Orthopedics ppt

1. Dr Manoj Das
Ortho Resident
Institute Of Medicine TUTH, Nepal
An Approach To Limping Child

2. INTRODUCTION
• An uneven, jerky, or laborious gait, usually caused by pain, weakness, or
deformity.
• It is a common complaint in childhood, accounting for 4 per 1000 visits in
pediatric emergency department. [ Uptodate 2016]
• Limp can be caused by both benign and life-threatening conditions; the
management varies from reassurance to major surgery depending upon
the cause.
INTRODUCTION

3. Pathophysiology
• Three major factors cause a child to limp:
pain, weakness, and structural or mechanical
abnormalities of the spine, pelvis, and lower
extremities (Clark, 1997; deBoeck & Vorlat, 2003; Lawrence, 1998).

4. Differential Diagnosis

5. Age
Tachdjian’s Pediatrics Orthopaedics
History

6. History…
• AGE..
Apley’ system of
orthopaedics and fractures

7. History…
• Sex
• Painful vs Nonpainful limp
• Location of pain
• Duration and course
• Does limp improves or aggravate with activity
• No. of involved joint
• Associated symptoms (e.g., fever, weight loss, anorexia, back pain, arthralgia)

8. History…
• Recent history of viral illness or streptococcal infection (post infectious
arthritis)
•
• Recent history of dysentry ( Reiters syndome)
• Recent history of new or increased sports activity
• Recent history of intramuscular injection (can cause muscle inflammation
or sterile abscess)
• History of endocrine dysfunction (may predispose to slipped capital
femoral epiphysis)
• Family history of connective tissue disorder, inflammatory bowel disease,
hemoglobinopathy, bleeding disorder, or neuromuscular disorder
• Prenatal and birth history

9. Red flags
• Children < 3 yr ( as septic arthrits more common in this age group)
• Inability to bear wt
• Fever or systemic illness
• Child > 9 yr with hip pain or restricted hip movement (SCFE)

10. PHYSICAL EXAMINATION
• GAIT

11. Normal gait variations in children
• The development of mature gait depends upon maturation of
C.N.S(postural ,labyrinthine and rightining reflexes )
• Normal variations of gait in children:-
-Toe walking is common up to 3 years
-In-toeing can be due to persisting femoral anteversion (this is most
common between ages 3-8 years)
-Internal tibial torsion is also common (knees point forwards but
feet point in)
-Metatarsus adductus resolve by the age of 6 years.

12. Normal gait variations in children…
-Bow legs (genu varus) are common from birth to early toddler-phase,
maximum at age 1 year, often with out-toeing. Most resolve by 18
months
-Knock knees (genu valgus) are common and associated with in-
toeing. Most resolve by the age of 7 years
-Flat feet are common. Most children have a flexible foot with a
normal arch on tiptoeing. Flat feet usually resolve by the age of 6
years
-Crooked toes. Most resolve with weight-bearing.

13. Normal gait variations in children…
 Toddler’s walking
-walks on wide base to avoid falling
-Reduced period of single limb support
-shorter step length
-Increased cadance
-more pelvic tilt
 The adult pattern of gait develops between 3-5 years of age.

14. PATHOLOGICAL GAIT
1. Muscle weakness:(source of
motion )
2. Deformities of bones and joints
(Articulated lever
3. Neurological disorders
“disturbed awareness of the need for
action and control of motion “

15. Antalgic Gait
• compensatory gait pattern adopted in order to remove or diminish
the discomfort caused by pain in the LL or pelvis
• Characteristic features:
– Decreased in duration of stance phase of the affected limb
– There is a lack of weight shift laterally over the stance limb and
also to keep weight off the involved limb
– Decrease in stance phase in affected side will result in a
decrease in swing phase of sound limb.

16. Trendelenburg Gait
1. Weak abductors
:poliomyelitis . muscular
dystrophies, motor neuron
disease
2. Defective fulcrum: Congenital
dislocaion of hip(CDH),
pathological dislocation of hip
3. Defective lever : Perthes
disease, Coxa vara.

