CHILD WITH A LIMP

DR. UTKARSH SHAHI

ASSISTANT PROFESSOR
ORTHOPAEDIC DEVISION
DEPARTMENT OF SURGERY
LEARNING OBJECTIVES

The involvement of which anatomical entity largely determines the prognosis

of fracture in child?

What is the essential difference between Salter Harris types 1 and 2 on the one
hand and type 3-5 on the other?

Which alignment defect is not corrected spontaneously and must therefore be

anatomically repositioned?

In which joint can non traumatic epiphysiolysis occur?

LEARNING OBJECTIVES

What is Coxitis Fugax (Transient Synovitis of Hip)

Why is early recognition and adequate treatment of Purulent Coxitis so

important?

Where is the pain caused by hip disorders often felt?

What two diagnoses should be considered in a child who has had many
fractures?
IS THERE ANY DIFFERENCE
BETWEEN GAIT OF A CHILD
AND AN ADULT ?

YES……
NORMAL VARIATIONS IN PEDIATRIC GAIT
Leg alignment varies with age and is often influenced by a family history of the
same pattern.

Habitual toe walking is common in young children up to 3 years.

• In-toeing can be due to persistent femoral anteversion and is characterised by the child walking with
patellae and feet pointing inwards
• Common between the ages of 3 and 8 years.

Internal tibial torsion is characterised by the child walking with patella facing
forwards and toes pointing inwards
• Common from onset of walking to 3 years
NORMAL VARIATIONS IN PEDIATRIC GAIT

Metatarsus adductus is characterised by a flexible 'C-shaped' lateral border of the foot.

• Most resolve by the age of 6 years.

Bow legs (genu varus) are common from birth to early toddler-hood, often with out-toeing
• Maximal at approximately 1 year
• Most resolve by 18 months

Knock knees (genu valgus). Often associated with in-toeing.

• Most resolve by the age of 7 years.

Flat feet
• Most children have a flexible foot with normal arch on tiptoeing.
• Flat feet usually resolve by the age of 6 years.
NORMAL VARIATIONS IN PEDIATRIC GAIT
Crooked toes
• Most resolve with weight-bearing.

Causes for concern are if these normal variations are persistent (beyond the expected age range)
• If changes are progressive or asymmetric, or if there is pain and functional limitation or evidence of neurological
disease.

In children with bow legs or knock knees, it is important to consider x-rays if the child is short
• A height less than the 25th centile raises suspicions of
• Hypophosphataemic rickets
• Skeletal dysplasias
• Genu varum
• Asymmetric leg alignment.
ABNORMAL GAIT PATTERNS IN CHILD

Circumduction gait
Antalgic gait Spastic gait Ataxic gait
('peg leg')

Toe-walking gait
Trendelenburg's ('equinus') with
Stepping gait Clumsy' gait
gait absent heel
contact
CAUSES

Adolescent
Toddler (1-3yr) Child (4-10)
(11+)
Infection
Infection SCFE
Transient synovitis
LCPD / AVN
Occult trauma Rheumatologic disorder
Rheumatologic disorder
Trauma
Neoplasia Trauma
Neoplasm
EVALUATION

History Xray
• Onset of symptoms
• Fever, systemic symptoms Labs
• History of trauma • CBC, ESR, CRP may be helpful in
• Often present, may be misleading some instances
Physical examination Other imaging
• Inspection • Ultrasound (hips)
• Observe gait • CT /MRI
• Range of motion (feet, knees, hips) • Bone scan
Case #1

18 month old with acute onset limp

Afebrile, otherwise no complaints

Happy and playful until stands up

• Fussing, resists weight bearing on Right
side
Normal examination
Toddler Fracture

Spiral fracture of distal 1/3 of tibia

Usually simple fall while running or stepping on object

May occur up to 6 yr age (peak 2-4yr)

May not be visible on normal AP/Lat film

• Oblique film
• Repeat films
• Callous formation within 1-2 week
Splint/cast
• Healing within 3-4 weeks
Case #2
2yo male with 1 week of progressive limp and leg pain

