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

11/12/2015 The limping child in your office Lori Tucker, M.D. FRCPC Associate Professor in Pediatrics Division of Rheumatology BC Children’s Hospital Vancouver BC 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. 1

11/12/2015 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 2

11/12/2015 Limp in older kids 3-10 yr old 11-17 yr old • Transient synovitis • Transient synovitis • Legg-Calves-Perthes • Late Perthes • Infection • SCFE – Septic joint, osteomyelitis • Infection • Tumor- malignant, benign • Tumor • Orthopedic • Orthopedic – Chondromalacae patella • Trauma – Chondromalacae patella – Sprain – Osgood Schlatter – fracture – Severs disease • Inflammatory disease – Tarsal coalition – Arthritis (acute, chronic) • Trauma • Neuromuscular • Inflammatory disease – Spinal cord pathology • Neuromuscular – Muscular dystrophy 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 3

11/12/2015 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. 4

11/12/2015 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 5

11/12/2015 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 mm 3 • 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 6

11/12/2015 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. 7

11/12/2015 15 yr old with knee pain for 8 months • Generally healthy. • Complains of episodes of knee pain, affecting one or the other 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. 8

11/12/2015 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 9

11/12/2015 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! 10