Limping Child

EKO PERDANA PUTRA

Orthopaedi and Traumatology Departement

Faculty of Medicine
Baiturrahmah University
PADANG
 Limp
• Normal gait

• Causes of limp

• Investigations
 Normal Gait
• Bipedal

• Rhythmic and effortless

• Depends
• On a number of reflexes
• Intact locomotor system
Gait Cycle
 Walking
• Cruise before 1year

• Walk at 14-18months

• Develop a mature(adult) gait at 3years

 Limp
• Is any disturbance of gait
• Is due to one or more of 3 general causes

• Pain

• Weakness

• Structural abnormalities
 Types of Limp
• Antalgic

• Neuromuscular

• Trendelenberg

• Short leg gait

 Causes of Limp
• Congenital
• Coxa vara, congenital short limb
• Inflammatory
• Juvenile chronic arthritis,transient synovitis
• Infectious
• Osteomyelitis,septic arthritis,discitis
 Causes of Limp
• Developmental
• Scfe, Ddh, Perthes , acquired limb length discrepancy
• Neoplastic
• Benign
• Malignant
• Secondary tumours
 Causes of Limp
• Traumatic
• Toddlers and stress fractures
• Neuromuscular
• Metabolic
• Haematological
• Referred
• Appendicitis
Stress Fracture
• Adolescent

• Upper Tibia

• Looks aggressive
Stress Fracture
 Investigations
• Plain x-rays

• Scannogram plus wrist x-ray

• MRI,CT scan, Bone scan

• FBC,ESR
 Hip
• Intoeing
• Transient synovitis
• Development dysplasia of the hip
• Perthes disease
• Slipped capital femoral epiphysis
 Intoeing
• Common condition
• Large number of children
• May be simple or complex
• Femur
• Tibia
• Foot
• Familial tendency
Foot progression angle
External and Internal Rotation of Femur
Thigh - Foot Angle (TFA) Tibial Torsion
Heel bisector line foot valgus
 Transient Hip Synovitis
• Inflammatory condition.
• Cause unknown.
• Peak incidence 3-6 years.
• Mild U.R.T.I.
• Pain and limp.
• Resolves in 48 hours.
• May need aspiration.
 Ultrasound
Normal Effusion

Capsule

Femur
 Joint Pain
Ultrasound
Joint Effusion

No Yes

Trauma Fever>38.5 Fever< 38.5

ESR>40 ESR<40
CRP>20 CRP<20

Aspiration Transient Synovitis

Cloudy fluid Aspiration

Positive gram stain

Arthrotomy
Joint Fluid Aspiration
 Developmental Dysplasia of the Hip
• Incidence 0.1%
• 4 times commoner in girls
• Risk factors
• 1st. Born
• Breech
• Oligohydramnios
Diagnosis
• Ortolani
• Barlow
• Asymmetrical folds
• Galeazzi sign
• Limp
• X-ray
• U/S
Ortolani Test

• Ortolani manoeuvre to
determine if the hip is
dislocated
Barlow’s Test

• the Barlow is a provocative

test for a dislocatable hip
Asymmetrical Folds
Galeazzi Sign
Ultrasound
• The a angle, which is a
measurement of the slope of
the superior aspect of the bony
acetabulum, and the b angle,
which evaluates the
cartilaginous component of the
acetabulum
 Ultrasound
• Indications for ultrasonography are not universally established

• Overdiagnosis above the expected incidence of DDH

• Not Cost–effective
 Treatment

• 0-6 months
• Pavlik
• 6-18 months
• Traction and casting
• More than 18 months
• Open reduction
• Osteotomy
• Thoracic band

• Shoulder straps

• Stirrups

• Ant. Post. Straps

• Ischaemic necrosis
• Collapse and repair
• Peak incidence 4-9 yrs
• Limp no pain
• Classification
• Lat.Pillar
• Containment
 Knee
• Genu varum

• Genu valgum
Genu Varum
Genu Valgum
 Foot
• Flatfoot

• Metatarsus varus

• Talipes equino-varus

• Pes cavus
 Flatfoot
• Mobile
• Infantile
• Postural
• Temporary
• Spastic
• Neuromuscular
Physiological Pes Planus
 Metatarsus Varus
• Partly genetic
• Normal hindfoot
• Adducted forefoot
• Usually resolves
• May need stretching and
casting
 Talipes Equino-varus
• 1.2/1000 live births
• Stiff
• Smaller calf
• Deformities
• Equinus
• Inversion
• Adduction
• Stretching,strapping
• Surgery
 Pes Cavus
• Neurological
• Pma
• Dysraphism
• Friedrich’s ataxia
Summary
 Differential Diagnosis
Age Painful limp Painless limp

1-3yr 1- Infection 1- Developmental

Septic arthritis / dyplasia of the hip
osteomyelitis/ cellulitis 2- Neuromuscular
/ synovitis disease
2- Trauma -Cerebral palsy
3- 1ry or metastatic -Muscular
neoplasm dystrophy
3- lower limb length
inequality
 Age Painful limp Painless limp

4 - 10yr 1-Infection 1-Developmental dyplasia

2- inflammatory JRA, SLE of the hip
3- Trauma 2- NMD
4- 1ry or metastatic 3- Lower limb length
tumor inequality
5- hematological disease
Hemophilia, SCA,
leokemia
6-Legg-Calve-Perthes
Disease , Kohler’s (AVN)
 Age Painful limp Painless limp

11- 18yr 1-Infection 1- Developmental

2- inflammatory :JRA, SLE dyplasia of the hip
3- Trauma 2- Neuromuscular disease
4-1ry or metastatic tumor Cerebral palsy
5-hematological disease Muscular dystrophy
Hemophilia, SCA, 3- lower limb length
leukemia inequality
6-Legg-Calve-Perthes 4- chronic slipped upper
Disease (AVN of femoral femoral epiphysis
head)
7-acute slipped upper
femoral epiphysis*
Thank You