The Limping Or Non-Weight Bearing Child

The Limping or Non-Weight Bearing Child

Guideline Review

Amy Romashko, MD Medical Director, Children’s Wisconsin I have no financial relationships to disclose except that I am employed at Children’s Wisconsin.

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Objectives

• Understand the utility of using an evidence based guideline when evaluating non-weight bearing or limping pediatric patients presenting to an Urgent Care setting. • Review elements of the H&P which are particularly helpful in narrowing down the differential dx of a child with a limp. • Reflect on how the guideline applies to sample cases of patients presenting with a limp or non-weight bearing. • Identify barriers that might result in providers not following the guideline.

• A 2 y.o. female presents to Urgent Care with a cc of “difficulty walking”. • Hx sig for: • Intermittent temps up to 100 for a few days approximately one week ago accompanied by one episode of emesis. • No fever and acting well for the past 3 days. • Has refused to put weight on her R leg since waking up this am, points to right knee when asked what hurts. • No hx trauma, patient is otherwise in good spirits. • Temp Measured in clinic 100.5.

• Source of limp: • Causes: • Osseous • Trauma • Articular • Infectious • Neurological • Immune Mediated • Soft tissue • Acquired or • Intra-abdominal Developmental • Other • Neoplastic • Referred • Benign Musculoskeletal • Neurologic • Metabolic

• How do we: • Ensure that we do not miss something very serious and time sensitive (e.g.: septic hip) • Keep in mind the less common things that could be causing the symptoms? (e.g.: malignancy, child abuse) • Not waste time and money working up something that could be benign (e.g. toxic synovitis)

• Thankfully, EBG can be used help guide us to the best and safest course for our patients. • Our guideline was developed by our Clinical Practice Group • Dr. Olorundami • Ilana Cabrera • Process: • Lit search/Established Guideline Review • Rough Draft • Review by Subspecialists at CW • Review and Edits by Group

• This guideline is not designed to fully diagnose a child with a limp. • Follow-up of those kids discharged home allows for further outpatient workup or subspecialty consult as necessary if the limp was to continue or reoccur. • FOLLOW UP IS KEY!!!!

© Children’s Wisconsin Guideline Format- Children’s Wisconsin Urgent Care • Subject • Purpose • Definition of Condition • Etiology and Differential Dx • Guideline • Subjective Data/Hx • Objective Data/PE • Diagnostic Studies • Treatment (if applicable) • Follow-up Recommendations • References • Appendices (Summary Charts, Pathways)

• True incidence unknown. • What is limping? • One published study on the • Deviation from normal gait limping child found: • Can be secondary to pain, weakness, or musculoskeletal deformity. • 1.8 per 1000 kids less than 14 years • Antalgic Gait • Male to female ratio 1.7:1 • Shortening of the stance phase of the • Median age: 4.4 years affected leg to avoid pain. • Most common dx: transient • Non-antalgic gait synovitis • Trendelenburg gait • The hip drops on the normal side during swing phase and the trunk leans to the affected side to compensate for hip abductor weakness. • SCFE, DDH, Legg-Calve Perthes Disease, Muscular Dystrophy

© Children’s Wisconsin © Children’s Wisconsin Subjective Data/History: Pain Characteristics • Site • Focal vs generalized • Unilateral vs bilateral • Onset • Acute • Chronic • Severity • How much is this effecting their activity? • Duration • Constant • Intermittent • Aggravating and relieving Factors • Present at rest? • What makes it better or worse?

• Radiation • Quality o Aching, dull, burning, sharp • Weight-bearing o Complete or partial refusal • Associated Pain o Abdomen o Back

• Systemic Symptoms • Fever, rash, weight loss, malaise, anorexia, night sweats

• Morning stiffness

• Neurologic symptoms • Incontinence, sciatica or leg weakness

• Medical Hx • Social Hx: • Bleeding disorders • Sports participation • Surgical Hx • Sexual activity • Developmental Hx • Sick Contacts • Prior Injuries

• Preceding Events • Viral illness/diarrhea • Tick Bite • Pharyngitis

• Do as much inspection/palpation in parent’s lap as possible! • What does “normal” limb look like? • Try to examine supine and seated.

