The document provides guidance on evaluating a limping child or child with hip pain, including taking a clinical history and performing a physical exam to determine the cause, which could include transient synovitis, septic arthritis, Legg-Calve-Perthes disease, or a slipped capital femoral epiphysis. Laboratory tests and imaging studies are recommended depending on the history and exam findings to identify the underlying condition causing the limp or hip pain. Treatment options vary according to the diagnosed condition but may include rest, anti-inflammatory medications, antibiotics, surgery, or physical therapy.
1. The Limping Child
and
Hip Pain
Patrick J. Maloney, MD
Denver Emergency Center for Children
Denver Health Medical Center
2. Evaluation of the Limping
Child or Child w/ Hip pain
Clinical History
Circumstances surrounding the limp
Trauma, pain, associated systemic
symptoms/illness
Physical Exam
Localize source of pain
Abdominal and genitourinary exam
Laboratory and Radiologic Studies
Tailored to findings in history and physical
exam
3. Evaluation of the Limping
Child
Physical Exam
Flexed, abducted, externally
rotated hip = fluid in hip joint
capsule
4. Evaluation of the Limping
Child
Physical Exam
Passive ROM of the hip
5. Evaluation of the Limping
Child
Trauma is the most common cause in all
age groups
Acute or repetitive
Oftentimes, parents will endorse minor trauma
as cause of limp
Coincidence or Causation?
6. Differential Diagnosis for
Non-Traumatic Limp
Transient Synovitis
Septic Arthritis
Legg-Calve-Perthes disease (Avascular
Necrosis of the Capital Femoral Epiphysis)
Slipped capital femoral epiphysis (SCFE)
Other
Peripelvic Pyomyositis
Osteomyelitis
Tumor/Leukemia
Occult Fracture (e.g. Toddler’s Fx)
7. Case 1
A 5-year-old boy presents with a 4-week
history of limp that has worsened
progressively. There are no significant
findings on the past medical history. He
has not been ill recently. There is not
history of trauma. Physical examination
reveals a decreased range of motion of the
left hip and an obvious limp with walking.
What is the MOST likely etiology of this
child’s limp?
8. Legg-Calve-Perthes Disease
Avascular necrosis of the capital
femoral epiphysis
Most common between 4-10 years of
age.
Male:Female is 4:1
Child may complain of pain in hip,
thigh or knee.
often insidious and can lead to
disuse of affected limb
Xray findings are pathopnomonic
9. Legg-Calve-Perthes Disease
4 distinct radiographic stages
Synovitis/Necrosis: Initial joint space widening
and irregularity of the physis. Ischemia of the
epiphysis resulting in dead bone. Ave age 5.6 years
Fragmentation: Fracturing of the weakened
demineralized epiphysis. Epiphysis may collapse
resulting in a shortened limb. Ave age 6.1 years
Re-ossification: Begins at the margins of the
epiphysis. Ave age 7 years
Remodeling: Newly formed head is soft. At risk for
poor prognosis if not allowed to heal. Ave age 9.1
years
MRI better at detecting early disease
11. Legg-Calve-Perthes Disease
Treatment
50% recover without treatment
Goal: maintain femoral head within the
acetabulum
Abduction splints/casts and non-weight bearing state
Surgically with an osteotomy of the proximal femur
Prognostic factors
Better Prognosis
Younger (<6y)
<50% epiphyseal necrosis
Worse Outcome
Obesity
12. Case 2
A 6 year-old boy presents with a 3-day history of a
limp. He has had a URI for 1 week. There is no
history of trauma. On physical examination, his temp
is 100.4 F (38C), he does not bear weight on the
right leg, and there is decreased ROM at the right
hip. WBC count is 8,000, and the ESR is 20 mm/hr.
What is the MOST likely
etiology of this child’s
pain?
13. Transient Synovitis
Also called “toxic synovitis” or “irritable
hip”
Most common cause of non-traumatic
hip pain in children
Accounts for 30-40% of all non-traumatic limps
Occurs in children 2-6 years old
typically <4 years old
Associated with recent URI in 32-50% of
cases
Male:Female is > 2:1
Almost always unilateral
14. Transient Synovitis
Benign, self-limited disorder
Sterile inflammation of the synovium of the joint
With or without a joint effusion
Unclear etiology (? Post-viral)
15. Transient Synovitis
Clinical History
Acute onset of pain and limited ROM of the hip
Limp or refusal to bear weight
Physical Exam
Hip is flexed and externally rotated
mildly decreased ROM
Afebrile/low-grade fever (<38.5)
Laboratory
Normal WBC (<12,000)
Normal or mildly elevated CRP (<2) and ESR (<40)
16. Transient Synovitis
X-Ray
Most commonly normal
Joint space widening (joint effusion)
Ultrasound
Joint effusion and/or synovial swelling
17. Transient Synovitis
Treatment
Rest; weight bear as tolerated
Ibuprofen
Decreased pain vs Placebo (2d vs. 4.5d)
80% of all patients with resolution by 7 days
Prognosis
Generally good
Recurrence in 4-15% have been reported
So why is it important to make the
diagnosis of transient synovitis?
Annals of Emergency Medicine 2002; 40:3:297
18. Case 3
A 6-month-old female infant presents to
you with fever to 102°F (38.9°C), poor
feeding, and decreased activity for 5 days.
Her mother has noted that over the last 7
days she cries whenever her diaper is
changed, and for the last 2 days she has
refused to move her left leg. On physical
examination, you note a febrile infant who
cries with passive movement of the left
leg.
What is the MOST likely etiology of this
child’s leg pain?
