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Evaluating the Limping Child: a Rheumatology Perspective

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Evaluating the Limping Child: a Rheumatology Perspective SCIENCE OF MEDICINE | Evaluating the Limping Child: A Rheumatology Perspective by Reema Syed, MD Taking a detailed Abstract important clues to the underlying history and completing Children often present diagnosis. Inquiring about recent a thorough evaluation to health care providers for travel will help with infectious causes. will help hone in on evaluation of limp. Having Associated pain versus painless limp raises different possibilities. the underlying cause. the knowledge of the different causes of leg pains both in the This article will review acute and chronic settings will Examination important causes of limp help in diagnosis, treatment, Assessing a child’s gait is crucial from the rheumatologist’s and referrals to subspecialists in completing an evaluation for lower viewpoint. in a timely manner. Taking a extremity complaints. Is the child detailed history and completing unable to bear weight or is the child a thorough evaluation will holding the affected joint in a fixed help hone in on the underlying position are important questions to cause. This article will review address and are signs of more serious important causes of limp from the issues. If the child appears toxic or has rheumatologist’s viewpoint. high fevers infectious etiologies need to be excluded. Introduction An antalgic gait signifies pathology A child may present to a primary in the hip, knee or ankle. A child with care provider with a limp due to acute antalgic gait will take a shorter stance on the affected limb to avoid bearing more urgent issues like infections weight on the diseased painful joint. or for more chronic issues like A circumduction motion of the hip is juvenile idiopathic arthritis or other also a clue of a painful joint aggravated rheumatologic issues. Picking up key by motion. Non-antalgic gait include information on history and a detailed toe walking for instance in leg length examination will often lead a provider discrepancy or due to tight heal cords. closer to the correct diagnosis. Trendelenburg gait is another form of non-antalgic gait seen with weak Clinical Evaluation abductor muscles. History The exam should not be limited Obtaining a detailed history to the affected joint but rather include regarding and surrounding the child’s the entire musculoskeletal system presenting symptoms will help narrow looking for tenderness, swelling, the differential diagnosis. Acuity warmth, erythema, ligament laxity, Reema Syed, MD, is Associate Professor of of onset, duration of symptoms, and restriction in range of motion. Internal Medicine and Pediatrics and Director, preceding injury or infections, The back and spine should also be Pediatric Rheumatology Fellowship Program, Saint Louis University. associated symptoms such as fevers, examined as well as the skin, which Contact: [email protected] rashes, weight loss, fatigue are may provide clues. Missouri Medicine | March/April 2016 | 113:2 | 131 Mar Apr Scientific.indd 131 4/21/2016 11:32:07 AM SCIENCE OF MEDICINE | Causes of Acute Limp Treatment should be started Septic arthritis promptly with intravenous Septic arthritis is a antibiotics followed by four to six medical emergency, which if not weeks of oral antibiotics. addressed promptly may lead to damage within one to two days.1 Toxic Synovitis The most commonly affected Toxic synovitis is self-limited joint is the knee but other joints benign inflammation of the including the hips and other large hip following a recent upper more than small joints may be respiratory infection within involved. The child is usually the last few weeks up to four febrile with inability or refusal months. Child will present to ambulate with a painful limp acutely with a painful limp, which usually resolves over seven if child does ambulate. The to ten days.5 Boys between the involved joint is warm, swollen, ages of three and ten years are and erythematous, with limited affected more than girls. The range of motion. In case of child does not appear toxic or the hip no swelling is found as ill as in septic arthritis or on exam and the child holds osteomyelitis. Low-grade fevers the joint in a flexed, abducted, may be noted and child will hold and externally rotated position. A child may present to a primary care provider with a the affected hip in a flexed and The most common causative limp due to acute more urgent issues like infections or externally rotated position. To organism is Staphylococcus Aureus for more chronic issues like juvenile idiopathic arthritis or help differentiate septic arthritis but may be different strains of other rheumatologic issues. Picking up key information from toxic synovitis Kocher on history and a detailed examination will often lead a streptococcus in neonates and provider closer to the correct diagnosis. et al. determined four clinical infant, salmonella in sickle cell predictors, if present, are more patients, and Neisseria gonorrhea in in favor of septic arthritis: fevers sexually active