The limping child in your office

Lori Tucker, M.D. FRCPCAssociate Professor in Pediatrics

Division of RheumatologyBC Children’s Hospital

Vancouver BC

The limping child in your office:Learning Objectives

• Differential diagnosis for the limping child or adolescentbased on likely diagnosis for age and presentation.

• Increase confidence in clinical assessment of MSKcomplaints.

• Review red flags requiring further investigation orreferral.

• Differential diagnosis for the limping child or adolescentbased on likely diagnosis for age and presentation.

• Increase confidence in clinical assessment of MSKcomplaints.

• Review red flags requiring further investigation orreferral.

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 doi10.1186/1546-0096-6-6

• Houghton KM. Review for the generalist: evaluation of pediatric hippain. 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 PractRes Clin Rheumatol. 2014 28(6) 888.

• Sawyer JR and Kapoor M. The Limping Child: A SystematicApproach to Diagnosis. American Family Physician 2009.

• Houghton KM. Review for the generalist: evaluation of pediatric footand ankle pain. Pediatric Rheumatology 2008. 6:6 doi10.1186/1546-0096-6-6

• Houghton KM. Review for the generalist: evaluation of pediatric hippain. 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 PractRes Clin Rheumatol. 2014 28(6) 888.

The normal gait in children

• Normal gait consists of:– Stance– Swing

• Mature gait pattern is established by 3 yrs old, and by 7yrs, gait is close to adult.

• Antalgic vs non-antalgic gait:– Antalgic gait- shortened stance phase, to avoid pain– Non-antalgic gait- trendelenberg; circumduction, equinus

• Normal gait consists of:– Stance– Swing

• Mature gait pattern is established by 3 yrs old, and by 7yrs, 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

• 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

• Developmental hip dysplasia• Toddlers fracture• Infection- septic joint, osteomyelitis• Trauma

– Consider non-accidental injury

• Neuromuscular– Mild cerebral palsy

• Inflammatory– JIA

Limp in older kids

3-10 yr old• Transient synovitis• Legg-Calves-Perthes• Infection

– Septic joint, osteomyelitis• Tumor- malignant, benign• Orthopedic

– Chondromalacae patella• Trauma

– Sprain– fracture

• Inflammatory disease– Arthritis (acute, chronic)

• Neuromuscular– Spinal cord pathology– Muscular dystrophy

11-17 yr old

• Transient synovitis• Late Perthes• SCFE• Infection• Tumor• Orthopedic

– Chondromalacae patella– Osgood Schlatter– Severs disease– Tarsal coalition

• Trauma• Inflammatory disease• Neuromuscular

• Transient synovitis• Legg-Calves-Perthes• Infection

– Septic joint, osteomyelitis• Tumor- malignant, benign• Orthopedic

– Chondromalacae patella• Trauma

– Sprain– fracture

• Inflammatory disease– Arthritis (acute, chronic)

• Neuromuscular– Spinal cord pathology– Muscular dystrophy

• Transient synovitis• Late Perthes• SCFE• Infection• Tumor• Orthopedic

– Chondromalacae patella– Osgood Schlatter– Severs disease– Tarsal coalition

• Trauma• Inflammatory disease• Neuromuscular

A tip…..

• Most kids with idiopathic limb pains of childhood(‘growing pains’) or diffuse pain syndrome do not have apersisting limp.

• A teen with a localized idiopathic pain syndrome (reflexsympathetic 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

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?

• 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, andneurologic systems.

• 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, andneurologic systems.

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

• Does this child look like they might have somethingserious?

• Think through:– Congenital– Developmental abnormalities– Trauma– Overuse– Infection– Tumor– Inflammatory disease

Sick 7 yr old boy with right leg pain andlimp

What are some serious things you need to consider quickly?Septic jointOsteomyelitisMalignancyJIA

What information would help move towards a diagnosis?Fever yes/noLength of symptomsSeverity of pain, time of dayLocalizing pain yes/noPreceding illness

What are some serious things you need to consider quickly?Septic jointOsteomyelitisMalignancyJIA

What information would help move towards a diagnosis?Fever yes/noLength of symptomsSeverity of pain, time of dayLocalizing pain yes/noPreceding illness

7 yr old boy with leg pain and limp

• Acute onset• Irritable if approached• Afebrile• URI last week

• Acute onset• Irritable if approached• Afebrile• URI last week

CRP 10Diff 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?

• 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 ittransient synovitis or septic arthritis

• History of fever• Non-weight bearing• ESR at least 40 mm/hr• WBC > 12,000 cells per mm3

• 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: anevidence based clinical prediction algorithm. J Bone Joint Surg Am 1999. 81(12): 1662

• History of fever• Non-weight bearing• ESR at least 40 mm/hr• WBC > 12,000 cells per mm3

• 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: anevidence based clinical prediction algorithm. J Bone Joint Surg Am 1999. 81(12): 1662

13 yr old basketball player with kneepain

• What are some serious things you should think ofquickly?– 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

• What are some serious things you should think ofquickly?– 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.

• 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.

• 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.

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.

• 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 monthsPatello-femoral syndrome

Ask about pain with deep knee bends/squats, walkingdownstairs, 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.

Ask about pain with deep knee bends/squats, walkingdownstairs, 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.

• 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.

An xray was done after 4 months of pain andlimp……

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

• 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 alimping 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

• 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

Take home messages:

• Attention to basic evaluation (history, PE) canprovide clues to correct diagnosis.

• Consider patient’s age when formulating adifferential diagnosis.

• Watch out for Red Flags!

• Attention to basic evaluation (history, PE) canprovide clues to correct diagnosis.

• Consider patient’s age when formulating adifferential diagnosis.

• Watch out for Red Flags!

Thank you for your attention!