The Limping Child Flashcards
What are the 5 main causes of hip pain (and age ranges) in children?
Congenital hip dysplasia: birth 1/1000
Septic hip/infections: 0-5 years old
Transient synovitis (4-8 ya)
Perthes’ disease: 5-10 years old 1/10 000
Slipped femoral physis: 10-15 1/100 000
Congenital Dislocation of hip: what is it? and how does it present?
Congenitally determined developmental deformation of the hip joint, in which the head of the femur is or may be completely or partially displaced from the acetabulum
2:1000 live births, F>M, higher incidence in breech presentation
S+S = legs turning outward, diff length, reduced ROM, delayed gross motor development
What test do you perform to check for CHD?
Ortolani’s test: hips and knees flexed to 90 degrees, thighs grasped in each hand and hips are abducted to 90 degrees. Should be able to do so easily and without resistance.
Can also do Barlow’s test
If either test + : do US - shows shape of cartilaginous socket and position of head femur
Outline CHD Mx
Put child in harness Pavlik, closed or open reduction: aim to reduce hip in position until acetabulum rim is sufficiently developed
Outline septic hip: demographics, presentation, x-ray results, Mx
0-4y
S+S = limp, minor or no trauma, limited ROM, erythema, warm, tender, fever, effusion, pain/referred
Ix = x-ray (exclude trauma, widening of joint space), WBC/CRP, blood cultures, USS (effusion), MRI (osteomyelitis)
Mx = Abx, analgesia, physio, splint, washing out/surgical drainage
What criteria do you use to diagnose septic hips in children?
Kocher criteria:
- Fever >38.2
- Non weight bearing
- ESR >40
- WBCs >12000
- If 2 criteria met (60%), if 3 criteria met (93%)
What is the aetiology and pathophysiology of septic hip in children?
Aetiology = staph, strep, haemophilus influenza, gram -ve bacilli
Inflammation causes compression of head of femur, which obstructs blood supply to head of femur
Leads to rapid onset of pain in swollen joint
Outline transient synovitis: demographics, S+S, Mx
Inflammation of synovium
2-12 years old = most common cause of sudden hip pain in children
Presentation: limping, minor or no trauma. Might have a Hx of recent infection of vaccination (but aetiology unknown) and have limited ROM, no pain at rest
Mx = self limiting, bed rest
Transient synovitis: imaging findings
X ray findings: no abnormalities
USS: may show some collection
Outline Perthes Disease: demographics, pathophysiology, S+S
Type of osteochondritis (AVN of femoral head - occurs when the blood supply to the rounded head of the femur is temporarily disrupted. Without an adequate blood supply, the bone cells die and get AVN)
Usually male, 4-10y, with limp
S+S = insidious pain, limp
Perthes Disease: important imaging findings
X ray initially normal: earliest change is increased density in bony part of epiphysis, which later flatters and fragments
Outline perthes disease management
- bed rest until pain subsides
- surgical = based on trying to contain head in acetabulum to enable it to retain best shape possible.
What is a SUFE? Age range, presentation and pathophysiology
Slipped upper femoral epiphysis (10-15 ya)
Children of pubertal age: affects either fat and sexually underdeveloped kids or tall and thin kids (M>F)
Presentation: limping, knee pain, minor trauma, no fever
Epiphysis slips posteriorly in either acute (20%) or chronic slip (60%) or combination (20%)
Acute: pt presents with groin pain/referred to thigh or knee, can be shortened and externally rotated
SUFE management?
Usually involves surgery to reduce epiphysis (fix with pin)
Chronic slip: don’t reduce b/c AVN may result - epiphysis usually pinned in situ to prevent further slippage
*Always do a hip exam on a child 8-10 ya with painful knee as can get referred pain. These people may develop deformity/OA/disability risk
SUFE: what is a klein line?
A line along the superior edge of the neck of the femur
Useful in detecting early slipped upper femoral epiphysis in adolescents
Line should normally intersect the lateral part of the superior femoral epiphysis. If the line of Klein fails to intersect the epiphysis during the acute phase, it is called Trethowan sign 3. In very subtle cases, asymmetry between the lines of Klein might be the only way of determining a slipped upper femoral epiphysis