17. Proximal Muscle Weakness Gait
- Increase lordosis
- Gower sign positive

18. Gluteus maximus gait(BACKWARD
LURCH)
• During midstance phase
ipsilateral hip must
maintain in extension to
prevent forward collapse
of trunk
• Trunk is thrust posteriorly
resulting in extension
lurch

19. Quadriceps gait
• Stabilizes knee by
- leaning on affected side
-Pressing over lower
thigh by ipsilateral hand and
finger

20. Equinus Gait
• Walks on toes
• Weakness of dorsiflexors
• Compensation for LLD

21. Steppage Gait/Foot Drop
Gait
- Weakness of foot and ankle
dorsiflexion
- Stance phase: Foot slap gait
- Swing Phase : Steppage gait

22. • Circumduction Gait
- In overcoming hip hike
gait or steppage gait
-To avoid the foot from
scrapping the ground,
the hip and the lower
limb rotates outward.

23. Scissoring gait
• one leg crosses directly
over the other with
each step due to
adductor tightness
• Seen in Cerebral palsy

24. Genu recurvatum gait
• In Paralysis of
hamstring muscles the
knee goes in for hyper
extension while
transmitting the weight
in mid stance phase.
• Seen in poliomyelitis

25. Short limb gait
• Shortening less than 1.5 cm compensated by
pelvic tilt, and shortening upto 5 cm
compensated by equinus.
• Shortening more than 5 cm the patient dips
his body on that side.

26. Physical Examination
Standing:
- back should be examined for scoliosis ,local tenderness, range
of motion.
-if there is pelvic tilt is present , it can be measured by placing
blocks under the shorter leg until the pelvis in level (horizontal)
-trendelenburg test
• Measurement of thigh and calf circumference should reveal atrophy
(more than 1 to 2 cm of difference between sides) in a patient with
any hip or knee condition that has limited function for more than
one to two months.

27. Supine:
- each joint should be examined separately
-look for swelling, feel for tenderness, assess the ROM
-for hip flexion contracture --------Thomas test
-neurological examination should be performed
-check for leg length discrepancy , the short leg must be differentiated
from apparent shortening that is caused by scoliosis or pelvic obliquity or
joint contracture.
Prone:
-hip rotation
*-femoral anteversion

28. Asymmetric Abduction

29. Prone internal rotation of the hip

31. Galeazzi’s test
- useful in diagnosing
developmental hip dysplasia or
leg length discrepancy.
- performed by putting the child
in a supine position and then
flexing the hips and knees by
bringing the ankles to the
buttocks .
- positive when the knees are of
different heights.
-Abnormal shortening of the leg
can be caused by DDH, Perth's
disease.

32. Klisic test

33. FABER TEST

34. Don,t forget!!!
Both intraabdominal pathology and testicular
torsion may present as limp
So always examine abdomen and testes in boys!

35. Investigations
Hematological
• CBC
• ESR, CRP
Kocher’s criteria for differentiating septic arthritis from transient synovitis
-Fever > 38.5 c
-Cannot bear wt
-ESR> 40 mm
-WBC > 12000/mm cu
Probability of septic arthritis
0= < 0.2%
1=3%
2= 40%
3= 93.1%
4= 99.6%

36. • Blood culture – Septic arthritis, OM
• Peripheral blood smear- leukemia
• Montoux test –TB
• PCR- TB
• Coagulation profile - Hemarhrosis
• Immunological : RF, ANA - JIA , SLE
• RFT- SCFE
Endocrinal screening -SCFE
- TFT

37. Synovial fluid analysis

38. X-Ray
Toddlers Fracture

39. Sign of effusion :
- Widening of the joint space.
-Discrepancies greater than 1
mm indicate the presence
of fluid

40. Septic arthritis
Narrowing of joint space and irregularity
of subchondral bone
Joint space loss subchondral erosions and
sclerosis of the femoral
osteonecrosis and
complete collapse of the
femoral head