Xray at beginning of symptoms negative

Splinted for presumptive fracture

Low grade fever, increasing fussiness, “dragging leg” and refusing to walk

Examination
• Fussy, ?tender to palpation distal L leg

CRP, ESR elevated

Osteomyelitis

Most common in children <10

Usually hematogenous seeding of bone

•Trauma (even minor) may predispose

Usually begins in metaphaseal region of long bone

Inflammatory exudate collects in marrow, cortex,

subperiosteal space
•Ischemia leads to infarction and pain
•Form area of necrotic bone called sequestrum
•Eventually separates to form free body or may be reabsorbed
Osteomyelitis
Common organisms
• Staphylococcus aureus most common
• Group B streptococcus in neonates
• Hemophilus influenzae
• Streptococcus pyogenes
• Salmonella sp.
• Pseudomonas sp.
• Kingella kingae
May be difficult to localize in
• Neonates
• Spine, pelvis
Osteomyelitis
Radiographs
• May be normal or nonspecific for 10-14 days
• Bone scan, CT, MRI may be needed

Acute phase reactants

• WBC normal initially in 60% cases
• CRP rises in 8 hours, peaks 2 days, normalizes over 1 week
• ESR normal in 25% new onset cases, may be useful for monitoring
therapy

Blood culture positive 50-60% cases

Bone aspiration or biopsy

Treatment is 3-6 weeks of antibiotic therapy

Case #3
4 year old female with
worsening limp and leg pain.

Tactile fever at home

Recent URI, otherwise healthy

Exam
• Uncomfortable,
• Lying in bed
• Cries when approached
Septic Arthritis
Also Known as Purulent Coxitis if involving hip joint

Usually Haematogenous seeding

• Extension of osteomyelitis
• Direct inoculation into joint from penetrating trauma
Etiology
• Staphylococcus aureus
• (Hemophilus influenzae historically)
• Kingella kingae
• Neonates: E. coli, Candida, Group Beta Hemolytic Streptococci
• Adolescents: N. Gonorrhea
Septic Arthritis : Clinical Presentation

Acute joint inflammation

• Swelling, redness, pain
• “Pseudoparalysis”
Joint held in position to maximize intra-articular space and minimize pressure and pain
• Hip – flexion, abduction, external rotation
• Knee - partial flexion
• Shoulder – adduction and internal rotation
• Elbow – midflexion
Often have fever and ill appearance
Septic Arthritis
Diagnosis
• Blood culture positive 30-40%
• Elevated CRP, ESR
• Arthrocentesis
• Imaging
• Widening of joint space, soft tissue swelling
• Ultrasound useful for hip effusion

Treatment
• Antibiotic
• Irrigation and drainage
• Prompt surgical drainage of hip (and often shoulder) needed to reduce intra-articular pressure and avoid
avascular necrosis of femoral head
Diagnostic Dilemmas
Transient Synovitis Of Hip
Also known as Coxitis Fugax

Non-infectious, inflammatory condition

Usually children 3 – 8yrs

May follow viral URI

Mild fever, limp, fussiness

Minimal limitation of range of motion

ESR, CRP, WBC usually normal

Managed with rest, NSAIDs, close follow up

Case #4
4 year old male with

3 day h/o limp and thigh pain

No fever

Some improvement with ibuprofen

Active and playful

Uncomfortable with rotation of hip

Avascular Necrosis
Legg-Calve-Perthes Disease
Usually occurs 2 – 12 yrs (avg 7)
Males > female
May be secondary to repeated micro-
trauma
Recurrent episodes of hip irritability
common
Risk of degenerative arthritis
• Worse prognosis with older age (>10)
and extensive femoral head deformity
• Very good prognosis in children <5
Treatment
• Symptomatic – rest, pain meds
• Observation for children <6
• Surgery for older children with severe
involvement
Case #5
5 year old female with several days of leg and back
pain

Decreased appetite and activity and weight loss

X-rays pelvis at outside facility negative 2 day before

Pt alert, thin, ill and uncomfortable appearing. Cries

with manipulation of hips/legs.

