approach to limping child

1. Muhammad Mustafa
First year resident
Medical ward 4
APPROACH TO LIMPING CHILD

3. LIMP
• Limp is defined as, an uneven, jerky gait caused by
pain, weakness or deformity.
• Limp can be caused by both benign and life threatening
conditions
• management varies from simple reassurance to major
surgery depending upon the cause.

4. PATHOPHYSIOLOGY
• Three main factors cause a child to limp.
• Pain, weakness, structural or mechanical abnormalities
of the spine, pelvis and lower extremities.

5. NORMAL GAIT
• 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 during which the foot is in contact with the
ground.
• And the swing phase 40%, during which the foot is in
the air.

6. ABNORMAL GAIT
• Abnormal gait can be
• Antalgic or non antalgic

7. ANTALGIC GAIT
• An antalgic gait is characterized by
• shortening of the stance phase (compensatory
mechanism adopted to prevent pain in the affected
leg)
• there is decreased contact between the affected leg
and the ground, a child may not report pain.

18. APPROACH
• History
• Examination
• Investigation
• Management

19. HISTORY
• Age
• Sex
• Onset
• Painless or Painful
• Acute or Chronic
• History of trauma
• Association: Night pain ( ALL) , Arthralgia. Swelling, Morning stiffness( JRA),
Backache( Malignancy or Rheumatologic disease).

20. HISTORY
SYSTEMIC REVIEW
• Recent illness: URTI
• Weight loss, anorexia
• Fever chills
• Unexplained rash (SLE) or Bruising (hematologic)
• Voiding problem ( neuromuscular disease)

21. EXAMINATION
• General inspection + Gait
• Vital signs and anthropometric measurements
• Musculoskeletal examination + back examination
• Neurologic examination
• Evaluate leg length : anterior iliac spin to medial
malleolus

22. INVESTIGATION
• To rule out infection
• Full blood count
• ESR
• CRP
• Blood culture
• To rule out hematologic al disorder
• Coagulation profile
• Peripheral blood film
• To rule out rheumatologic disorder
• Immunological: RA, ANA,

23. INVESTIGATION
IMAGING STUDIES
• Plain X-RAY
• Ultrasound
• CT
• MRI
• Radio nucleotide studies
• Bone scan

25. SOME IMPORTANT EXAMINATIONS
• Internal rotation of hip:
• Hip abduction method
• Galeazzi test
• Flexion and external rotation
• The patrick ( Faber ) test

26. DISEASES

27. LEGG-CALVÉ-PERTHES
• Legg-Calvé-Perthes disease is a hip disorder of unknown
etiology resulting from intruption of blood supply to the
femoral head leading to osteonecrosis.
• Usual age is 4-8 years
• Male to female ratio, 5:1
• CLINICAL FEATUREs:
• limping gait
• pain on activity or exercise mostly by the end of the day

28. SIGNS
• There is limited abduction and internal rotation.
• Leg length discrepancy may be present
• Mild hip flexion contracture may be present
• Internal rotation of the hip is measured by placing the
child in a prone position with knees flexed 90 degrees,
while rotating the feet outward.
• Loss of internal rotation is a sensitive indicator of intra-
articular hip pathology and is common in children with
LCPD and SCFE.

29. INTERNAL ROTATION

30. SLIPPED CAPITAL FEMORAL EPIPHYSIS

31. OSGOOD SCHLATTER DISEASE

33. DEVELOPMENTAL DYSPLASIA OF HIP
• A spectrum of disorder in the development of immature hip joint.
• It includes Acetabular dysplasia without displacement,
Subluxation, Dislocation
• Male to female ratio 1:7
• Risk factors: breech presentation, oligohydroamnios, large birth
weight, female ,family history and genetic factors
• Left hips joint mostly affected.
• BARLOW AND ORTOLANI TESTS

34. BARLOWS AND ORTOLANI

35. HIP ABDUCTION METHOD
• Hip abduction is measured with the child in a supine
position with hips and knees flexed and the toes placed
together.
• To measure abduction, the knees are allowed to fall
outward, away from each other. Limited hip abduction,
as in this child's left hip, is seen with developmental
dysplasia of the hip.

36. HIP ABDUCTION METHOD

37. GALEAZZI TEST
• The child lies supine with the hips and knees flexed. In
a positive test, the knee on the affected side is lower
than the normal side.
• This can occur in any condition that causes a leg-length
discrepancy, such as developmental dysplasia of the
hip, Legg-Calvé-Perthes disease, or femoral
shortening.

38. GALEAZZI TEST

40. FLEXION AND EXTERNAL ROTATION
• Characteristic position of flexion and external rotation.
This position decreases intracapsular pressure and is
highly suggestive of septic arthritis.

41. FLEXION AND EXTERNAL ROTATION

42. THE PATRICK TEST ( FABER)
• The Patrick (FABER) test. Note how the examiner has
flexed, abducted, and externally rotated the child's right
hip.

43. THE PATRICK TEST

46. HEMOPHILIA
• Its a bleeding disorder due to clotting factor deficiency (8.9
and 11)
• Age : young age, males.
• C/F : history of prolong bleeding during circumcision, IM
injection, swelling of large joints, and spontaneous bleeding
through other sites.
• The child may present with limping gait and pain due to
involvement of knee and ankle joint. The pain is worst in
evening and during activity.
• Family h/o will be positive.

47. TUMOR/LEUKEMIA
• In leukemia patients may have limping gait due to arthritis
along with that patient will have history of weight loss, bony
pains, petechae, pallor and patient will be toxic looking with
lymphadenopathy and visceromegaly.
• Ewing sarcoma; age- < 10 yrs,
• C/F: local pain, and swelling, with fever, night sweats, and
weight loss without history of trauma.
• Involvement of diaphysis of long and flat bones giving onion
skin appearance.

48. • Osteo sarcoma;
• age- second decade of life, active adolescent
• C/f: local pain, limp and swelling.
• Initial complaint may be attributed to sport injury and
sprain, not responding to conservative treatment.
• Involved metaphysis of long bones, giving sun burst
pattern.

49. EWING SARCOMA

50. OSTEOSARCOMA

51. TAKE HOME MESSAGE
• Good history and examination is the key to diagnosis.
• Index of suspicion should be high but think of common
things first.