The Challenge of the Limping Child

Eddie Needham, MD, FAAFP Program Director and Academic Chairman, Florida Hospital Family Medicine Residency Eddie Needham, MD, FAAFP

Program Director and Academic Chairman, Florida Hospital Family Medicine Residency; Professor, University of Central Florida College of Medicine; Clinical Associate Professor, Florida State University College of Medicine

Dr. Needham has been a family medicine educator for 25 years. In 2017, he received the Gold Level Program Director Recognition Award from the Association of Family Medicine Residency Directors (AFMRD) for his years of leadership and experience. He has been a requested speaker at FMX since 2010, as well as speaking for the Georgia and Florida chapters of the AAFP for more than 15 years. Dr. Needham practices full-service family medicine, providing care from “conception to resurrection.” In 2013, he received the Full- Time Florida Family Physician Educator award. He is also the recipient of the 2007 Georgia Academy of Family Physicians Teacher of the Year award and the AAFP Foundation’s 1997 Parke-Davis teaching award. It is his joy and passion to teach students of medicine the wonders of the human body and spirit. Learning Objectives 1. Use an evidence-based, systematic approach to diagnosis children with deviations from normal age-appropriate gait patterns. 2. Order or provide appropriate laboratory tests and imaging studies to confirm a diagnosis, as suggested by the history and physical exam. 3. Coordinate referral and follow-up care with a pediatric orthopedic surgeon, or other subspecialist, as indicated by confirmation of the diagnosis. 4. Counsel parents on developmental milestones to evaluate their children. Perspective

Taking a history and gaining perspective on each patient is ALWAYS a physician’s best resource Limping children in the Peds ED

• 243 children presenting with a limp to the ED, no trauma, median age = 4 yo • What was the most common diagnosis? – Transient synovitis/irritable hip were the most common diagnoses: 40% • 77%: benign cause • Painful or not? – Painful in 80% – Pain Location: hip 34%, knee 19%

Fischer SU, Beattie TF. The limping child: epidemiology, assessment and outcome. J Bone Joint Surg Br 1999;81:1029–1034 Differential diagnosis by age group 1 to 5 years 5 to 12 years 13 to 19 All ages (Acute) Acute Acute Acute Cellulitis Child abuse Myositis Sprain or strain Contusion Hand-foot-mouth Salter-Harris type 1 Tendinopathy Foreign body in Hemarthrosis foot (Hemophilia) Chronic Chronic Fracture Salter-Harris type 1 Acute rheumatic fever Chondromalacia patellae Osteomyelitis Septic hip Baker’s cyst Herniated disk Poor shoe wear Toddler’s fracture Connective tissue disease IBD Reactive arthritis Leukemia Osgood-Schlatter Septic arthritis Chronic Legg-Calve-Perthes (LCP) Osteochondritis dissecans Transient synovitis Cerebral palsy Scoliosis Clubfoot SCFE Developmental dysplasia of the hip Spondylolisthesis Leg-length discrepancy SLE Tumor Adapted from: Naranje S, Kelly DM, Sawyer JR. A Systematic Approach to the Evaluation of a Limping Child. American Family Physician. 2015;92(10):908-916. History elements of note Acute < 1 week • Minor trauma, apophysitis

Subacute >1 week: (trivial to life threatening?) • Older children will “play through” the pain • Younger children (history?) • Growth plate fracture, apophysis, osteochondrosis • Infection /Inflammation: transient synovitis of the hip? • Rheumatologic JRA: No simple test • Tumors: benign to life threatening

General physical exam findings • Assess gait – ambulatory or not • Assess range of motion: active and passive • Systemic signs: – New heart murmur (infection) – Weight loss, bruising (cancer, leukemia) – Skin, joints (connective tissue disease) Laboratory and Radiology testing • Labs – CBC: infection, autoimmune/inflammation – ESR/CRP: infection/inflammation • Plain films – AP/LAT of affected joint/area on exam • Ultrasound to evaluate for hip/joint effusion • Bone scan/MRI to evaluate for infection • In a child with limp and no localizing findings, consider plain films both lower extremities Case: 5 yo with acute left thigh pain Evaluation? In this condition, what is the gold standard test? What is the gold standard diagnostic test? ARS 1. CBC 2. C-reactive protein 3. Blood culture 4. Hip aspiration 5. Ultrasound Transient synovitis Transient synovitis of the hip (toxic synovitis) • Diagnosis of exclusion • Septic arthritis? • Most common cause of limping child – 80% some studies • Self limited • Etiology? Not always sure. • Age range 18 months – 12 years • Boys>girls (2:1) • Bilateral in 5% on patients

Toxic Synovitis of the Hip Diagnostic studies – significant overlap

Case: 12 yo male with painful left hip

• Pain slowly increasing over the past 2 months • No trauma • Exam: obese male, antalgic gait • ROM: mild pain, decreased internal rotation AP Pelvis and “Frog Leg” lateral Image in public domain at: https://openi.nlm.nih.gov/ Slipped capital femoral epiphysis • Most common cause of adolescent limp • Incidence – 2/100,000 – M/F=2.5:1 – L>R? • Peak incidence – Early adolescent growth spurt.

