A Child with a Limp Lydia Burland. Learning Outcomes By the end of the session you should be able to; Recognise common orthopaedic conditions List important.

A Child with a Limp

Lydia Burland

Learning Outcomes

By the end of the session you should be able to;

• Recognise common orthopaedic conditions

• List important risk factors

• Explain investigations and management to parents

• Answer questions on key topics

Case 1: DDH

• Left hip affected more often than the right

• 20% of cases are bilateral

• More common in cultures where swaddling is used

• Detection methods include newborn and 6-8 week screening and ultrasound

• Most stabilise spontaneously by 2-6 weeks

Case 1: DDH

• If still unstable the need prompt treatment

• Bracing is 1st line under 6 months of age

• Surgery is needed if bracing fails (~5%) or for children >6 months at presentations

• Risk of surgery include re-dislocation, stiffness and avascular necrosis (5-15%)

• Long-term complications include OA and lower back pain

Case 2

• A 6 year old boy presents with cough, fever and refusal to weight bear on the left

• Has been ‘not quite himself’ for 2 days

• He is happy at rest, but cries as soon as you try to examine the left leg

• Obs: T 37.8, HR 105, RR 28

• What are your differentials?

Case 2

Differential diagnosis;1. Septic arthritis2. Transient synovitis3. Perthe’s disease4. Discitis

What tests would you do?

Case 2

Bloods;FBC 145 WCC 11.5 plt 395CRP 18

What do you think of the results?

Case 2

Left hip USS: small effusion, synovial thickening

Case 2: Transient Synovitis

• Acute onset hip pain +/- refusal to weight bear

• Generally no pain at rest

• Child is otherwise well, bloods unremarkable

• Often preceded by a viral URTI

• Treat with rest and analgesia

• Usually resolves spontaneously in 2 weeks

Case 3

• A 7 year old boy presents with left knee pain and a limp

• He is otherwise well

• There is no history of trauma

• All movements of the hip are limited

• There is guarding when the examiner rolls the hip internally and externally

Case 3

What can be seen on the x-ray?

Case 3: Perthe’s Disease

• Loss of blood supply (avascular necrosis) to the femoral epiphysis

• Leads to abnormal growth of the epiphysis and eventual remodelling of the bone

• Risk factors;Boys 4-8 years of ageCaucasians +ve family historyLow birth weight

Case 3: Perthe’s Disease

• Presents with hip/knee pain and effusion

• 12% of cases are bilateral

• Early x-rays show joint widening

• Later x-rays show femoral head collapse and deformity

• MRI may be needed to better define anatomy

Case 3: Perthe’s Disease

• Conservative management for;Children <8 years Bone age <6 years

• This involves physio and strengthening

• Surgery involves proximal varus osteotomy

• Prognosis is good for children < 6 or less severe disease

Case 4

• A 13 year old boy has severe left hip pain

• He has had mid-thigh pain for the last 2 months

• Worse on running and jumping

• He is otherwise well

• PMH: of hypothyroidism

What are you differentials?

Case 4: SUFE

The most common adolescent hip disorder

Due to instability of the proximal femoral growth plate

4 types exist1. Pre-slip: wide epiphyseal line, no slippage2. Acute: sudden slip, usually spontaneous3. Acute-on-chronic: acute pain on chronic slip4. Chronic: steadily progressive slip

Case 4: SUFE

• Commonly affects boys, aged 10-17 years

• Other risk factors include;Obesity Pelvic radiotherapyTrauma Hypothyroidism

• The left hip is more often involved

• 20-40% of cases are bilateral

Case 4: SUFE

Case 4: SUFE

Management involves;Immediate bed rest and analgesiaImmediate ortho opinionUrgent surgical closure of the epiphysis

Complications include chondrolysis and AVN

Prognosis is best if there is <1/3 displacement

Summary

DDHHip instability is common under 6 weeksMore common in girlsDetected by Barlow’s/Ortolani’sIt should be treated with a long-term harness

Transient SynovitisAcute onset hip painMore common in boysTreated with rest and analgesiaUsually resolves within 2 weeks

Summary

Perthe’s DiseaseAvascular necrosis of the femoral headMore common in boys aged 5-10 yearsUsually managed conservativelySurgery if severe or >8 years

SUFEHip, thigh and knee painMore common in boys at pubertyTreated with percutaneous screws

Questions

Questions

• 6 MCQs

• 2 EMQs

• 4 clinical images

• Review of answers

Questions: MCQs

1. Which of the following is a common cause of septic arthritis?a. Strep. viridans b. E. colic. Staph. aureus d. N. meningitidis

