the limping child aapa. definition limp = asymmetry joint - range of motion bone - deformity pain...
TRANSCRIPT
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The Limping ChildThe Limping Child
AAPAAAPA
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Definition
Limp = Asymmetry• Joint - Range of motion• Bone - Deformity• Pain• Control
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The Limping Child
•Diagnosis
•Mechanism
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The Limping Child
• Pitfalls• Being misled by the parents’ analysis
• Always a leg length discrepancy
• Being misled by the patient’s complaint• Hip problems can cause knee pain
• Complaints of pain
AGE
NEWBORNINFANT
TODDLER
CHILD
PRE-TEEN
TEENAGER
ADULT
5
COMPLAINS
LIMPS
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The Limping Child
Causes of limp• Joint - Range of motion• Bone - Deformity• Pain
• Hip• Control
-Physical exam-X-ray-‘Antalgic’ gait -Abductor lurch-Upper limb
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Too much to cover
The Limping Child
Hip
Best Bets
Age
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The Limping Child
• Age 1 – 3 years
• Age 3 – 6 years
• Age 6 – 10 years
• Age 10 – 14 years
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• DDH• Developmental Dysplasia of the Hip
• CDH• Congenital Dislocation of the Hip
Best Bet
The Limping Child:Age 1 – 3
1
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The Limping Child: Age 1 – 3DDH
Physical findings• Girl• Asymmetrical skin folds• Limited abduction• Short leg• Pistoning• Ortolani’s sign• Barlow’s sign
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X-ray findings• Delayed appearance of ossific nucleus• Small ossific nucleus• Dysplastic acetabulum• Proximal displacement of femur
The Limping Child: Age 1 – 3DDH
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The Limping Child: Age 1 – 3DDH
Treatment• 0 – ½: Pavlik harness• ½ – 1½: Closed reduction, cast• 1 ½ - 5 or 8: Open reduction, pelvic osteotomy• Older: Leave dislocated
Pavlik Harness
• Check at 3 weeks to confirm reduction
• Adjust position every 6 – 12 weeks
• Continue until the hips are clincally and radiologically normal
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• Transient synovitis
• Septic arthritis
Best Bet
The Limping Child:Age 3 – 6
s
• Flu
• Tonsillitis2
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The Limping Child:Age 3 – 6
Transient synovitis• Child refuses to walk• Movement of hip is painful• May have fever• Moderately elevated WBC• Lasts a few days• Disappears without treatment
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The Limping Child:Age 3 – 6
Septic arthritis• Child refuses to walk• Movement of hip is painful• May have fever• Elevated WBC• Progressively sicker• Progressive joint destruction
WIDENED JOINT SPACE
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The Limping Child: Age 3 – 6Septic Arthritis
Bacteria
Enzymes
Destroy cartilage
Irreversable joint damage
White cells
Enzymes
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The Worst Scenario
• Destruction of articular cartilage
• Destruction of femoral head
• Destruction of femoral neck
The Limping Child: Age 3 – 6Septic Arthritis
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Treatment1. Kill the bacteria
• Antibiotics
2. Eliminate the white cells• Incision and drainage
3. Don’t delay• 48 hour window
The Limping Child: Age 3 – 6Septic Arthritis
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• How to tell the difference?• Four predictors
• History of fever• Refusal to weight-bear• ESR > 40 mm/hr• WBC > 12,000
• If in doubt• Review in 12 hours• Do incision and drainage!