41. X-ray related to overuse syndrome

42. SCFE

43. Perthes Disease

44. Congenital coxa vara
Hilgenreiner’s epiphyseal angle

45. Hemophilic arthritis

46. Discitis
• Decrease disc space

47. Ultrasonography
• Effusion
-Widening of space between capsule and bone of > 2mm indicates
effusion.
-Echo-free  transient synovitis
-Positively echogenic  septic arthritis
• useful in the detection of early slips by demonstrating joint
effusion and a “step” between the femoral neck and the epiphysis
created by slipping-SCFE
• Acute osteomyelitis- periosteal thickening , subpriosteal thickening

48. CT scan
• deep soft tissue infections of the Para
spinal and retroperitoneal regions
• Three dimensional images of shape
of femoral head and acetabulum in
perthes disease
• SCFE- confirm closure of the proximal
femoral physis. Provide three-
dimensional reconstructed CT images
used to assess the severity of residual
deformity of the upper
femur,[ especially when
reconstructive osteotomy is being
considered.

49. MRI
• evaluation of the spine (for discitis or
spinal tumors), soft tissue tumors and
abscesses in the Para spinal and
retroperitoneal regions, osteomyelitis
of the pelvis and long bones.
• Legg-Calvé-Perthes disease
• Highly specific for detection of AVN
• MRI with gadolinium-contrast
arthrography- the evaluation of the
adolescent patient with hip dysplasia
and pain for assessing of the
condition of the labrum and the
articular cartilage of the hip joint

50. Radionuclide scans :
- sensitive means of detecting alterations
in the metabolic rate of bone and thus a
sensitive means of localizing pathology
-lacks specificity because such alterations in
bone metabolism can occur in Legg-
Calvé-Perthes disease, osteomyelitis,
osteoid osteoma, and malignant bone
tumors.
- Decrease uptake in AVN
- increased uptake in the capital femoral
physis of an involved hip, decreased
uptake in the presence of AVN, and
increased uptake in the joint space in the
presence of chondrolysis

51. Antalgic Gait
History of trauma / oveuse YESNO
Acute traumatic event
Oveuse
Fracture, soft
tissue injury, FB
Osgood Schlatter Dz,
Sever Dz, Stress #,
Osteochondritis
dessicansRadiograph
y
Radiography
Are there Systemic Symptoms
NO
Knee pain or thigh
pain
Hip pain
Normal hip
Accessory
navicular/Discoid
lateral meniscus
Radiography
SCFE/Perth
e s dz
Radiography
YES
Radiography, CBC ,
ESR,
Back pain
/tenderness
Discitis /
vertebral OM
Hip pain, elevated
ESR CRP, WBC
Joint Aspiration Pelvic Abscess
Bone pain / Tenderness
Elevated TLC
ESR, CRP
Night pain ,
Palpable mass
Pancytopenia,
night pain
Osteomyelitis
MRI
Osteosarcom
a/ Ewing
sarcoma
Leukemia
Septic Arthritis/
Transient Synovitis
Positive psoas
sign FABER TEST,
Tender SI Jt
Sacroilitis

52. Non Antalgic Gait
Steppage gait
Any neurologic
condition in which
child loses ability to
dorsiflex foot and
ankle
Trendelenberg
gait
Circumduction
gait
Equinus gait
DDH, Abnormality
in hip abductor
mechanism
CTEV,Cerebral
palsy,
Idiopathic tight
achillis, Limb
length
discrepancy
Neurogenic or
mechanical
condition
causing stifness
of hip
Positive
Galleazzi
Sign
Limb length
discrepancy

53. TAKE HOME MESSAGE
• Acute limp in a child should be taken seriously as it can indicate serious
underlying pathology
• Age of child is important when considering the most likely aetiology
• If trauma has occurred there is lower threshold for performing x-rays in
children as fractures and dislocations are more common
• For atraumatic limp, red flags are age < 3 yr , inability to bear wt, systemic
illness, pain or restricted movement of hip

54. TAKE HOME MESSAGE…
• In children 3-9 who are well , have no fever , are able to bear wt,
and < 48 hr history of atraumatic limp transient synovitis is usually
the cause
• Suspect SCFE in children > 10 yr if there is reduced internal rotation
of hip and pain on extreme of movement
• Kocher’s criteria may be useful in distinguising transient synovitis
from septic arthritis

55. THANK YOU