11/12/2015 The limping child in your office Lori Tucker, M.D. FRCPC - - PDF document

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Lori Tucker, M.D. FRCPC Associate Professor in Pediatrics Division of Rheumatology BC Children’s Hospital Vancouver BC

The limping child in your office

The limping child in your office: Learning Objectives

• Differential diagnosis for the limping child or adolescent

based on likely diagnosis for age and presentation.

• Increase confidence in clinical assessment of MSK

complaints.

• Review red flags requiring further investigation or

referral.

References

• Sawyer JR and Kapoor M. The Limping Child: A Systematic

Approach to Diagnosis. American Family Physician 2009.

• Houghton KM. Review for the generalist: evaluation of pediatric foot

and ankle pain. Pediatric Rheumatology 2008. 6:6 doi 10.1186/1546-0096-6-6

• Houghton KM. Review for the generalist: evaluation of pediatric hip
• pain. Pediatric Rheumatology 2009. doi 10.1186/1546-0096-7-10
• Tse, S. and Laxer, R. “Approach to Acute Limb Pain in Childhood”.

Pediatrics in Review, Vol. 27, No. 5, May 2006.

• http://www.uptodate.com/contents/overview-of-the-causes-of-limp-

in-children

• Sen ES et al. The child with joint pain in primary care. Best Pract

Res Clin Rheumatol. 2014 28(6) 888.

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The normal gait in children

• Normal gait consists of:

– Stance – Swing

• Mature gait pattern is established by 3 yrs old, and by 7

yrs, gait is close to adult.

• Antalgic vs non-antalgic gait:

– Antalgic gait- shortened stance phase, to avoid pain – Non-antalgic gait- trendelenberg; circumduction, equinus

A limp: where is the pathology?

• Soft tissue
• Bone
• Articular
• Spine
• Neuromuscular
• Intra-abdominal

Limp in the young child

• Developmental hip dysplasia
• Toddlers fracture
• Infection- septic joint, osteomyelitis
• Trauma

– Consider non-accidental injury

• Neuromuscular

– Mild cerebral palsy

• Inflammatory

– JIA

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Limp in older kids

3-10 yr old

• Transient synovitis
• Legg-Calves-Perthes
• Infection

– Septic joint, osteomyelitis

• Tumor- malignant, benign
• Orthopedic

– Chondromalacae patella

• Trauma

– Sprain – fracture

• Inflammatory disease

– Arthritis (acute, chronic)

• Neuromuscular

– Spinal cord pathology – Muscular dystrophy

11-17 yr old

• Transient synovitis
• Late Perthes
• SCFE
• Infection
• Tumor
• Orthopedic

– Chondromalacae patella – Osgood Schlatter – Severs disease – Tarsal coalition

• Trauma
• Inflammatory disease
• Neuromuscular

A tip…..

• Most kids with idiopathic limb pains of childhood

(‘growing pains’) or diffuse pain syndrome do not have a persisting limp.

• A teen with a localized idiopathic pain syndrome (reflex

sympathetic dystrophy) might limp.

To get to the cause for a limp….

• History

– detailed

• Physical examination

– Child is undressed – Observe movements around the room

• Directed investigations

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Taking the history

• Symptom description

– Acute vs chronic – First episode vs recurrent – Mechanical symptoms- joint locking, catching, instability

• Pain

– Location, character, change with activity or rest, night pain – Alleviating or aggravating factors

• Trauma

– Acute – Repetitve microtrauma – Recent vs remote

• Other associated symptoms

– Systemic i.e. fever, weight loss – Inflammatory i.e. morning stiffness, swelling – Neurologic i.e. weakness, altered sensation

• Past history
• Current medications
• Recent immunizations?

To get to the cause for a limp….

• History

– detailed

• Physical examination

– Child is undressed – Observe movements around the room

• What’s the differential diagnosis?
• Directed investigations

Physical examination

• Watch the child walk and run.
• pGALS might be a good screening exam but you will

need to do a more detailed localized examination.

• Look for swelling, erythema, asymmetry.
• Palpate for pain.
• Examine the joints.

– Hip pathology can present as knee or thigh pain.

• Make sure to look at the spine, abdomen, GU, and

neurologic systems.

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To get to the cause for a limp….

• History

– detailed

• Physical examination

– Child is undressed – Observe movements around the room

• What’s the differential diagnosis?
• Directed investigations

Getting to the diagnosis

• Does this child look like they might have something

serious?

