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Child with a limp
This document provides guidance on evaluating a child presenting with a limp. It discusses various possible differential diagnoses to consider, including septic arthritis, developmental dysplasia of the hip, Perthes disease, slipped femoral epiphysis, and more. Key aspects of history to obtain include age, presence of pain, associated symptoms, and past medical/family history. The examination should evaluate gait, limb length, range of motion, and tenderness. Initial investigations may include blood tests, x-rays of the hip and/or knee, ultrasound if effusion is suspected, and bone scan or MRI if further imaging is needed. The goal is to identify serious conditions like infections while considering more benign possibilities.
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Child with a limp
- 1. Child With aLimp K. Kavindya M. Fernando JMJ 1
- 2. Objectives • Differential diagnosis •History • What to look for on examination of a neonate, infant and child • Investigate a child with a limp to rule out serious conditions • Difference between an ill and a well child JMJ 2
- 3. DD • Septic arthritis •Irritable hip • Developmental dysplasia of the hip (DDH) • Perthes disease • Slipped upper femoral epiphysis (SUFE) • Osteomyelitis • Occult trauma • Neuromuscular causes • Juvenile idiopathic arthritis • Malignancy JMJ 3
- 4. History forcusing onthe child with a limp • Contents • Age • Sex • Is the child ill • Pain • Painless limp • Associated symptoms • PMHx • Family Hx JMJ 4
- 5. Age All ages -Infection (septic arthritis or osteomyelitis) - Juvenile idiopathic arthritis Infant + 2 years (1-3years) - Late presenting developmental dysplasia of the hip (DDH) - Irritable hip - Neuromuscular - Occult trauma (including non-accidental injury) Childhood (3 –11 years) - Perthese disease - Irritable hip - Neuromuscular - Slipped upper femoral epiphysis (SUFE) Adolescent (12-16 years) - SUFE - Infection JMJ 5
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- 7. Sex • Perthes muchcommoner in boys than girls JMJ 7
- 8. Is the childill? • Systemically unwell or not • Play little • Eat little • Fever, rigors and night sweats • Unwell child suggests • Infection • Juvenile idiopathic arthritis (JIA) JMJ 8
- 9. Pain • Most withlimp has pain • Any child complaining of knee pain • Must be suspected of having hip pathology • Perthese disease • Vague, gradual onset of pain and limp • Trauma or infection • More sudden onset of pain and limp JMJ 9
- 10. Pain • Classical hxof SUFE • Is often a background of hip pain for weeks followed by sudden increase in pain • Transient synovitis of the hip • Gives pain in groin • Mimics septic arthritis • Sinister causes of pain • Gradual increase in pain • Night pain+ • Not relieved by simple analgesia JMJ 10
- 11. Painless limp • Late-presentingDDH • Presents with a limp and leg length discrepancy • Neuromuscular disorders (Cerebral palsy) • Poor gait due to muscle imbalance rather than pain • Muscular atrophy • Can present with gradual onset of weakness and limp JMJ 11
- 12. Associated Symptoms • Nonaccidental injuries – NAI • Multiple joint pains & aches • Suggestive of juvenile arthritis • Recent Hx of URTI or otitis media • Often found in patients with transient synovitis JMJ 12
- 13. Past Medical History •Perthes disease • Slipped upper femoral epiphysis (SUFE) • These patients carry a risk of developing the same condition on the opposite direction JMJ 13
- 14. Family History • Perthesdisease • DDH • Increase risk JMJ 14
- 15. Examining a child witha limp General Inspection Gait Standing Fixed Flexion Limb length discrepancy Palpation Movement JMJ 15
- 16. General • Systemic featuresof ill health • Pyrexia • Drowsiness • Irritability • Multiple joint problems – initially • Suggesting juvenile idiopathic arthritis • Neuromuscular examination • Neuromuscular disorders JMJ 16 Points towards infection
- 17. Inspection - Gait •Antalgic gait • Present in painful conditions • Such as Perthes disease, or irritable hip • Trendelenburg gait • Present in a toddler with late DDH • Neuromuscular disorders • Gives variety of patterns of gait abnormalities JMJ 17
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- 19. Inspection - Standing •DDH • Abnormal single large posterior skin crease + • SUFE or infection • Hip is often held in an abnormal position of external rotation and flexion JMJ 19
- 20. Inspection – FixedFlexion • If Thomas test is positive • A fixed flexion deformity) • Suspect significant pathology • Such as • Advanced Perthes • DDH • SUFE JMJ 20
- 21. Inspection – LimbLength Discrepancy • A short leg is typical of DDH • Apparent shortening will be present • If there is any fixed flexion deformity JMJ 21
- 22. Palpation - • Palpateany tender areas for • Effusion , warmth and localized pain • Osgood-Schlatter disease • Tenderness over the tibial tubercle • Hip joint cannot be palpated- it is a deep joint • Osteochonritis or, meniscal tears in older children • Pain around knee joint JMJ 22
- 23. Movement • Loss ofhip movements – indicates pathology • DDH • Results in loss of abduction compared with the other side • Perthes disease • Loss of abduction and flexion • “complete loss of abduction is a worrying sign in Perthes as this may indicate subluxation of the joint.” • In septic arthritis – movements gives extreme pain JMJ 23
- 24. Investigating a child witha limp Blood tests X-rays Ultrasound Isotope bone scanning Magnetic Resonance imaging (MRI) JMJ 24
- 25. Blood tests • Markedrise in WCC • ESR ↑ • CRP ↑ • All are markedly increase in infections • Mildly increase in inflammation • Synovitis • JIA • Creatinine Kinase – raised in muscular dystrophy JMJ 25
- 26. X- Rays • Hipradiograph may shows • Dislocated hip • Perthes disease • A slipped upper femoral epiphysis • Evidence of infection (remember X-ray are initially normal) • A fracture JMJ 26 If a SUFE is suspected, request a frog lateral X-ray
- 27. X- Rays • Ifyou are sure the problem is from the knee the AP and lateral knee x-ray should perform • It may show • Osgood- Schlatter disease • Osteochondritis dissecans • Fracture JMJ 27
- 28. Ultrasound • Very usefulinvestigation • It may show effusion in • Septic arthritis • Transient synovitis • Perthes disease (early) JMJ 28
- 29. Isotope bone scanning •If hot- possible causes are • Osteomyelitis • Will show any seeding of infection • Malignancy JMJ 29
- 30. MRI • Not the1st line investigation • But useful in • Diagnosis of knee disorders • Bone and soft tissue tumors • Osteomyelitis JMJ 30
- 31. Algorithm for theIx of a child with a limp, JMJ 31
- 32. JMJ 32 History Multiple joint problems JIA Painful Acutehot swollen joint Knee pain Hip pain Could still be reffered from hip X-ray knee Osgood- Schlatter disease Osteochond ritis Normal Consider MRI Sports injurirs No pain Examination X-ray hip Suspected NM disorder Reffer peadiatrics DDH X-ray Normal Abnormal Perthes, SUFE
- 33. JMJ 33 Normal X- ray USS Inflammatory markers Noeffusion Effusion Consider bone scan Osteomyelitis Transient synovitis Septic arthritis ↑ marker
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