• Looking for: • Erythema • Swelling • Deformity • Lacerations/Abrasions • Bruising • Increased warmth • Tenderness to movement and palpation • Limb length discrepancy

• Ankle • Knee • Hip

• Back • Abdomen • Palpate Paraspinal Muscles, • Tenderness Spinous Processes, Iliac • Masses Spines • Psoas and obturator signs • ROM Back

• Have child barefoot and minimally clothed • Will child bear weight? • Standing, Walking and Running • Symmetry • Stance • Gait pattern/Type of Limp

© Children’s Wisconsin Diagnostic Studies: Imaging • Begin with the area of • X-Ray can be initially normal concern in: • Both AP and lateral views • Some acute fractures • Hips: • Early Legg-Calve Perthes • AP and frog leg views of hips • Osteomyelitis or septic arthritis • Suspected SCFE • AP and true lateral of BOTH hips for comparison • NO FROG LEG VIEW • Other Imaging Modalities • Ultrasound • Young children or non-focal • CT exam: image both legs • MRI • Bone scan

• Directed by the H&P findings • Not indicated if: • Initial Lab Assessment • Afebrile Child • CBC with diff • Normal imaging • ESR • Esp if: • CRP • Isolated injury • Pain <24 hours • Additional Labs to Consider: • Lyme Studies • Indicated if: • Blood Cultures • Concern for infectious, • If suspicious for septic arthritis or inflammatory, or neoplastic osteomyelitis etiology

• The risk of septic arthritis has • Inability to been found to be successively ambulate greater with each additional number of positives. • Fever of 38.5 C (101 F) or above • If all 5 are present, septic arthritis is highly likely (99%) • WBC > 12K • ESR > 40 • If none of these are present, the risk of septic arthritis is • CRP > 2 very low (0.2%).

Septic arthritis Osteomyelitis

Most often infants and young children under age 4 Most common under age 5, but can occur at any age

Hip and knee most common sites Effects metaphyseal regions of bones so can cause peri-articular pain and tenderness

Child is often toxic, febrile, with decreased appetite Child may appear toxic or have very little outward evidence of infection

Prognosis for full recovery good only if treatment Prognosis is better than septic arthritis provided w/in 24 hours of symptom onset

Delay in diagnosis causes proportionally bad prognosis Established infection can damage growth plate causing for osteonecrosis and permanent joint damage limb length discrepancy © Children’s Wisconsin Treatment and Follow-up • Afebrile child, no hx trauma, normal imaging (suspected toxic synovitis) • Bed rest • Pain relief with NSAD or acetaminophen • FU with PCP in 2-3 days • Consider referral to Rheumatology for sx >4 weeks • Prompt reassessment for + fever, worsening symptoms

• Suspected toddler fracture • Splint and ortho FU

• Febrile child without joint effusion, normal radiologic and blood studies • Close FU as an outpatient

• Lack of resources in our UCs (Blood work) • Pushback from family when transfer necessary for further work-up • Desire to “solve the mystery now.” • Lack of awareness of guideline

HISTORY • Since yesterday, slightly fussy when walking and seems to be favoring L leg. • No known injury/trauma. • Had some loose stools and tactile fever for a few days earlier in the week. • Pt otherwise has been acting well and is in good spirits. Eating and drinking well. • Tylenol given, no help • Sick contacts: around lots of other kids for birthday party the day before yesterday, nobody sick.

OBJECTIVE: (POSITIVE FINDINGS ONLY) • AF, VS normal • MSK: No apparent tenderness to palpation, swelling, erythema, or apparent loss of ROM left leg. Fussing during exam due to stranger anxiety, possibly more fussy when L hip ROM tested. • GAIT: Not very cooperative with exam, significant stranger anxiety and wants to be in Mom’s arms. Antalgic gait favoring L leg observed briefly. Patient will bear weight on leg when standing.

