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The Limping Child

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The Limping Child The Limping Child Norman Y. Otsuka, MSc, MD, FRCSC, FAAP, FACS Chief, Division of Pediatric Orthopaedics Children’s Hospital at Montefiore Professor of Orthopaedic Surgery and Pediatrics Albert Einstein College of Medicine Disclosures None. Defining excellence. Come see for yourself. Orthopaedic Surgery 2015 Highlights Orthopaedic Surgery 2015 Highlights Children’s Improving Outcomes through Novel Hip Preservation Procedures Through a cutting-edge procedure that uses surgical hip dislocation with recontouring of the femoral head Hospital at and neck, our surgeons are able to correct acute and chronic deformities resulting from slipped capital femoral epiphysis–an obesity- related hip condition that leads to impingement in young adults–while Montefiore minimizing the risk of avascular necrosis. Adolescents and young adults with hip dysplasia also benefit from our surgeons’ use of the Bernese periacetabular osteotomy, a novel procedure that allows patients to return (CHAM) to activity far sooner than with previous forms of osteotomy. Orthopaedic Surgery Minimizing Surgical Intervention for Early- Onset Scoliosis We are reducing the need for surgery in young children with early-onset scoliosis by applying new approaches to traditional treatments. For example, casting has gotten a second life, thanks to the application of techniques and materials that improve compliance and new research proving its efficacy. Call us today for a For patients with more severe deformity, our surgeons can now implant magnetically controlled growing consultation rods that allow us to “grow” the spine with an external magnet, minimizing the need for repeat anesthesia and surgery in this vulnerable population. 718-920-2060 cham.org/orthopaedics Improving Quality of Life for Children with Cerebral Palsy Call 855-CHAM-247 for Correcting musculoskeletal problems in children with cerebral palsy has traditionally required multiple emergency transport 24/7 surgeries. Through single-event multilevel surgery–which addresses many of these challenges at once– Find more research and our surgeons are minimizing the risks associated with anesthesia and surgical interventions while programs on our new website significantly improving function and performance in these children. cham.org Need for Urgent or Emergent Intervention? Toddlers Septic arthritis Osteomyelitis Adolescents Slipped capital femoral epiphysis Three Groups Toddlers (Ages 1-3) Children (Ages 4-10) Adolescents (Ages 11-15) Case 1: EG Temperature: 101.2 ˚F • Pain/swelling right knee • ESR = 115 / WBC 16 • Refusal to walk 24 hours Case 1: EG • Exam – TTP medial femoral condyle – Able WB right LE – Able to fully extend right knee The age of the child is an important diagnostic factor Occult Limp - Common Causes 1-3 yrs: Infection, Toddler’s fracture, Transient Synovitis 4 -10 yrs: Infection, Trauma, Transient Synovitis, Blount, Discitis, JRA, Lyme, Toe-walking 10+ yrs: Trauma (avulsions), SCFE, Tarsal Coalition, Knee Derangement Occult Limp - Uncommon Causes 1-2 yrs: JRA; Scurvy, Sickle Crisis, DDH, Renal Osteodystrophy 2-5 yrs: Perthes, Leukemia, Sickle Crisis 5-10 yrs: Sickle Crisis, Leukemia, Tumor, Osteochondritis Dissecans 10+ yrs: Sickle Crisis, Infection: TB; Fungus, GC, Brodie’s Abscess, Tumor, Myositis Ossificans, AVN Why does a child limp? Attributes of Gait • Stability in stance • Foot clearance • Adequate stride length • Conservation of energy GAIT CYCLE Causes of a Limp 1) reduce pain 2) compensate for muscle weakness 3) accommodating for deformity 4) CNS/PNS dysfunction Hip Joint Capsule Pressure • Hip joint pathology – Increased production of fluid – Pressure minimized • flexion, abduction and external rotation – Explains positioning with a septic hip • Provactive Test – Extension and internal rotation – Look for a difference in rotation Physical Exam: Hip • Hip abduction Symmetry – Sensitive for hip pathology • Galeazzi test – Ankles to the buttocks with the hips and knees flexed. – positive when the knees are at different