Date post: | 09-Apr-2018 |
Category: |
Documents |
Upload: | qasem-rababah |
View: | 227 times |
Download: | 0 times |
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 1/51
THE LIMPING CHILDTHE LIMPING CHILD
MahmoudMahmoud M.M. OdatOdat MDMD
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 2/51
Late diagnosis of septic arthritis will causepermanent disability
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 3/51
Role of the OrthopedistRole of the Orthopedist
Recognize the gait abnormalityRecognize the gait abnormality
Determine the site of originDetermine the site of originDevelop a good working diagnosisDevelop a good working diagnosis
Develop a treatment planDevelop a treatment plan
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 4/51
Making the diagnosisMaking the diagnosis
Some cases require urgent treatmentSome cases require urgent treatment
Some conditions affect all age groupsSome conditions affect all age groupsSome presentations are not straightforwardSome presentations are not straightforward
Many conditions have a peak age of onsetMany conditions have a peak age of onset
No single algorithm will be reliable for all presentationsNo single algorithm will be reliable for all presentations
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 5/51
THE LIMPING CHILDTHE LIMPING CHILD
Common reason for consultationCommon reason for consultation
Parents are keen observersParents are keen observers
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 6/51
Events
Normal Gait Normal Gait
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 7/51
Gait change with ageGait change with age
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 8/51
Primary causesPrimary causes
PainPain Antalgic Antalgic
WeaknessWeakness NonNon--Antalgic Antalgic
Mechanical factorsMechanical factors
Tight shoe Tight PersonWide DD
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 9/51
DD: Antalgic gait (All ages)DD: Antalgic gait (All ages)
Fractures, TraumaFractures, Trauma
Infection (OM, septic arthritis, diskitis)Infection (OM, septic arthritis, diskitis)
Arthritis (JR A) Arthritis (JR A)
Discoid meniscusDiscoid meniscus
Foreign body in the footForeign body in the foot
tumorstumors
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 10/51
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 11/51
Bone tumors and leukemia are rare causes of limp
but life threatening
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 12/51
DD: nonantalgic limpDD: nonantalgic limp
EquinusEquinus gait (toegait (toe--Walking)Walking)Idiopathic tight TAIdiopathic tight TA
Club footClub foot
CPCPLLDLLD
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 13/51
DD: nonantalgic limpDD: nonantalgic limp
Circumduction gaitCircumduction gait
LLDLLD
CPCP
Ankle & Knee stiffness Ankle & Knee stiffness
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 14/51
DD: nonantalgic limpDD: nonantalgic limp
Steppage gaitSteppage gait
CPCP
MyelodysplasiaMyelodysplasia
CharcotCharcot--MarieMarie-- Tooth diseaseTooth disease
Friedriech¶s ataxiaFriedriech¶s ataxia
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 15/51
DD: nonantalgic limpDD: nonantalgic limp
TrendelenburgTrendelenburg gaitgait
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 16/51
DD: nonantalgic limpDD: nonantalgic limp
TrendelenburgTrendelenburg gaitgait
LCP diseaseLCP disease
DDHDDH
SCFESCFE
Muscular dystrophyMuscular dystrophy
Hemiplegic CPHemiplegic CP
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 17/51
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 18/51
Waddling gaitWaddling gait
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 19/51
Waddling gaitWaddling gait
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 20/51
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 21/51
DD: according to ageDD: according to age
Toddler Toddler 11--33 yrsyrs
Transient synovitisTransient synovitis
Septic arthritisSeptic arthritis
DiskitisDiskitis
#s#sPauciarticular JAPauciarticular JA
CPCP
Muscular dystrophyMuscular dystrophy
DDHDDH
Coxa varaCoxa vara
RaritiesRarities
LeukemiaLeukemia
OOOO
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 22/51
DD: according to ageDD: according to age
ChildChild 44--1010 yearsyearsLeggLegg--CalveCalve--Perthes diseasePerthes disease
Transient synovitisTransient synovitis
Septic arthritisSeptic arthritisDiscoid meniscusDiscoid meniscus
Osteochondritis dissecans (knee, ankle)Osteochondritis dissecans (knee, ankle)
Sever¶s apophysitisSever¶s apophysitis
Accessory tarsal navicular Accessory tarsal navicular LLDLLD
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 23/51
DD: according to ageDD: according to age
Adolescent > Adolescent > 1010 yearsyearsSCFESCFE
Hip dysplasiaHip dysplasia
Overuse syndromeOveruse syndrome
ChondrolysisChondrolysis