• Think through:

– Congenital – Developmental abnormalities – Trauma – Overuse – Infection – Tumor – Inflammatory disease

Sick 7 yr old boy with right leg pain and limp

What are some serious things you need to consider quickly? Septic joint Osteomyelitis Malignancy JIA What information would help move towards a diagnosis? Fever yes/no Length of symptoms Severity of pain, time of day Localizing pain yes/no Preceding illness

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7 yr old boy with leg pain and limp

• Acute onset
• Irritable if approached
• Afebrile
• URI last week

CRP 10 Diff dx: Septic arthritis vs toxic synovitis

Toxic synovitis (transient synovitis)

• Most common acute hip condition in children.
• Symptoms similar to septic arthritis.
• Ages 2-10 yrs, M>F, often preceded by viral infection.
• Self limited, resolves within 1 week.
• Important to rule out septic arthritis.
• 15% may have recurrence.

– Recurrent toxic synovitis or is it JIA?

Clinical prediction algorithm: is it transient synovitis or septic arthritis

• History of fever
• Non-weight bearing
• ESR at least 40 mm/hr
• WBC > 12,000 cells per mm3
• Chance of having septic arthritis:

– 0.2% if 0 predictors – 9.5% if 1 predictor – 35% if 2 predictors – 72.8% if 3 predictors – 93% if all 4 predictors

• Validated in a prospective cohort
• Kocher MS et al. Differentiating between septic hip and transient synovitis of the hip in children: an

evidence based clinical prediction algorithm. J Bone Joint Surg Am 1999. 81(12): 1662

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13 yr old basketball player with knee pain

• What are some serious things you should think of

quickly?

– Fracture or ligament tear – Osteomyelitis – Septic joint – malignancy

• What questions can you ask to get to the diagnosis?

– Fever yes/no – Length of pain history – Character of pain- severity, time of day, frequency, interference with activity – Trauma

13 yr old basketball player with knee pain

• Afebrile, no constitutional symptoms
• Gradual onset pain over 4 months, with occasional

locking and swelling.

• No night pain.
• No morning stiffness.

Osteochondritis dissecans

• Focal aseptic necrosis of subchondral bone.
• Can result in a loose body in the joint.
• Most common in knee, ankle, elbow.

– Knee medial condyle frequent

• Teens, M:F 3:1
• Likely due to repetitive microtrauma.
• Symptoms- pain, swelling, locking.
• Xray is required to diagnose.
• Orthopedic assessment required.

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15 yr old with knee pain for 8 months

• Generally healthy.
• Complains of episodes of knee pain, affecting one or the
• ther knee.

– When present, can be severe. – Occurs mostly late in day, or even at night. – They say there is swelling but sometimes only for an hour.

• No other constitutional symptoms.
• Has been missing dance classes because of pain.
• Mother has been diagnosed with RA.

15 yr old girl with knee pain for 8 months Patello-femoral syndrome

Ask about pain with deep knee bends/squats, walking downstairs, walking downhill. Pain is often intermittent, and can be severe. F>M (teen population), hypermobility. Examination: pain with resisted quad contraction. Treatment: Physio to strengthen quads. Reassurance.

16 yr old girl with a limp and hip pain

• Healthy teen.
• No trauma.
• Upper thigh/hip pain for 2 months.
• Active in sports….presumed to be groin pull.
• Sent by FP to physio.
• Returned for assessment.
• Limp is constant.
• Pain worse at night.
• Referred to sports medicine…waits 6 weeks to be seen.

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An xray was done after 4 months of pain and limp……

Dx: Osteosarcoma

Red Flags

• Child is unwell.

– Fever, weight loss, weakness – Unexplained weight loss

• Bone pain or night pain.
• Complete non weight bearing.
• Progression or non-resolution of symptoms.
• Regression of motor milestones.
• Significant functional disability.

– Child not ambulating – Child missing school or activities

What investigations should be done on a limping child?

• Guided by the clinical situation and differential diagnosis.
• Simple laboratory tests

– CBC, ESR/CRP – Don’t do an ANA or RF unless there is actual arthritis or a strong suspicion of autoimmune disease.

• Radiographs

– Consider doing bilateral views – Hips- do frog leg laterals

• Rarely need CT scan
• Ultrasound may be useful for effusion but not diagnostic.
• MRI

– Limited availability – May not be needed to reach a diagnosis

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Take home messages:

• Attention to basic evaluation (history, PE) can

provide clues to correct diagnosis.

• Consider patient’s age when formulating a

differential diagnosis.

• Watch out for Red Flags!

Thank you for your attention!