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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