Creative commons license at: http://commons.wikimedia.org/wiki/File:Epilys.jpg

Physical therapy can’t hurt, right?

11/27 → 12/18 3 weeks Case: 8 yo female with 1 year c/o LBP • Two month h/o limp, favoring left leg • No constitutional symptoms • No PMH • Birth & Development – NSVD – Walked at 10 m • Initial Dx: Growing pains Physical Exam • 75 lbs, AFVSS • No TTP of spine • Pelvis – nontender • Mild TTP left anterior groin • ROM – R: F-120; Abd-70; ER-60; IR-30 – L: F-120; Abd-45; ER and IR-20 Initial Diagnosis: Growing Pains

Legg-Calve-Perthes Disease (LCP)

Treatment for LCP • Initial RX – Adductor tenotomy – Petri Cast-5m – Non weight bearing in a wheelchair • Second Rx – Varus derotation osteotomy L proximal femur • Complete resolution of symptoms at 2 years Legg-Calve-Perthes disease (Osteonecrosis of the femur head) • History: – Described early in 20th century – Dr. Legg from Boston, USA – Dr. Perthes from Germany • Definition: – Ischemic necrosis, collapse, and subsequent repair of the femoral head Image in public sector at: https://openi.nlm.nih.gov/

Which of the following is consistent with Legg-Calve Perthes? Legg-Calve Perthes Disease • Incidence – Peak 4-9y, 18 months -12 years • Risk Factors – Male:female = 4:1 – Low birth weight – Delay in skeletal maturation • History – Limping: often asymptomatic Legg-Calve Perthes Disease • PE – Antalgic gait – Decreased internal rotation – (+) Roll test • Dx: – X-ray – (+) high index of suspicion because initial radiographs often are normal – MRI & bone scan if high suspicion with normal xrays

Femoral stress fracture • Overuse injury – New Army recruit with hip/thigh pain after 4-6 weeks of new activity – A high school athlete who keeps trying to maintain high level of conditioning • If initial xrays are negative, consider bone scan or MRI • Some athletes may need severe restrictions to stop activity and enable healing to occur Tibial stress fracture vs growing pains

• Both occur in the mid to distal tibia • Stress fractures usually occur in patients with high levels of activity • Pain with stress fracture occurs with activity • Growing pains can occur at rest or awaken the patient from sleep Traction apophysitis

Sever’s Disease

• History – Occurs during peak growth spurt. – Running and jumping sports, particularly soccer. • Physical Exam – (+) squeeze test & tight heel cords. – X‐ray to r/o other pathology Treatment and Prognosis • RICE: rest, ice, compression, elevation • Heel lifts • Stretching & strengthening exercises • Acetaminophen/NSAIDS • Symptoms resolve in 98% • Return to play 2 months Traction apophysitis of the leg leading to limp

• Osgood-Schlatter’s Disease (OSD) – Traction of the patellar tendon on the tibial tubercle (In black) • Sinding-Larsen-Johansson SLJ – Traction on the patellar tendon at the inferior pole of the patella (other end from OSD – in red) OSD Clinical tips • Chronic limp: LCP, overuse, apophysitis, SCFE, systemic illness (tumor, CTD) • Malignant bone tumors – pain at rest, pain that awakens a patient from sleep • Always palpate with intention – find the orthopedic “PMI” and xray accordingly • Consider CBC, CRP, ESR Best Practice Recommendations

1. Transient synovitis is the most common cause of an acute limp in a child. 2. Initial evaluation should include anteroposterior and lateral radiography of the involved site 3. Septic arthritis should be considered in the child with temperature > 101.3 (38.5 C), refusal to bear weight, ESR > 40, WBC > 12, or CRP > 20. References

1. McCanny PJ, McCoy S, Grant T, Walsh S, O'Sullivan R. Implementation of an evidence based guideline reduces blood tests and length of stay for the limping child in a paediatric emergency department. Emerg Med J. 2013;30(1):19–23. 2. Peck D. Slipped capital femoral epiphysis: diagnosis and management. Am Fam Physician. 2010;82(3):258–262. 3. Krul M, van der Wouden JC, Schellevis FG, van Suijlekom-Smit LW, Koes BW. Acute non-traumatic hip pathology in children: incidence and presentation in family practice. Fam Pract. 2010;27(2):166–170. 4. Milla SS, Coley BD, Karmazyn B, et al. ACR Appropriateness Criteria limping child—ages 0 to 5 years. J Am Coll Radiol. 2012;9(8):545–553. 5. Sultan J, Hughes PJ. Septic arthritis or transient synovitis of the hip in children: the value of clinical prediction algorithms. J Bone Joint Surg Br. 2010;92(9):1289–1293. 6. Naranje S, Kelly DM, Sawyer JR. A Systematic Approach to the Evaluation of a Limping Child. American Family Physician. 2015;92(10):908-916.