Prof. Mamoun Kremli AlMaarefa College The limping child.
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Transcript of Prof. Mamoun Kremli AlMaarefa College The limping child.
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Prof. Mamoun KremliAlMaarefa College
The limping child
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Introduction
Limping is a common presentation in childrenSeen by orthopedic surgeons, pediatricians, primary
care physicians
Need to take a properHistoryphysical examinationInvestigations
Some diseases related to specific age groups
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History
Duration, when first noticed
Pain
History of trauma
Associated systemic symptomsFever, night sweating, anorexia, weight loss
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Limping
PainfulAntalgic gait – short stance phase of gait cycle
Child may not complain of pain
Painless
History of trauma often reported in all casesRelevantIrrelevant
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Types of gait
High steppage:Foot drop – neurologic disease
Trendelenburgh:DDH, weak hip abductors, could not abduct
Circumduction:Stiff hip, neurologic disaese
Tip-toeTight achilles tendon, CTEV, Cerebral Palsy, habitual,
compensating length discrepency
Lurching:Short length
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Types of gait
Wide-base:To gain balance – neurologic disease
ScissoringTight hip adductors – Cerebral Palsy
Hemiplegic gaitCerebral palsy - neurologic
AtaxicNeurologic disease
Foot inversion / eversionFoot deformity / avoiding pain
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Types of gait
Stiff-kneeKnee disease / arthrogryposis
Hand-knee Weak quadriceps femoris muscle
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Causes of painful limping
TraumaMajor musculoskeletalSplinter into foot
InfectionAcute OM, Septic arthritis
Malignant bone tumor
Rheumatic disease
Acute slipped capital femoral epiphysis
Perthes disease (Avascula necrosis)
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Causes of painless limping
Benign bone tumors
CongenitalDDH, club foot, congenitally short femur, short tibia
Post injury deformity / length discrepancy
AVN – Perthe’s disease
Slipped capital femoral epiphysis (chronic)
Deformity and leg length discrepancy
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History
Sudden onset:Trauma
Gradual onset:Disease
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Pitfalls
Misled by parents’ historyHistory of traumaAlways a leg length inequality
Misled by patients’ complaintHip problems may present with knee pain
Children below 5 years do not complain of pain
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Many causes
Different diseases occur more commonly at specific age groups
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Age 1-4 years
CDH – DDH
History: at risk groups
Physical findings:Asymmetrical foldsLimited abductionHamstring stretch signOrtolani / BarlowShorteningTrendelenburgh
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Age 3 – 6 years
Transient synovitisLimping, painful to move, ?WBC, ? Fever, ? ESRResolves in daysDisappears without treatment
Septic arthritisLimping-refuses to walkFever >38.5WBC >12,000ESR >40 mm
If in doubt: Aspiration
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Age 5 – 10 years
Legg-Calve-Perthes diseaseBoy, antalgic gaitPain and muscle spasm with passive motionLimitation of rotation and abductionPositive Trendelenburgh
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Legg-Calve-Perthes
Age usually: 4-8 years, Boys= 4X girls
Idiopathic avascular necrosis of femoral head
Blood supply of femoral head:Neonates: metaphyseal,lateral epiphyseal, and scanty
ligamentum teres vessels4 years: no epiphyseal vessels7 years: ligamentum teres vessels developed well
4 – 7 years: dependent on lateral epiphyseal vesselsIf trauma or synovitis, pressure occludes blood
supply
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Legg-Calve-Perthes
Stages:1. Bone death:
may still look normal on x-ray
2. Revascularization and Repair:Increased density and fragmentationon x-ray
3. Distortion and Remodelling
1. Distortion, falttening (coxa plana), and enlargement (coxa magna), with partial uncoverage
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Legg-Calve-Perthes
Clinical picture:Limping (painful / painless)May present with knee/thigh painEarly: limitation of all movementsLater: limitation of abduction and internal rotation
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Legg-Calve-Perthes
Apley’s System of Orthopedics and Fractures
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Legg-Calve-Perthes
Apley’s System of Orthopedics and Fractures
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Legg-Calve-Perthes
Different stages of Perthes in a patient
Sclerosis Collapse Fragmentation Remodelling
http://community.tsrhc.org/Perthes-disease-about-perthes-disease
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Legg-Calve-Perthes
Treatment:RestPhysiotherapy: abductionContainment by splintSurgery:
Containment, improved coverLater: for aftermath
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Age 10 – 15 years
Slipped Capital Femoral Epiphysis (SCFE)Acute Vs. chronicBoys, overweight, ?hypogonadismLimited internal rotationHip externally rotates when flexedX-ray: AP and Frog lateral
Really is an antero-lateral slippage of the metaphysiswww2.massgeneral.org/ortho/SCFE.htm
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SCFE
Around puberty
? Hormonal imbalance between gonadal and growth hormones
Tall, or obese, gonads underdevelopment
Presents with limping
May present with thigh/knee pain
Acute slip Vs. chronic slip
Apley’s System of Orthopedics and Fractures
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SCFE
Externally rotated hip
Loss of internal rotation
External rotation on flexion
Slippage of other hip in one third of patients
Apley’s System of Orthopedics and Fractures
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SCFE
X-rays diagnosis:
Apley’s System of Orthopedics and Fractures
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SCFE
http://reference.medscape.com/
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SCFE
TreatmentManipulation to try to reduce the slip may cause AVNFixation in situ? Fix the other hip
Complications:Avascular NecrosisCoxa varaSlippage of opposite hipSecondary osteoarthritis
http://bestpractice.bmj.com/
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3 – 12 years
Acute osteomyelitis:Constitutional symptomsWBC, CRP, ESRX-ray may initially be normalMRI
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5 – 18 years
Trauma – place related to ageHousehold - earlyPlayground - childhoodSchool and Sports 0 older child - teenagerRTA – teenager
A prick or a splinter in sole of foot
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Time algorithm
years1 2 43 5 6 7 8 9 10 1211 13 14 15
DDHPerthes
SCFE
Trauma
Infection