19. Septic Arthritis
True Orthopedic emergency
Single most important prognostic factor for
a good outcome is early treatment!!!
Results from bacterial invasion into the
joint space
Most commonly hematogenous spread
Contiguous spread from neighboring
osteomyelitis
Direct inoculation from penetrating wound
Can occur at any age but >50% of cases
are in children <3 years old
Hip is most commonly affected joint in
children
20. Septic Arthritis
Organisms
Staphycoccus aureus (most common)
Streptococcus species
Strep pneumoniae
Strep pyogenes
Group B Strep (neonates)
Haemophilus Influenzae
Neisseria gonorrhea (adolescents)
Salmonella (sickle cell disease)
Gran negative bacilli (neonates)
Acute inflammatory response (TNF-α, IL-1,
proteases
destroy the articular cartilage
Continues after eradication of the bacteria
21. Diagnosis may be very difficult
Septic Arthritis occur in children
Usually previously healthy children <5
years (>50% of cases
<3 years)
Early peak in the first months of infancy
1/3 w/ URI’s within the past month
Usually temp > 38.5
22. Septic Arthritis
Physical Exam
DOES NOT present with erythema, warmth or swelling
(hip)
Hip is usually held in flexion, external rotation, abduction
Usually very painful ROM
23. Septic Arthritis
Joint Aspiration is definitive diagnosis
Cloudy, turbid
WBC count >50,000; predominantly PMNs
Glucose levels < ½ of serum
50% positive gram stain
50-70% with positive culture
24. Septic Arthritis
Joint Aspiration
Performed under ultrasound guidance
Usually needs procedural
sedation
Complications
iatrogenic infection
Bleeding
neurovascular injury
25. Septic Arthritis
Other Diagnostic Tests
WBC: elevated with left shift (>12,000)
ESR: elevated (>40)
CRP: elevated (>2)
Xray: may show wide joint space (effusion)
late findings (10 days): osteopenia, joint
narrowing, soft tissue swelling
Ultrasound: may demonstrate joint effusion
early in disease
MRI: helps evaluate for abscess and/or
osteomyelitis
26. Septic Arthritis vs Transient
Synovitis
Kocher et al. Journal Caird et al. Journal of
of Bone and Joint Bone and Joint
Surgery. 1999 Surgery. 2006
Boston Children’s CHOP
Prospective study
Retrospective study
53 patients who all had hip
Risk Factors aspiration
WBC >12,000/mm3 Risk Factors
ESR >40 mm/hr WBC >12,000/mm3
Temp >38.5 Oral ESR >40 mm/hr
Refusal to bear weight CRP >2 mg/dL
Temp >38.5 Oral
Refusal to bear weight
27. Septic Arthritis vs Transient
Synovitis
PPV of Septic Arthritis
# of Caird et al Kocher et al
factors
Fever (>38.5 C) was best
0 16.9 0.2 predictive factor
1 36.7 3 CRP >2mg/dL was only other
independent risk factor
2 62.4 40
Caveat:
3 82.6 93.1 studies evaluated children
4 93.1 99.6 with high clinical suspicion
for septic arthritis
5 97.5 N/A
28. Septic Arthritis
Treatment
Joint drainage (“wash-out”)
IV antibiotics for 2-4 weeks
<2 months: Nafcillin + Gentamicin
>2 months: Ceftriaxone +/- Vancomycin
• Prognosis: risk of avascular necrosis
• Good outcome
Initiation of treatment within 4 days of symptom onset
• Poor outcome
Initiation of treatment after 5 or more days
Severe joint destruction: osteonecrosis
29. Case 4
• A 14 year-old boy presents to your office
for evaluation of low-grade, diffuse knee
pain on the right. On exam you have the
child stand on the right leg and notice that
he has a mild downward tilt of the pelvis
to the left.
What is the most likely etiology of his
knee pain?
30. Slipped Capital Femoral
Epiphysis (SCFE)
An acquired growth plate injury (Salter-Harris I)
Separation of the proximal femoral epiphysis from the
metaphysis
Most commonly occurs in adolescents and
preadolescents
81% BMI >95th Percentile
Peak age is 10-13y in females and 12-16y in males
Overweight boys
Rare after menarche
African Americans and Pacific Islanders >> Caucasian
and Hispanics
Associated with endocrinopathies (growth hormone
deficiency) in 8%
31. Slipped Capital Femoral
Epiphysis
Clinical History
Preceding history of trauma with acute pain/limp
common
Subacute or chronic pain with insidious onset that
can be referred to the hip or knee
Pain increased with physical activity
May be able to bear weight if stable
Examination
Hips is slightly flexed and externally rotated
Often unable to fully flex hip
Limited internal rotation and abduction of the hip
Limited passive ROM secondary to pain
Bilateral in up to 30%
35. Slipped Capital Femoral
Epiphysis
Treatment
Strict non-weight bearing to prevent further slip
Occasionally may discharge on crutches
Surgical fixation
Screw fixation under flouroscopy
Some prophylactically fix contralateral hip as well
Osteotomy may be necessary for advanced slippage
36. Slipped Capital Femoral
Epiphysis
25-40% have bilateral SCFEs
Contralateral slip usually occurs within 6-12
months of index side
Prognosis
Usually good prognosis (stable and chronic slips)
Increased risk of subsequent acute chondrolysis,
avascular necrosis, and premature hip arthritis
37. Other Etiologies of Limp
Peripelvic Pyomyositis
Osteomyelitis
Occult Fractures (Toddler’s Fx)
Tumors
Leukemia
Deep Muscle Hematomas/Abscesses
Abdominal and Genitourinary Dx
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