causes and management of child with a limp

1. A CHILD WITH A LIMP
DR MANORI GAMAGE
(MBBS.MD.DCH.MRCPCH)
DEPARTMENT OF PEDIATRICS
FACULTY OF MEDICAL SCIENCES
UNIVERSITY OF SRI
JAYEWARDENEPURA

2. INTRODUCTION
• Limp is not a diagnosis; only a clinical description
• Is a diagnostic challenge and clinical assessment may not
be easy.
• Trauma is the commonest cause .
.

3. CAUSES OF LIMPVARY WITH THE AGE OFTHE
CHILD
Possible causes for child of any age
• Septic Arthritis/Osteomyelitis
• Non-accidental injury
• Testicular torsion/ Inguinal hernia/ Appendicitis/ Urine infection
• Juvenile idiopathic arthritis
• Metabolic conditions (Example: Rickets)
• Haematological disease (Example: Sickle cell anaemia)

4. ACCORDING TO AGE OF THE CHILD CAUSES ARE
0-3 years:
• Toddler’s fracture
• Developmental dysplasia of the hip
• Malignancy – neuroblastoma
4-10 years:
• Transient synovitis
• Perthes’ disease
• Leg-length discrepancy
• Acute lymphocytic leukaemia
11- 16 years:
 Slipped capital femoral epiphysis
 Primary bone tumours
 Osgood-Schlatter disease

5. CLINICAL ASSESSMENT FOR DIAGNOSIS
HISTORY
• Onset of the limp: Sudden or Gradual Onset
• Anatomical area involved: Hip, Knee, Spine etc.
• Any H/O trauma
• Age of the child
• Associated symptoms: Pain (Constant pain/referred pain), Fever
• Features suggestive of Anaemia, thrombocytopenia, leukopenia
• Ask for the features to exclude other differential diagnosis
• Family history
• Past medical history with previous medications

6. CLINICAL EXAMINATION
General Examination
• Vital signs (heart rate, temperature, respiratory rate, blood pressure)
• Evidence of anaemia, bruising or lymphadenopathy
• Evidence of rashes (E.g.: exanthems, insect bites)
• Abdominal examination (and testis in boys)
• Lower limb neurological examination (e.g.: nerve root irritation)
• Pattern of injury and features to suggest non-accidental injury

7. MUSCULOSKELETAL EXAMINATION
• Paediatric regional examination of the musculoskeletal system based on
the
‘look,
feel, move,
function, measure’
approach to detailed joint examination, starting with the obvious
affected limb or joint(s).

8. LOOK
• Skin changes over the joint
• Joint swelling
• Signs of discomfort
• Signs of chronicity, for example, leg length discrepancy, fixed flexion deformity,
muscle wasting/hypertrophy, deformity
• Asymmetrical skin creases
• Soles of feet (for foreign bodies; evidence of trauma)
• Alignment of spine and overlying skin changes

9. FEEL
• Local tenderness
• Increased temperature

10. MOVE
Focus on spine and all joints in lower limbs
• Range of movement (check for symmetry with other
side and evidence of discomfort

11. FUNCTION
• Weight bearing status
• If can walk, observe the gait pattern
Measure
Leg length, muscle strength (as appropriate)
Paediatric gait, arms, legs and spine examination may be helpful to identify abnormal joints
elsewhere

12. MEASURE
• Leg length, muscle
• strength

13. • Paediatric gait, arms, legs (pGALS) and spine
examination is helpful to identify abnormal
joints elsewhere

14. ‘RED FLAGS’ FOR SEVERE LIFE-THREATENING CONDITIONS
Sepsis (septic arthritis or osteomyelitis)
• Complete non-weight bearing
• Resist any attempt to passively move the limb
• Severe pain
• Limb held in a position which accommodates increased joint volume due to effusion
• Pseudo-paralysis of limb
• High Fever
• Immune compromised child: increased risk of septic arthritis and osteomyelitis

15. MALIGNANCY
• Pain which is severe, and occurs during the night
• Localized bone Pain
• Pallor +
• Bruising +
• Lymphadenopathy +
• Hepato-splenomegaly
• Anaemia,Thrombocytopenia in full blood count
• Systemic symptom (lethargy, weight loss, night sweats, fever)
• Weight loss

16. Non-accidental injury
• Delay in seeking medical care
• Changing history inconsistent with the pattern of injury
• Repeated presentations to healthcare
• Unwitnessed injury suggestive of negligence
• Presence of injuries suggestive of NAI