heights – Suggesting DDH or LLD Physical Exam: Hip Irritability • Modified log-roll test • Demonstrates hip irritation FABER Test • hip flexion, abduction and external rotation • placing the ipsilateral ankle on the contralateral knee • providing gentle downward pressure on the knee • Hip or SI joint pathology Transient (toxic) Synovitis • Diagnosis of exclusion • Clinical presentation like septic joint • BUT…. Less fever Near normal labs Joint aspirate unremarkable Transient (toxic) Synovitis • Treatment Anti-inflammatories Activity restriction Resolves over 7-10 days Toddlers Septic Arthritis and Osteomyelitis Septic arthritis / Osteomyelitis • Fever • Refusal to use affected extremity • Symptoms localized to one area • Swelling • Tenderness Kocher’s Criteria 1. Fever 4/4 99% 2. Inability to weight bear 3/4 93% 3. ESR > 40 2/4 40% 4. WBC > 12,000 mm3 1/4 3% Septic arthritis / Osteomyelitis WORK-UP Laboratory: C-reactive protein Sedimentation rate WBC with diff Blood cultures Joint aspiration Imaging Start with radiographs In my opinion, a “clinical diagnosis” based on “old” test: History and Physical Examination Septic arthritis / Osteomyelitis • Ultrasonography Septic arthritis / Osteomyelitis • Bone scan (skeletal scintigraphy) Septic arthritis / Osteomyelitis • MRI ? Deep soft tissue abscess ie. Iliopsoas Piriformis Quadriceps Septic arthritis / Osteomyelitis • (+) Fever Irritable joint Elevated CRP and ESR Effusion on U/S • ASPIRATE ! Septic arthritis / Osteomyelitis • Treatment Incision & Drainage Septic arthritis / Osteomyelitis • Antibiotics Follow C-reactive protein Lyme Disease • Parts NY & CT endemic areas • 3 stages – Rash: erythema migrans – Carditis, neuritis, rash – Arthritis: acute, polyarticular or migratory • Minimally painful • Resembles JRA Diagnosis • ELISA /Western blot • Clinical pattern • Treatment: amoxicillin, doxycycline – Latter not before age 8 – Treat only if disease presents, not prophylactic – 4 weeks – 98% cure Don’t forget about joint above and below Toddlers - Infection Discitis 6 mo – 4 years Lumbar spine Organism Staph aureus Treatment Antibiotics Toddlers - Infection Toddlers - Trauma Toddler’s Fracture Toddlers - Congenital Developmental Dysplasia of the Hip (DDH) Painless limp Trendelenburg Gait Toddlers - Congenital DDH Toddlers - Congenital DDH • Skin folds and limited abduction Toddlers - Congenital DDH Treatment Toddlers - Inflammatory Pauciarticular arthritis 2 years old Localized swelling and warmth Restricted range of motion Female:male 4:1 Toddlers - Neuromuscular Mild cerebral palsy Hemiplegic pattern Other Neurologic Cause Past Medical History !! Toddlers - Neoplastic Benign (Rare) Osteoid osteoma Solitary bone cyst Toddlers - Neoplastic Malignant (Rare) Leukemia 12% present with a limp Next - • Older kids Children (Ages 4-10 years) Legg-Calve-Perthes Seen most commonly in those 3-8 years Children Legg-Calve-Perthes Disease (LCP) Children Perthes Disease Etiology uncertain Deficiencies in antithrombotic factor C or S Elevated levels of lipoprotein A Hypofibrinolysis Presence of factor V Leiden Children Perthes Disease Treatment Debatable !! Children Discoid Menisci Clicking in knee Discomfort Lateral aspect Treatment Partial excision Children Limb Length Discrepancy Hemihypertrophy Trauma Infection Neoplasm Congenital Adolescent (ages 11-15) Overuse Syndromes Osgood Schlatters Disease Patellar tendonitis Anterior knee pain Treatment Rest and anti-inflammatories Adolescents Slipped Capital Femoral Epiphysis (SCFE) Adolescents SCFE Most common adolescent hip disorder Overweight Hip or knee pain Klein’s Line Adolescents SCFE Treatment Urgent !! Adolescents Hip Dysplasia Adolescents Hip Dysplasia - Treatment Adolescents - Foot pain Flat feet Common complaint Most are flexible Respond to shoe inserts Beware of Tarsal Coalitions ! Adolescents - Foot pain Tarsal Coalitions The Limping Child • Variety of reasons • History and Physical Exam IMPORTANT BEWARE INFECTION ! On behalf of Division of Pediatric Orthopaedics Thank you for the kind invitation! [email protected] [email protected] (718) 920-5532 .
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