Evaluation of the Child with Acute Limp Bruce Minnes MD, FRCPC Staff Physician and Assistant Professor, Division of Paediatric Emergency Medicine Chief Medical Editor, AboutKidsHealth SickKids and The University of Toronto [email protected]@AesklepianBruce
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Evaluation of the Child with Acute Limp Bruce Minnes MD, FRCPC Staff Physician and Assistant Professor, Division of Paediatric Emergency Medicine Chief.
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Evaluation of the Child with Acute Limp
Bruce Minnes MD, FRCPCStaff Physician and Assistant Professor,
Division of Paediatric Emergency MedicineChief Medical Editor, AboutKidsHealth
• Subtle undisplaced spiral fracture of tibia• Preschoolers• Sudden twist• History of injury may be absent• Tenderness over tibial shaft• Radiographs: may be subtle, absent, require
oblique views or nuclear medicine scan• Immobilize and arrange follow-up
Toddler’sfracture
Non-Accidental Injury
• Injury pattern vague or inconsistent with history of mechanism or developmental stage
• Recurrent minor fractures• Other unrelated fractures• Variable stages of healing• Fracture pattern: Metaphyseal (bucket-
handle) fracures in long bones
NAI
Non Accidental Injury
Non-Accidental Injury
Transient Synovitis
• Most common cause of atraumatic limp in children
• Boys• Ages 4 – 8 years• Self limiting• ? Post viral• Hip effusion and exclusion of more important
causes
Septic Arthritis
• Infection of synovium and joint space• May originate from haematogenous spread
(Staphylococcus aureus), osteomylelitis of metaphysis or epiphysis
Probability of septic arthritis:•None: <0.2%•One: 3%•Two: 40%•Three: 93.1%•Four: 99.6%
Kocher, MS et al. J Bone Joint Surg Am. 1999. 81:1662-70
Septic Arthritis in Children• Most common organisms: S. aureus and Group A
streptococcus• Typical signs/symptoms may be absent,
particularly in neonates and infants• CRP, ESR added to Kocher’s criteria useful• Recommend early initiation of antibiotics• Length of treatment based on clinical and
serologic response• Arthrotomy, arthroscopy usually recommended• Multidisciplinary approach
Kang, S-N et al. J Bone Joint Surg (Br) 2009. 91B:1127-33
Osteomyelitis:
Lucency in right femoral neck
Cor T2 fs Cor T1
Osteo and septic hip seen on MRI
Slipped Capital Femoral Epiphysis
• Children over 10 years• More common in boys and overweight
patients, hypothyroid, GH deficiency• Displacement of epiphysis relative to
metaphysis (Kline’s Line)• Knee pain• Early fixation improves outcome• Xrays: Hips AP and frog-leg (lateral)
SCFE
SCFE: Frog-leg lateral view
Kline’s Line
Legg Perthe’s Disease
• Idiopathic avascular necrosis of the femoral head
• Ages 4 – 8 years, usually boys• Xray: Hips AP. Lateral sometimes helps.• Sclerosis, fragmentation, irregularity,
flattening of femoral epiphysis• Persistent limp (contrast to transient
synovitis)
Rt AVN: plain film shows sclerosis and irregularity
ASIS Avulsion
• Larger forces – MVC or sport-related• Inability to bear weight from pain• Extremely tender over ASIS, reduced active
hip flexion and pain on passive extension• Non-weight bearing and analgesics with
orthopaedic follow up
Rt ASIS avulsion
Limp – Red Flags
• Age under 3 years• Inability to bear weight• Fever• Systemic illness• Older child with painful or restricted hip
movement
Acute Limp - Summary• Non-traumatic limp is a common presenting
problem in children and adolescents• Age is key in identifying differential
considerations• Hip is most common site of pathology• Delayed diagnosis may worsen outcome