17. PATTERNS OF FEATURES SUGGESTIVE OF NAI:
• Multiple bruises and bruises that carry the imprint of an object ( finger marks)
• Cigarette burn marks , marks suggestive of forced immersion burn
• Presence of fractures like metaphyseal fractures.
• Multiple injuries
• History given is not compatible with child’s developmental stage
• Presence of features of negligence – poor hygiene

18. INVESTIGATIONS
Child with ACUTE onset LIMP
• Full blood count
Neutrophilia is suggestive of septic arthritis.
• C-reactive protein
CRP becomes elevated earlier than ESR (within 6 h of the inflammatory process).
• Erythrocyte sedimentation rate
ESR becomes elevated 24-48 h after the start of the inflammatory process

19. INVESTIGATIONS CONTD…….
• Blood culture
Are positive in majority of patients with osteomyelitis and septic arthritis.
• Blood film
A normal blood film does not exclude leukaemia or other malignancy.A
bone marrow aspirate may be required to exclude leukaemia if any other
red flag sings present

20. TRANSIENT SYNOVITIS OF THE HIP
• Commonest cause of hip pain in children.
• Occurs with preceding upper respiratory tract or gastrointestinal infection
• Characterized by sudden onset of hip pain and limping in a child who is
not systemically ill.
• Commonly present during 3 to 8 years of age
• Common in boys.

21. TRANSIENT SYNOVITIS CONT.
• Limited and painful internal rotation of the hip – the most
consistant finding in transient Synovitis.
• Ultra sound scan of the hip: Intracapsular synovitis with joint
effusion
• Treatment: Bed rest, Pain relief
• Review - IF limp persists to exclude evolving Perthes’ disease.

22. LEGG-CALVE-PERTHES DISEASE CONT.
• Clinical features:
- Common in boys (4-8 years),
- insidious onset painless limp
- Hip or groin pain, which may be referred to the thigh. Can be bilateral.
- Decreased range of motion, particularly with internal rotation and abduction.

23. LEGG-CALVE-PERTHES DISEASE CONT.
• FBC, CRP, ESR usually normal.
• Initial radiographs - normal but
• Will progress in to avascular necrosis of the developing femoral
head showing radiological changes

24. MANAGEMENT
• Goal of treatment: Preservation of the contour of the femoral
head and prevention of deformity while the condition runs its
course.
Conservative management: Relieve weight bearing

25. MANAGEMENT CONTD….
Surgical management
- Femoral osteotomy = varus+/- derotation to reduce the degree of
anteversion and extension
- Pelvic osteotomy (Salter, Chiari, Shelf) or femoral osteotomy have similar results.

26. SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)
Aetiology:
Mechanical- overload due to obesity, decreased anteversion, changes within physeal plate
Inflammatory - synovial inflammation
Hormonal – obesity, panhypopitiarism, primary and secondary hypothyroidism, renal
osteodystrophy, gonadal immaturity
- Trauma
• Age distribution: Males> Females ; Usually over 10 years of age
• Left side> right side but 25% - 40% bilateral.

27. SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) CONT.
• Symptoms:
- sudden onset hip or knee pain (referred) with difficulty weight bearing
and restriction of hip internal rotation (or abduction).
- Can be acute, chronic, or acute on chronic slip.

28. SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) CONT.
• Investigations:
- X rays of the affected hip
• Management:
- Stabilasation of epiphysis and prevention of further slippage
- Stimulation of physeal plate arrest
- Functional improvement by restoration of anatomy in severe cases.

29. CLINICAL MESSAGES
• The limping child is a common presentation: careful clinical assessment, knowledge and
judicious use of often simple investigations will often facilitate a correct diagnosis.
• The hip is a common site of pathology but is important to exclude pathology elsewhere.
• Ultrasound scan is more sensitive than plain X-ray for detection of hip effusions.
• Limping is not a diagnosis: all children need clear follow-up plans.
• If a limp persists (>3 weeks); the likelihood of JIA is high and referral to a paediatric
rheumatologist is recommended.

30. REFERENCES
• Nelson textbook of pediatrics: 20th edition
• Illustrated textbook of pediatrics: 4th edition
• “The child with a limp: a symptom and not a diagnosis” by Eve Smith, Mark Anderson ,
Helen Foster. Journal of Education and practice: an edition of Archives of Disease in
childhood.Volume 97 Issue 5 October 2012.

31. THANKYOU