced by closed method or operation Closed reduction Performed under GA with arthrogram Gradual traction to minimize avascular necrosis Plastic spica for 6 weeks (60° flexion, 40° abduct, 20° int rotate) Reassess and spica for another 6 weeks checking by x-ray – to ensure femoral head concentrically reduced and acetabular roof develop normally
    105. 105. Management Operation Indicated when concentric reduction failed Psoas tendon is divided Redundant tissue is removed Hip is reduced (60° flexion, 40° abduct, 20° int rotate) Spica is applied (6wks) and hip is splinted
    106. 106. Management 18months-4 years Closed reduction is less likely to succeed. Traction: help to loosen the tissue and bring the femoral head down opposite the acetabulum Arthrography: clarify anatomy of hip shows whether there is an inturned limbus or any marked degree of acetabular dysplasia. Operation remove redundant capsule Usually require derotation femoral osteotomy held by a plate and screw 1cm segment removed from proximal femur to reduce pressure on hip If there is marked acetabular dysplasia, may require acetabuloplasty After operation, hip is held in a plaster spica for 3 months Keep under clinical and radiological surveillance
    107. 107. Management Children >4 years Up to 8 y/o; reduction and stabilization as above, risk of AVN and hip stiffness (>25%) Over 8 y/o; – unilateral [mobile hip, little pain, abnormal gait.] • no intervention @ open reduction + acetabular reconstruction. – bilateral [deformity + waddling gait not so noticeable] • non-intervention unless painful/severe deformity. (fail leads to asymmetrical deformity.)
    108. 108. -THANK YOU-
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