2. A Pavlik harness is used in the treatment of which condition?a. Perthes’ disease b. SUFEc. Genu valgum d. DDH

Questions: MCQs

3. A 15 year old has knee swelling, sore red eyes and dysuria. What’s the diagnosis?a. Osgood-schlatter’s b. Reiter’s syndromec. Perthe’s disease d. Osteochondritis

4. A boy presents with delayed walking, bowed legs and short stature. What’s the diagnosis?a. Osteoporosis b. Ehlers-danlos syndromec. Rickets d. Osteochronditis

Questions: MCQs

5. A tall thin boy has arachnodactyly has a high arched palate. What’s the diagnosis?a. Marfan’s disease b. Ehlers-danlos syndromec. Osgood-schlatter’s d. Osteomyelitis

6. Duchenne muscular dystrophy is classically associated with which of the following signs?a. Kernig’s sign b. Trendelenburg’s signc. Gower’s sign d. Dysdiadokinesis

Questions: EMQ 1

Select the most likely diagnosis.a. Osgood-schlatter’s b. Irritable hipc. Perthe’s disease d. Henoch-schonlein purpurae. SUFE f. DDH

1. A 7 year old boy presents with right knee pain and an antalgic gait. There is no history of trauma.

2. A 5 year old girl presents refusing to weight bear. She has been suffering with a cold for the last 4 days and is febrile.

Questions: EMQ 1

Select the most likely diagnosis.a. Osgood-schlatter’s b. Irritable hipc. Perthe’s disease d. Henoch-schonlein purpurae. SUFE f. DDH

3. A 13 year old presents with 2 months of below knee pain and swelling. Made worse by running and jumping.

4. A 13 year old boy presents with groin discomfort of walking and jumping. The leg is externally rotated.

Questions: EMQs 2

Select the most likely diagnosis.a. Impetigo b. Eczemac. Scabies d. Erythema nodosume. Kawasaki’s disease f. Rheumatic fever

1. A 7 year old presents with an itchy red area on his chin. Over the course of the day the skin breaks and a yellow scab forms.

2. A 5 year old presents with high fevers, knee and hip pain and a red rash on the trunk and arms.

Questions: EMQs 2

Select the most likely diagnosis.a. Impetigo b. Eczemac. Scabies d. Erythema nodosume. Kawasaki’s disease f. Rheumatic fever

3. A mum brings in her two children with intensely itchy rashes on their hands. The rash is in little lines between the fingers.

4. A 16 year old is diagnosed with a chest infection. 10 days later he returns with tender, purple lesions on this shins.

Questions: Image 1

A 6 year old boy has the following x-ray signs.

a. What is the most likely cause of this condition?

b. Give 2 risk factors.

Questions: Image 2

This 12 year old presents with fever and shoulder pain.

a. What investigation should be performed?

b. What treatment should be started?

Questions: Image 3

This 3 year old boy presents with a painful rash following 4 days of cough, coryza and sore throat.

a. What’s the diagnosis?

b. What other symptoms would you ask about?

Questions: Image 4

A 14 year old presents pain and refusal to weight bear on the left.

a. What’s the diagnosis?

b. Give two risk factors.

Answers

Answers: MCQs

1. Which of the following is a common cause of septic arthritis?a. Strep. viridans b. E. colic. Staph. aureus d. N. meningitidis

2. A Pavlik harness is used in the treatment of which condition?a. Perthes’ disease b. SUFEc. Genu valgum d. DDH

Answers: MCQs

1. Which of the following is a common cause of septic arthritis?a. Strep. viridans b. E. colic. Staph. aureus d. N. meningitidis

2. A Pavlik harness is used in the treatment of which condition?a. Perthes’ disease b. SUFEc. Genu valgum d. DDH

Answers: MCQs

3. A 15 year old has knee swelling, sore red eyes and dysuria. What’s the diagnosis?a. Osgood-schlatter’s b. Reiter’s syndromec. Perthe’s disease d. Osteochondritis

4. A boy presents with delayed walking, bowed legs and short stature. What’s the diagnosis?a. Osteoporosis b. Ehlers-danlos syndromec. Rickets d. Osteochronditis

Answers: MCQs

3. A 15 year old has knee swelling, sore red eyes and dysuria. What’s the diagnosis?a. Osgood-schlatter’s b. Reiter’s syndromec. Perthe’s disease d. Osteochondritis

4. A boy presents with delayed walking, bowed legs & short stature. What’s the diagnosis?a. Osteoporosis b. Ehlers-danlos syndromec. Rickets d. Osteochronditis

Answers: MCQs

5. A tall thin boy has arachnodactyly has a high arched palate. What’s the diagnosis?a. Marfan’s disease b. Ehlers-danlos syndromec. Osgood-schlatter’s d. Osteomyelitis