OsgoodOsgood--Schlatter diseaseSchlatter disease
SindigSindig--LarsenLarsen--Johanssen syndromeJohanssen syndrome
Osteochondritis dissecans (knee, ankle)Osteochondritis dissecans (knee, ankle)
Chondromalacia patellaeChondromalacia patellae
Tarsal coalitionTarsal coalition
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 24/51
HistoryHistory
Limp character Limp character
± ± Injury (mechanism)Injury (mechanism)
± ± Pain or other localizing symptomsPain or other localizing symptoms ± ± Frequency & duration of symptomsFrequency & duration of symptoms
± ± Absence of pain Absence of pain
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 25/51
PatternPatternOnsetOnset
± ± Acute (trauma, infection, malignancy) Acute (trauma, infection, malignancy)
± ± Gradual (inflammatory, mechanical)Gradual (inflammatory, mechanical)
DurationDurationQualityQuality
± ± Constant, intermittent or mechanicalConstant, intermittent or mechanical
TimingTiming
± ± Morning, after activity, nightMorning, after activity, nightRelief Relief
ReferredReferred
Multiple jointsMultiple joints
PainPain
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 26/51
Past medical historyPast medical history
Recent traumaRecent trauma
Exposure to infectious diseaseExposure to infectious disease
Recent fever, weight loss, malaiseRecent fever, weight loss, malaise
Developmental milestoneDevelopmental milestone
Motor abilityMotor ability
Family history of Family history of
Neuromuscular diseaseNeuromuscular diseaseMetabolic diseaseMetabolic disease
Inflammatory arthritisInflammatory arthritis
Infectious diseaseInfectious disease
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 27/51
Physical examination:Physical examination:
Gait examGait exam
Standing examStanding exam
TableTable--tope examtope exam
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 28/51
Standing examStanding exam
SpineSpine
Balance in coronal and saggitalBalance in coronal and saggital
Scoliosis,Scoliosis,LS stepLS step--off off
pelvic obliquitypelvic obliquity
cutaneous findingscutaneous findings
(café(café--auau--lait, hairy patches)lait, hairy patches)Bend Forward, backward, sidewayBend Forward, backward, sideway
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 29/51
Standing examStanding exam
PelvisPelvis
ObliquityObliquity
Trendelenburg testTrendelenburg test(flexed knee, extended hip)(flexed knee, extended hip)
waitwait 2020 secondsseconds
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 30/51
Standing examStanding exam
LLLL
Gower test (Muscular dystrophy)Gower test (Muscular dystrophy)
R
epetitive heel raises, toe raisesR
epetitive heel raises, toe raisesClawing or CavusClawing or Cavus
Deep tendon reflexes and ClonusDeep tendon reflexes and Clonus
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 31/51
TableTable--tope examtope exam
InspectionInspection
Asymmetry, Deformity, Erythema, Rashes, Asymmetry, Deformity, Erythema, Rashes,
SwellingSwelling
Wounds or FBs (Foot, knee)Wounds or FBs (Foot, knee)
Position, muscle (atrophy, hypertrophy)Position, muscle (atrophy, hypertrophy)
PalpationPalpation
Max. tenderness (most valuable part)Max. tenderness (most valuable part)
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 32/51
TableTable--tope examtope exam
JointsJointsROM, pain, contracture, spasticity.ROM, pain, contracture, spasticity.
PF joint, SI jointPF joint, SI joint
Rotational profile
Rotational profile
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 33/51
TableTable--tope examtope exam
Neurological examNeurological exam
LLD (measure, Galeazzi test)LLD (measure, Galeazzi test)
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 34/51
When the cause of limp cannot be localizedWhen the cause of limp cannot be localizedby history and pysical examinationby history and pysical examination
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 35/51
Radiographic evaluation:Radiographic evaluation:
Plain radiographyPlain radiography
Isotope bone scan (techIsotope bone scan (tech--9999m)m)
UltrasonographyUltrasonographyCT scanCT scan
MRIMRI
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 36/51
Laboratory testing:Laboratory testing:
TestsTests
CBC diff CBC diff
ESRESR
CRPCRP
Aspiration Aspiration
ANA ANA
Rh F
Rh F
HLA TYPINGHLA TYPING
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 37/51
Radiographic evaluation:Radiographic evaluation:
Plain radiographyPlain radiography
Isotope bone scan (techIsotope bone scan (tech--9999m)m)
UltrasonographyUltrasonographyCT scanCT scan
MRIMRI
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 38/51
Radiographic evaluation:Radiographic evaluation:
Plain radiographyPlain radiography
Inexpensive, any time, sensitive, specificInexpensive, any time, sensitive, specific
Entire LL in nonverbalEntire LL in nonverbal
? early bone and joint infection? early bone and joint infection