The Limping Child: Age 3 – 6Transient Synovitis vs. Septic Arthritis
Kocher, Kasser, et al.JBJS 86-A: 1629, 2004
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Legg-Calvé-Perthes Disease
Best Bet
The Limping Child:Age 6 - 10
3
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Physical findings• Boy• Limp• Antalgic gait• Pain with passive motion• Limited abduction• Positive Trendelenburg sign
The Limping Child: Age 6 – 10Perthes Disease
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The Limping Child: Age 6 – 10Perthes Disease
• X-ray findings• Perhaps nothing
• MRI
• Irregular consistency• Flattening• Lateral bump/ridge• Lateral hinging
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The Limping Child: Age 6 – 10Perthes Disease
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Treatment1. Maintain range of motion
• Physical therapy
• Anti-inflammatory medication
2. “Containment”• Bracing in abduction
• Femoral osteotomy
• Pelvic osteotomy
The Limping Child: Age 6 – 10Perthes Disease
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The Limping Child: Age 6 – 10Perthes Disease
50% need a Total Hip by age 50
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Slipped Capital Femoral Epiphysis(SCFE – skiffey)
Best Bet
The Limping Child:Age 10 – 14
4
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The Limping Child: Age 10 – 14SCFE
Always get a frog lateral view
Always check the other side
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• Pediatric orthopaedic surgeons• See 6 per year
• General orthopaedic surgeons• See 1 every 6 years• Same as fixing a fracture
The Limping Child: Age 10 – 14SCFE
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• ClassificationClassification• Acute or chronicAcute or chronic• Stable or unstableStable or unstable• Severity of displacementSeverity of displacement• Slip angleSlip angle
• BilateralityBilaterality• 10 – 15% at presentation10 – 15% at presentation
The Limping Child: Age 10 – 14SCFE
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Useful ClassificationUseful Classification
• StableStable• Walks inWalks in
• UnstableUnstable• Wheels inWheels in
• Bone in one pieceBone in one piece • Slow plastic Slow plastic deformationdeformation of the growth plate of the growth plate
•Bone in two piecesBone in two pieces• Physeal fracturePhyseal fracture
No reductionNo reductionOne screwOne screw
Closed reductionClosed reductionTwo screwsTwo screws
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Unstable SCFEUnstable SCFE
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Xray FindingsXray Findings
• Displacement of neck on headDisplacement of neck on head• Mainly anteriorMainly anterior• Somewhat superiorSomewhat superior
• Decreased projected femoral head heightDecreased projected femoral head height• ChronicityChronicity
• Inferior new boneInferior new bone• Superior rounding off of metaphysisSuperior rounding off of metaphysis• Curved neckCurved neck
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CastroAPCastroAP
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Silva Chronic SlipSilva Chronic SlipDegree of slip??
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Castro Right LateralCastro Right Lateral
Slip angle
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ConceptConcept
Displacement of head on neckDisplacement of head on neck
Gradual change in shapeGradual change in shape
The femoral neck “curves” posteriorlyThe femoral neck “curves” posteriorly
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Starting Point – Severe Slips
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Correct PathCorrect Path
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Controlling DepthControlling Depth
• Approach WithdrawApproach Withdraw• Rotate hip through full rangeRotate hip through full range• Observe projected distance of pin tip from Observe projected distance of pin tip from
subchondral bonesubchondral bone• Watch for change in directionWatch for change in direction• That moment presents the critical viewThat moment presents the critical view
BLIND SPOT
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3–D Geometry3–D Geometry
The Critical ViewThe Critical View
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Approach-Withdraw 1Approach-Withdraw 1
1
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Approach-Withdraw 2Approach-Withdraw 2
2
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Approach-Withdraw 3Approach-Withdraw 3
3
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Approach-Withdraw 4Approach-Withdraw 4
4
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Approach-Withdraw 5Approach-Withdraw 5
5
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Approach-Withdraw 6Approach-Withdraw 6
6
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Approach-Withdraw 8Approach-Withdraw 8
7
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Approach-Withdraw 7Approach-Withdraw 7
8
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Approach-Withdraw 5Approach-Withdraw 5
5The Critical View
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The Contralateral HipThe Contralateral Hip
• Out of 100 patients:• 10 are bilateral at presentation• 10 will slip on the other side later• 5 will have painless slips on the other side
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Follow-up for BilateralityFollow-up for Bilaterality
• Follow radiologicallyFollow radiologically
• Every three monthsEvery three months• For 18 monthsFor 18 months
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The Limping Child
• Age 1 – 3 years - DDH• Age 3 – 6 years - Septic arthritis• Age 6 – 10 years - Perthes Disease• Age 10 – 14 years - SCFE
Best Bets
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The Limping ChildThe Limping Child
AAPAAAPA