6. Duchenne muscular dystrophy is associated with which of the following signs?a. Kernig’s sign b. Trendelenburg’s signc. Gower’s sign d. Dysdiadokinesis

Answers: MCQs

5. A tall thin boy has arachnodactyly has a high arched palate. What’s the diagnosis?a. Marfan’s disease b. Ehlers-danlos syndromec. Osgood-schlatter’s d. Osteomyelitis

6. Duchenne muscular dystrophy is classically associated with which of the following?a. Kernig’s sign b. Trendelenburg’s signc. Gower’s sign d. Dysdiadokinesis

Answers: EMQ 1

Select the most likely diagnosis.a. Osgood-schlatter’s b. Irritable hipc. Perthe’s disease d. Henoch-schonlein purpurae. SUFE f. DDH

1. A 7 year old boy presents with right knee pain and an antalgic gait. There is no history of trauma.

2. A 5 year old girl presents refusing to weight bear. She has been suffering with a cold for the last 4 days and is febrile.

Answers: EMQ 1

Select the most likely diagnosis.a. Osgood-schlatter’s b. Irritable hipc. Perthe’s disease d. Henoch-schonlein purpurae. SUFE f. DDH

1. A 7 year old boy presents with right knee pain and an antalgic gait. There is no history of trauma.

2. A 5 year old girl presents refusing to weight bear. She has been suffering with a cold for the last 4 days and is febrile.

Answers: EMQ 1

Select the most likely diagnosis.a. Osgood-schlatter’s b. Irritable hipc. Perthe’s disease d. Henoch-schonlein purpurae. SUFE f. DDH

3. A 13 year old presents with 2 months of below knee pain and swelling. Made worse by running and jumping.

4. A 13 year old boy presents with groin discomfort of walking and jumping. The leg is externally rotated.

Answers: EMQ 1

Select the most likely diagnosis.a. Osgood-schlatter’s b. Irritable hipc. Perthe’s disease d. Henoch-schonlein purpurae. SUFE f. DDH

3. A 13 year old presents with 2 months of below knee pain and swelling. Made worse by running and jumping.

4. A 13 year old boy presents with groin discomfort of walking and jumping. The leg is externally rotated.

Answers: EMQs 2

Select the most likely diagnosis.a. Impetigo b. Eczemac. Scabies d. Erythema nodosume. Kawasaki’s disease f. Rheumatic fever

1. A 7 year old presents with an itchy red area on his chin. Over the course of the day the skin breaks and a yellow scab forms.

2. A 5 year old presents with high fevers, knee and hip pain and a red rash on the trunk and arms.

Answers: EMQs 2

Select the most likely diagnosis.a. Impetigo b. Eczemac. Scabies d. Erythema nodosume. Kawasaki’s disease f. Rheumatic fever

1. A 7 year old presents with an itchy red area on his chin. Over the course of the day the skin breaks and a yellow scab forms.

2. A 5 year old presents with high fevers, knee/hip pain & a red rash on the trunk/ arms.

Answers: EMQs 2

Select the most likely diagnosis.a. Impetigo b. Eczemac. Scabies d. Erythema nodosume. Kawasaki’s disease f. Rheumatic fever

3. A mum brings in her two children with intensely itchy rashes on their hands. The rash is in little lines between the fingers.

4. A 16 year old is diagnosed with a chest infection. 10 days later he returns with tender, purple lesions on this shins.

Answers: EMQs 2

Select the most likely diagnosis.a. Impetigo b. Eczemac. Scabies d. Erythema nodosume. Kawasaki’s disease f. Rheumatic fever

3. A mum brings in her two children with intensely itchy rashes on their hands. The rash is in little lines between the fingers.

4. A 16 year old is diagnosed with a chest infection. 10 days later he returns with tender, purple lesions on this shins.

Answers: Image 1

A 6 year old boy has the following x-ray signs.

a. What is the most likely cause of this condition?Vitamin D deficiency

b. Give 2 risk factors.Almost no sunlight exposure and low dietary calcium intake

Answers: Image 2

This 12 year old presents with fever and shoulder pain.

a. What investigation should be performed?Joint aspiration

b. What treatment should be started?IV antibiotics (flucloxacillin +/- benpen)

Answers: Image 3

This 3 year old boy presents with a painful rash following 4 days of cough, coryza and sore throat.

a. What’s the diagnosis?Henoch-schonlein purpura

b. What other symptoms would you ask about?Arthritis, haematuria and abdo pain

Answers: Image 4

A 14 year old presents pain and refusal to weight bear on the left.

a. What’s the diagnosis?SUFE

b. Give two risk factors.Male gender, obesity and trauma

Any questions?

Lydia Burland