Firmness to palpation in upper abdomen

CBC, chemistry normal

Neoplasm
Leukemia

Neuroblastoma

Primary bone tumors

• Benign
• Unicameral bone cyst
• Osteoid osteoma
• Malignant
• Ewing and osteogenic sarcomas
Spinal tumors
Case #6

12yo male with chief complaint of knee pain

Present for a couple weeks, acutely worsened

after playing basketball

No fever, no other symptoms

Exam: walks with limp

• Knee – no swelling, no tenderness, normal

range of motion
Slipped Capital Femoral Epiphysis (SCFE)
Most common adolescent hip disorder

Type of epiphyseal fracture (epiphysiolysis)

Common in obese adolescents

• (also in tall, thin kids after growth spurt)
May present with chronic limp, acute pain or combination

Hold leg in slight external rotation and have limited internal rotation
Slipped Capital Femoral Epiphysis (SCFE)
Need both hips for comparison

Need frog-leg radiograph

Earliest sign is widening of epiphysis

• “Pre-slip” condition

Klein’s Line
• Drawn along outer aspect of femoral
neck should intersect the femoral
capital epiphysis
PAEDIATRIC
TRAUMA
ANATOMICAL DIFFERENCES
The physis (growth plate) It is weaker than bone predisposing the child to injury through this delicate area

The periosteum in a child is thick, this holds the fragments close to other and aids in closed reduction

Ligaments in children are functionally stronger than bone. Therefore, a higher proportion of injuries that
produce sprains in adults result in fractures in children

Blood supply to the growing bone is rich

The thick periosteum and rich blood supply leads to rapid healing and very rare incidence of non-union
REMODELING CAPACITY IN CHILDREN
Unlike in the adult, considerable fracture deformity may be
permitted, because the remodeling potential of the young child is
great.

Rotational mal-alignment does not remodel .

The high remodeling capacity is due to presence of growth plate.

FACTORS AFFECT REMODELING

Remodeling is higher in young children and decrease with increasing age.

Remodeling is better when the deformity is in the plane of joint movement.

The closer the fracture is to the physis, the better the deformity is tolerated.

Remodeling is greater when the fracture is more close to the main growth
plate of the limb
REMODELING CAPACITY IN CHILDREN
FRACTURES SPECIFIC TO PEDIATRIC BONE

Buckle fracture or (torus fracture):

mechanism of injury is compression.
occurs at the metaphyseal diaphyseal
junction

Torus fracture are impacted and stable

,do not require manipulative reduction
and treated by short period of
immobilization in a cast.
FRACTURES SPECIFIC TO PEDIATRIC BONE

Greenstick fracture :
• Bending forces
• The bone is incompletely fractured
• (fracture of one cortex)
Plastic deformation :
• Bending moments can also result in microscopic
fractures that create of the bone with no visible
fracture lines on plain radiographs
• Permanent deformity can result.
SALTER HARRIS CLASSIFICATION OF PHYSEAL INJURIES

Physeal Fracture occurs through the growth plate

 SALTER HARRIS CLASSIFICATION
TYPE CHARACTERSTIC

I Transphyseal fracture.
Prognosis is usually excellent.
II Transphyseal fracture that exits through the metaphysis
Most common type.
Prognosis is excellent.
Complete or partial growth arrest may occur rarely.
III Transphyseal fracture that exits the epiphysis, causing intra-articular disruption.
Prognosis is guarded.
Partial growth arrest and resultant angular deformity are common problems.

IV Traverses the epiphysis ,physis and metaphysis.

Prognosis is guarded.
Partial growth arrest and resultant angular deformity are common.

V Crush injury to the physis.

Difficult to diagnose on x-ray.
Prognosis is poor.
Growth arrest and partial physeal closure are common.
PHYSEAL INJURIES
Type 2
 PHYSEAL INJURIES
Type 3
RADIOGRAPHIC EVALUATION
Two views

Two joints:
• To avoid missing other associated injuries and
• To judge regarding displacement
Two limbs : for comparison

Two occasions: repeat the x-ray if not sure

Two physicians: incase of suspicion

INJURIES SUSPICIOUS OF CHILD ABUSE

Transverse femur fracture in a child <1 year old

A transverse humerus fracture in a child <3 years old

Metaphyseal corner fractures (caused by a traction/rotation mechanism)

A history (mechanism of injury) that is inconsistent with the fracture pattern

An unwitnessed injury that results in fracture

METAPHYSIAL CORNER FRACTURES
(TRACTION & ROTATION)
INJURIES SUSPICIOUS OF CHILD ABUSE

Multiple fractures in various stages of healing

Skin stigmata suggestive of abuse:

• Multiple bruises in various stages of resolution
• Cigarette burns
Posterior ribs fracture or Skull fracture
THANK YOU

utkarshshahi@gmail.com