Provider did not feel imaging was necessary since no hx trauma or focal tenderness on exam, patient weight bearing. (Pre Guideline)

DX: • Likely toxic synovitis

PLAN: • DC home • FU with PMD in 48-72 hours • RTC or call PMD sooner if + fever over 100.5

• Followed up with PMD 2 days later, still favoring L leg • Mom has since remembered that he was playing with all the other bigger kids in a bounce house just before leaving the birthday party, he fell asleep on the way home and woke up with the limp the next day. • X-ray obtained, demonstrating an oblique lucency through the mid tibial diaphysis without evidence of cortical disruption, • Dx: Nondisplaced toddler fracture.

HISTORY • Intermittent pain complaints on and off for past few months, no hx trauma or sports participation • Walking with a limp for “a while now” • Pain became suddenly worse when standing up from his desk at school today • Pain localized to upper R thigh but sometimes radiates to his R knee as well • Worse with activity, especially running but sometimes just the act of sitting down hurts. • Rest and ibuprofen have helped in the past, but have not helped much over the past week.

OBJECTIVE: (POSITIVE FINDINGS ONLY) • VS: normal • Wt: 85.7 kg (188 lb 15 oz) • GEN: Alert, cooperative, nontoxic • MSK: + pain to palpation anterior R hip. Significantly decreased ROM R hip compared to L, increased pain to R hip with flexion, extension, and internal and external rotation.

• PROCEDURE COMMENTS: • AP and frog leg view • FINDINGS: • There is mild widening of the right physis. The right Klein lying barely touches the lateral aspect of the femoral head. The left hip joint is normal. • IMPRESSION: • Mild widening of the right physis with very mild inferomedial displacement of the right femoral head may represent early SCFE. • Pt transferred to ER for Ortho Consult • Admitted for bed rest prior to surgery next day

HISTORY • Woke up from nap at home daycare unwilling to stand on L leg • Babysitter (Mom’s cousin) reports slightly sleepier than usual since nap, doesn’t want to be put down • Took two naps today, not normal for him. • No recent colds or illnesses, no fevers • No sick contacts

OBJECTIVE: (POSITIVE FINDINGS ONLY) • Axillary Temp: 37.7 °C (99.1 °F) (VS otherwise normal) • GEN: Tired appearing but appropriately responsive to exam • HEENT: scant rhinorrhea and nasal congestion • MSK: Left leg: upper thigh firm and warm to touch, blotchy erythema and mild swelling to knee (compared to R). Discomfort expressed with straightening of leg at knee and with any movement or touch.

• FINDINGS: Spiral fracture of the mid left femoral diaphysis with minimal displacement or angulation. No other bone lesions. No articular malalignment. • CPS Report initiated • Patient splinted in a long leg splint with stirrup • Transfer via ambulance to CWED • Advocacy consult obtained, NAT workup obtained.

© Children’s Wisconsin 13 yo competitive soccer player with 3 days knee pain causing limp HISTORY • Pain began 3 days prior to visit • Felt better next day so he played soccer (mild pain with activity), no pain that night • Pain reappeared next day with sprints during soccer practice and has progressively worsened since • Localized to both medial and lateral sides of knee • Mom treated with turmeric natural anti-inflammatory and ibuprofen with some improvement of pain • Sat on sidelines for practice today, trainer noticed swelling and suggested he be further evaluated. • Otherwise healthy, no recent illness or fevers

OBJECTIVE: (POSITIVE FINDINGS ONLY) • VS: Temp 100.5, otherwise normal • GEN: Alert, cooperative, nontoxic • MSK: L knee with point tenderness of the medial and lateral knee joint, + swelling, no obvious warmth or erythema of joint • NEURO: Gait antalgic favoring the R leg, able to weight bear despite pain

• Two views of L knee and Sunrise: • IMPRESSION: No fracture or dislocation. Trace joint effusion.