adolescents.2 The affected joint fluid should more than 101.3°F, blood white cell count greater than be aspirated which will reveal elevated WBC > 50,000 12,000/μL, erythrocyte sedimentation rate (ESR) more and cultures will be positive in 70% of individuals. Blood than 40mm/hour, and inability to bear weight. Caird et al. cultures will be positive in 50% of patients. Infected joints added c-reactive protein (CRP) more than 2.5mg/dL to the will need to be irrigated to allow for better healing. The criteria. Treatment is symptomatic with NSAIDs and most children recover in seven days with or without treatment hip joint always needs to be opened and surgically drained though NSAIDs may shorten treatment. Seventeen percent to prevent joint damage. Intravenous antibiotics should be of children may have recurrence out of which 10% may go started promptly followed by oral antibiotics for at least on to develop inflammatory arthritis especially seronegative three weeks is needed for complete recovery. spondyloarthropathy.6 Synovial fluid will reveal WBC counts between 5000 to 15000/μL and negative cultures. Osteomyelitis The serum WBC, ESR, and CRP are mildly elevated. Child will present acutely with fevers, localized pain, limping or refusal to ambulate.3 The most commonly Trauma involved bone is the femur and the most common causative Limping is a common manifestation of ligament strains, muscle strains, contusions, and fractures and should be organism is Staphylococcus aureus either via blood or direct kept in mind whenever a child presents with a limp.7,8 spread from adjacent infected tissue. There may be soft Apophysitis usually presents subacutely or is chronic tissue swelling, local tenderness on palpation, and pain with but avulsion fractures may present acutely. Runners are resistance on range of motion of the affected joint. Blood especially prone to avulsion fracture of the anterior superior cultures are positive in 60% of cases and bone cultures iliac spine at the insertion of the Sartorius muscle. are positive in 80%. There usually is a delay in changes on Compartment syndrome is one complication of plain xrays by a week or more such as soft tissue swelling, fractures and may lead to severe swelling and diminished subperiosteal changes, and bone destruction.4 Thus if the distal blood flow and should be recognized. suspicion is high, bone scan or MRI, which is as sensitive Traumas are addressed more often by orthopods thus but more specific than a bone scan, should be performed. beyond the scope of this paper. 132 | 113:2 | March/April 2016 | Missouri Medicine Mar Apr Scientific.indd 132 4/21/2016 11:32:08 AM SCIENCE OF MEDICINE | Chronic Causes of Limp and increases the risk of silent uveitis. The rheumatoid Juvenile Idiopathic Arthritis factor (RF) and anti-cyclic citrullinated peptides (anti-CCP Juvenile Idiopathic Arthritis (JIA) is noninfectious antibodies) are mostly negative in oligoarticular JIA. joint swelling, which persists in a child 16 years or younger for more than six weeks. The prevalence of JIA in the U.S. Complications Seen in Oligoarticular JIA ranges from 1.6 to 86.1 per 100,000 persons.9 It is the Uveitis most common rheumatic illness in childhood. Underlying Uveitis specifically involving the anterior chamber is etiology is multifactorial occurring in genetically susceptible seen in 45% of oligo-JIA patients. Risk factors to developing host in the opportune environment. There are 17 loci uveitis besides the positive ANA include earlier onset of 13 found to be associated with JIA risk. The concordance rate disease < four years of age and female gender. The in monozygotic twins is between 25-40%. Many cytokines course of joint disease does not correlate with eye disease. are elevated in JIA including Tumor Necrosis Factor-alpha, Five percent of patients present with eye disease prior to developing joint disease, which is linked with poorer Interleukin-1, Interleukin-6, which cause activation and prognosis. If a child is diagnosed with JIA especially proliferation of many inflammatory cells and adhesion oligoarticular JIA they must be referred to ophthalmology molecules. for evaluation for uveitis.14 In patients with positive ANA JIA is subclassifed based on the International League follow-ups with ophthalmology should be every three of Associations for Rheumatology (ILAR) into systemic months for three to four years then spaced out to every six onset (SoJIA), oligoarthritis with involvement of four or less months for another three years then annually. Those with a joints, polyarthritis rheumatoid factor negative, polyarthritis negative ANA need to be followed by ophthalmology every rheumatoid factor positive, psoriatic arthritis, enthesitis six months. Untreated uveitis may lead to visual loss, band 10 related arthritis, and other arthritis. The oligoarthritis is keratopathy, posterior synechiae, and formation of cataracts, subclassifed further into persistent if the number of joint glaucoma, and abnormal intraocular pressures. counts after six months of disease onset remain less than five or extended if five or more joints become involved.
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