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 39/51
Radiographic evaluation:Radiographic evaluation:
Isotope bone scan (techIsotope bone scan (tech--9999m)m)SensitivitySensitivity 8484%% --100100%, specificity%, specificity 7070%% -- 9696%%
Accumulate at the sites of increased blood flow Accumulate at the sites of increased blood flow
Osteoblastic activityOsteoblastic activityOMOM
Stress #sStress #s
Occult #sOccult #s
NeoplasmNeoplasm
MetastasisMetastasis
Superior to {temp, WBC, ESR, plain XSuperior to {temp, WBC, ESR, plain X--ray}ray}
Localization in difficult areas (pelvis, spine)Localization in difficult areas (pelvis, spine)
Ability to image the whole body Ability to image the whole body
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 40/51
Radiographic evaluation:Radiographic evaluation:
UltrasonographyUltrasonographyIrritable hip VS septic arthritisIrritable hip VS septic arthritis
Cannot differentiateCannot differentiate
{sterile, purulent, hemorrhage}{sterile, purulent, hemorrhage}Guided aspirationGuided aspiration
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 41/51
Radiographic evaluation:Radiographic evaluation:
UltrasonographyUltrasonography
Helpful in Diagnosing OMHelpful in Diagnosing OMdeep soft tissue swellingdeep soft tissue swelling
periosteal thickeningperiosteal thickening
subperiosteal collectionsubperiosteal collection
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 42/51
Radiographic evaluation:Radiographic evaluation:
CT scanCT scan
Rarely necessary as an initial studyRarely necessary as an initial study
Localized cortical abnormalitiesLocalized cortical abnormalities
Central nidus (OO)Central nidus (OO)
Tarsal coalitionTarsal coalition
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 43/51
Radiographic evaluation:Radiographic evaluation:
RIRI
Bone arroBone arro
ointointartilageartilage
oft ti ueoft ti ue
u or and treu or and tre
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 44/51
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 45/51
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 46/51
Laboratory testing:Laboratory testing:
Rapid diagnosis and treatmentRapid diagnosis and treatmentInfectionInfection
InflammatoryInflammatory
MalignancyMalignancy
Assist in Assist in
Making a diagnosisMaking a diagnosis
Monitoring the efficacy of treatmentMonitoring the efficacy of treatment
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 47/51
Laboratory testing:Laboratory testing:
TestsTests
CBC diff CBC diff
ESRESR
CRPCRP
Aspiration Aspiration
ANA ANA
Rh F
Rh FHLA TYPINGHLA TYPING
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 48/51
Laboratory testing:Laboratory testing:
ESR :ESR :
Reflects the changes in the concentration of Reflects the changes in the concentration of
fibrinogen synthesized by the liver fibrinogen synthesized by the liver
Sensitive indicator of inflammationSensitive indicator of inflammation
Sensitive indicator of infection (Sensitive indicator of infection (9090% in OM)% in OM)
Increase after Increase after 2424--4848 hh
Return to normal inReturn to normal in 33 weeksweeks
Helpful in diagnosis and follow upHelpful in diagnosis and follow up
Extreme elevation ? Associated septic arthritisExtreme elevation ? Associated septic arthritis
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 49/51
Laboratory testing:Laboratory testing:
CRP:CRP:
An acute An acute--phase protein synthesized by thephase protein synthesized by the
liver in response to inflammationliver in response to inflammation
Rises withinRises within 66hh
Returns to normal withinReturns to normal within 66--1010 daysdays
More sensitive (WBC, ESR) inMore sensitive (WBC, ESR) in
assessing the ttt effectivenessassessing the ttt effectiveness
predicting recoverypredicting recovery
22ry rise suggests relapsery rise suggests relapse
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 50/51
Laboratory testing:Laboratory testing:
Aspiration AspirationCell countCell count
WBC >WBC >8080,,000000
7575% Polymorphonuclear % Polymorphonuclear Gram stainGram stain
Protein, glucose analysisProtein, glucose analysis
CultureCulture
HipHipTechnically difficultTechnically difficult
Sedation, LA, fluoroscopic guidance with arthrogramSedation, LA, fluoroscopic guidance with arthrogram
US guided aspirationUS guided aspiration
8/7/2019 2THE LIMPING CHILD-JOA
http://slidepdf.com/reader/full/2the-limping-child-joa 51/51
SUMMARYSUMMARY
Understand the normal & abnormal gaitUnderstand the normal & abnormal gait
Appropriate history, physical exam and the Appropriate history, physical exam and the
use the child¶s age will narrow the DDuse the child¶s age will narrow the DDPlan a selective approach to diagnosticPlan a selective approach to diagnostic
testingtesting
Plan the treatment scenarioPlan the treatment scenario