Normal Knee

• Provider consulted ER physician via telephone: • Stated he would not guarantee further workup if we sent the patient. • Felt that the low-grade temperature and non-compelling xray of the left knee were unlikely to be indicative of an osteomyelitis and the patient was not sick enough to consider septic joint. • Recommended FU with sports medicine on Monday (visit was on a Sat) • Discussed with family, patient went home for remainder of weekend on NSAIDs and RICE instructions • Appt with sports med made for following Monday afternoon

© Children’s Wisconsin 13 yo competitive soccer player with 3 days knee pain causing limp • Mon PM Sports Med Visit • History: • Concern for septic joint or • Swelling and pain persisted over osteomyelitis again raised weekend • Temp to 100.5 Sunday, tmax 99.5 • Labs drawn sent to hospital lab Monday • Plan to call family first thing in the • No NSAIDs given over the am with results weekend • If + fever over 100.5 overnight to ER • Exam: • Moderate R knee effusion • + increased warmth to touch • Unable to fully extend knee, pain with ROM testing • Unable to assess joint stability due to muscle splinting from pain

LABS: ADMISSION: Hospitalist Service • WBC 7.4, Hgb/Hct 13.6/40.9, Plt 326 (Diff WNL) • Clinda ( to cover possible septic arthritis) • ESR 56 • Ceftriaxone (to cover possible Lyme) • CRP 4.5 • MRI with contrast scheduled • Also sent: • Large knee joint effusion • ANA Panel • Prominent poplieteal lymph nodes • Lyme Titers • Diffuse synovitis • ASO/ADB (antistrep Dnase B) • No acute injury to structures • No sign of osteomyelitis SENT TO ER: • US + effusion • Joint Aspiration performed • 58 cc fluid • WBC 28K, 90% PMN • Blood and joint fluid sent for Cx

© Children’s Wisconsin 13 yo competitive soccer player with 3 days knee pain causing limp • L elbow became swollen, warm day of admission • Lyme titers came back positive (IGG and IGM) • Rapid Improvement in both elbow and knee symptoms on ceftriaxone x 2 days followed by doxycycline x 28 days as an outpatient • Confirmatory Positive Western Blot

© Children’s Wisconsin References • American Academy of Pediatrics. (2014). Evaluating the limping child. In J. F. Sarwark & C. R. LaBella (Eds.), Pediatric orthopaedics and sports injuries (pp. 111-120). Elk Grove Village, IL: American Academy of Pediatrics. • Aronson, P., Posner, J., Dooley, S., Coffin, S., Jacobstein, C. & Lavelle, J. (2017). ED pathway for the evaluation/treatment of the child with suspected septic arthritis. Children’s Hospital of Philadelphia. Retrieved from https://www.chop.edu/clinical-pathway/septic-arthritis-suspected-clinical-pathway • Barkin, R.M., Barkin, S.Z., & Barkin, A.Z. (2000). The limping child. Journal of Emergency Medicine, 18(3), 331-339. • Brady, M. (1993). The child with a limp. Journal of Pediatric Health Care, 7(5), 226-228. • Clark, C.M., Fleicher, G.R., & Drutz, J.E. (2018). Approach to the child with a limp. UpToDate. Retrieved from http://www.UpToDate.com • Clark, C.M., Fleicher, G.R., & Drutz, J.E. (2017). Overview of the causes of limp in children. UpToDate. Retrieved from http://www.UpToDate.com

• Herman, M.J. & Martinek, M. (2015). The limping child. Pediatrics in Review, 36, 184. • Kocher, M.S., Mandiga, R., Zurakowski, D., Barnewolt, C., & Kasser, J. (2004). Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. Journal of Bone and Joint Surgery, 86-A(8), 1629-1635. • Lawrence, L.L. (1988). The limping child. Emergency Medicine Clinics of North America, 16(4), 911-929. • Leung A.K. & Lemay J.F. (2004). The limping child. Journal of Pediatric Health Care, 18(5), 219-223. • Sawyer, J.R., Kapoor M. (2009). The limping child: A systemic approach to diagnosis. Am Fam Physician. 79(3), 215-224. • Shah, A.P., Indra, S., Kannikeshwaran, N., Hartwig, E., & Kamat, D. (2015). Diagnostic approach to limp in children. Pediatric Annals, 44(12), 552-554, 556.