The limping child and an introduction to paediatric musculoskeletal clinical skills Professor Helen Foster 15 July 2020 This slide deck • Important aspects of musculoskeletal clinical skills in context of limp – History taking and Examination – Apply Clinical Reasoning in clinical cases www.pmmonline.org Introduction • Please feel free to use these slides in your teaching and add your own cases to highlight key points • Some links to key web pages are provided on the slides to help navigate around PMM • There are lots of images, videos and cases on PMM to supplement these slides Learning outcomes • Be aware and practice how to perform pGALS • Know about limp – Spectrum of causes – Approach to assessment and investigations – Key conditions that can present with limp • Limp as a common presentation to emergency departments e-Resources – all free www.pmmonline.org • History • Examination pGALS, pREMS Video demos • Red flags • Normal development • Cases Knowing what is normal is important • Motor milestones • Leg alignment / normal variants • Ranges of joint movement http://www.pmmonline.org/doctor/approach-to-clinical- assessment Hypermobility is common often ‘benign’ (a normal variant) • Younger the child the more flexible • More so in girls and non-Caucasians. Often familial • Changes are symmetrical, usually symptom free • Advantage in sports – dancers, gymnasts • Remember: – Children with rheumatic disease or other pathology can also be hypermobile ! – Don’t forget rare but significant causes of hypermobility • Marfanoid syndromes (family history, body habitus) • Ehlers Danlos (elastic skin, scars) • Osteogenesis imperfecta (family history, low trauma fractures, blue sclera) http://www.pmmonline.org/doctor/approach-to-clinical-assessment/normal-variants/hypermobility Growing pains • Young children often get non-specific aches and pains in their legs – Often after exercise – Often runs in families and with hypermobility • Pain can be severe and disturb children (and parents !) at nights • A common cause of presentation to primary care as parents are concerned http://www.pmmonline.org/page.aspx?id=808 The “rules” of Growing pains • Age 4-12 years • Bilateral (symmetrical) • Never present in the morning • Never limps • Milestones normal • History and examination normal – Hypermobility is common http://www.pmmonline.org/page.aspx?id=808 Adapted from EMD Smith Arch Dis Child Educ Pract Ed 2012;97:185-193 http://www.pmmonline.org/doctor/limping-child Arch Dis Child Educ Pract Ed 2012;97:185-193 What is a limp ? • Abnormal / asymmetrical gait • Usually painful but not always • Various causes – Congenital/developmental or acquired causes – Pathology (infection, trauma, inflammation, trauma, malignancy, metabolic, developmental, etc) – Site (anywhere in lower limb, spine, abdominal, genitalia) http://www.pmmonline.org/doctor/limping-child Causes of Limp – by pathology • Trauma – fracture, contusion, sprain • Infection – septic arthritis, osteomyelitis, TB • Neoplasia – bone, leukaemia, lymphoma • Inflammatory – Juvenile Idiopathic Arthritis, transient synovitis/irritable hip, reactive arthritis • Metabolic – rickets, genetic syndromes (usually symmetrical abnormal gait) • Congenital – Developmental Dysplasia Hip (DDH), short leg, club foot • Neuromuscular – Cerebral palsy, myopathies • Developmental – Perthes, Slipped Capital Femoral Epiphysis (SCFE), Tarsal coalition • Other – Testicular torsion, inguinal hernia, appendicitis, urine infection Causes of limp * * * * * EMD Smith Arch Dis Child Educ Pract Ed 2012;97:185-193 ‘Red flags’ Infection, malignancy or non-accidental injury • Unwell child • Fever, malaise, systemic upset, reduced appetite, weight loss, night sweats • Bone or joint pain with fever – ‘red hot joint’ • Refractory or unremitting pain • Persistent night-waking • Incongruence between history and presentation • Child abuse / safeguarding http://www.pmmonline.org/page.aspx?id=384 Key Conditions to Focus on • Common: – Irritable hip/transient synovitis • Important: – Perthes Disease – Slipped Capital (Upper) Femoral Epiphysis (SCFE) – Juvenile Idiopathic Arthritis • Serious/life threatening (red flags): – Acute Lymphoblastic Leukaemia – Septic Arthritis Non-weightbearing or ‘pseudoparalysis’ • Always Serious ! • Sepsis • Fracture • Malignancy • Acute hip - SCFE / transient synovitis/ Perthes The limping child • Diagnosis rests on history, examination and careful consideration (and interpretation) of investigations http://www.pmmonline.org/doctor/limping-child http://www.pmmonline.org/doctor/limping-child/making-a- diagnosis • Key points History – Age – What has been observed - What are the concerns ? – Onset and duration - acute / chronic / precipitating factors ? – Course - intermittent / getting worse ? – Pain / weakness / falls / ‘clumsy’ ? • Lack of reported pain does not mean no pain • Change in mood and behaviour may be surrogates for pain – Nature (of pain) • Site – remember may not localise / consider referred pain • Resolving or getting worse? Night pain ? Response to analgesics or NSAIDS ? – Systemic Upset / red flags ? • Weight loss / Night sweats / Fever / Night pain – Development and Motor Milestones – Social history - concerns about safeguarding – Trauma (careful… all children fall over ! ) Also ask… • What can the child do / no longer do ? – Home / Schoolwork (handwriting) / Play / Sport – Report from others (teachers?) • Consider motor milestones (e.g walking, stairs, sitting) – Regression – suggests acquired pathology – Delay – suggests developmental / congenital cause Also ask… • Any suggestion of diurnal variation ? – Morning stiffness / gelling (car rides, after sitting) • Consider inflammation – Joints / muscles / both – Ask about swollen joints – Ask about joints not just in the legs ! Examination • Screening - overall assessment – Vital signs (‘sick child’?) – Abdomen, pelvis, genitalia, back, and extremities • Inspection and palpation • Stance and Gait ..pGALS is a good start ! – Barefoot and minimally clothed – Observe several gait cycles – Running often accentuates subtle abnormalities • Specific – ‘Look, Feel, Move, Function’ and upper limbs too – Occult trauma (soles of feet / shoes!) – Spine – Neurological • Measure and compare leg lengths • Comparing both sides really helpful Investigations • Imaging studies – Plain X Rays -AP pelvis +/- AP and lateral views of both lower extremities • Long bones as well as joints / look out for unsuspected fractures – Ultrasound (Joint / muscle +/- abdo) – CT scan (Abdo / pelvis / bony detail) – MRI (soft-tissue pathology, evaluation of bone tumours) – Isotope bone scan very rarely used if MRI available • occult fractures, osteomyelitis, Perthes disease • Laboratory studies – FBC, differential +/- film, ESR and CRP – Urinalysis +/- culture – Blood cultures / Joint aspiration if suspicion of septic arthritis / TB • Synovial fluid analysis - cell count, glucose, culture and Gram / ZN stain – +/- Muscle enzymes, vitamin D, Bone chemistry – +/- autoantibodies (ANA / Rheumatold factor) – +/- bone marrow – +/- catecholamines (neuroblastoma) http://www.pmmonline.org/doctor/investigation-and-management Autoantibodies • Antinuclear antibody (ANA) – Not diagnostic! Positive in many transient illnesses – Detected in JIA, SLE • Rheumatoid factor – Not diagnostic ! Often negative in JIA • BUT in a clinical picture of arthritis or suspected multisystem disease they help to establish diagnosis and prognosis – JIA (ANA associates with risk of uveitis, RF associates with worse prognosis) – SLE (dsDNA more helpful) http://www.pmmonline.org/doctor/investigation- and-management/blood-and-urine-tests/auto-abs Some cases Boy aged 6 years • Limp 2 days, getting worse • Today can hardly weight at all • Pain in knee • Fever and generally unwell • Examination – red ‘hot’ swollen knee – he winces when you approach his knee and cries when you touch it. No movement is possible. Thoughts Investigations Differential diagnosis WCC high ESR high Xray normal Septic Arthritis and Osteomyelitis • Pathophysiology: – Bacterial infection of the joint +/- bone • Clinical features: – Acute onset of fever with unexplained limp – Reluctance to use a limb or inability to weight bear – Bone or joint pain with a hot swollen joint, bone or joint tenderness, or complete reluctance to move a joint or limb Septic arthritis • Early Orthopaedic assessment – Washout and culture – Prolonged antibiotics • Microbiology input • Don’t forget TB ! – Often more indolent presentation – Immunosuppressed EMD Smith Arch Dis Child Educ Pract Ed 2012;97:185-193 A 5 year old girl • Limp about 1 week, pains in legs • Pain at night – crying ++ • Tired in the day (naps), less interested in play • Pale and quiet - “not herself” • Joints normal Thoughts Investigations Differential diagnosis A 5 year old girl • Limp about 1 week, pains in legs • Pain at night – crying ++ • Tired in the day (naps), less interested in play • Pale and quiet - “not herself” • Joints normal • Hb 10.9 • WBC 7.5 (lymph 4, neut 3) • Platelets 100 • ESR 10 Diagnosis – Acute leukaemia • Worrying indicators – Night waking (every night, difficult to console) – Reduced function (play, daytime activity, energy) – Systemic features (pallor, fatigue) – Abnormal bloods – thrombocytopenia Acute Lymphoblastic Leukaemia • Pathophysiology: – Malignancy of lymphocyte precursor cells, infiltrates marrow & can metastasise to bone – Commonest malignancy in childhood • Clinical features: – Bone pain common, often at night – Weight loss, lethargy, pallor, bruising,