The Limping

Child
Anna Maria Patricia L. Ayate
1st Year Resident
Limping
• Painful (Antalgic) Gait
• stance phase is shortened
• result of trauma, infection, or pathologic fracture
• Painless Gait
• underlying proximal muscle
weakness or hip instability
• stance phase is equal between the
involved and uninvolved sides
• child leans or shifts the center of gravity
over the involved extremity for balance
Limping
• Trendelenburg Gait
• produced by weak abnormal hip abductors
• caused by congenital, developmental, or muscular disorders
• Trendelenburg sign (i.e., sagging rather than rising of the unsupported buttock)
can often be elicited when abductors are weak.
 AGE EARLY WALKER CHILD ADOLESCENT
GROUP (1-3 YEARS OLD) (3-10 YEARS OLD) (>11 YEARS OLD)
• Septic arthritis • Septic arthritis • Septic arthritis
• Osteomyelitis • Osteomyelitis, myositis • Osteomyelitis, myositis
• Transient synovitis • Transient synovitis • Trauma
Painful • Occult trauma (“toddler’s • Trauma • Rheumatologic disorder
Limp fracture”) • Rheumatologic disorders • Slipped capital femoral
• Intervertebral diskitis • Juvenile idiopathic arthritis epiphysis (acute,
• Malignancy • Intervertebral diskitis • unstable)
• Abuse • Malignancy • Malignancy
• Developmental dysplasia of
• Slipped capital femoral
the hip
• Developmental dysplasia of epiphysis (chronic,
• Legg-Calvé-Perthes disease
the hip • stable)
• Lower extremity length
• Neuromuscular disorder • Developmental dysplasia of
Painless inequality
• Polio the hip
Limp • Neuromuscular disorder
• Cerebral palsy • (acetabular dysplasia)
• Polio
• Lower extremity length • Lower extremity length
• Cerebral palsy
inequality inequality
• Muscular dystrophy
• Neuromuscular disorder
(Duchenne)
OSTEOMYELITIS
Etiology
• Staphylococcus aureus: most common infecting organism among all
age groups
• After 6 year of age: most cases are caused by S. aureus, group A
streptococci, or Pseudomonas aeruginosa
• Pseudomonas infection - related almost exclusively to puncture wounds of the
foot
Etiology
• Salmonella species and S. aureus: most common causes of
osteomyelitis in children with sickle cell disease
• Streptococcus pneumoniae: most commonly causes osteomyelitis in
children younger than 24 months of age and in children with sickle
cell disease
• frequency has declined because of pneumococcal conjugate vaccines.
Etiology
• Kingella kingae: second most common cause of osteomyelitis in
children younger than 4 years of age.
• established as a cause of osteomyelitis, spondylodiskitis, and septic arthritis
• difficult to detect unless polymerase chain reaction (PCR) testing is used.
Epidemiology
• Median age: ~6 years old
• Bone infections: more common in boys
• increased incidence in patients with sickle cell disease
• Most cases in previously healthy children are hematogenous
• Minor closed trauma: common preceding event (~30% of patients)
Clinical Manifestation
Neonates
• might exhibit pseudoparalysis or pain with movement of the affected
extremity (e.g., diaper changes).
• Half of neonates do not have fever and might not appear ill.
Clinical Manifestation
Older infants and Children
• pain, fever, and localizing signs (edema, erythema, and warmth)
• Local swelling and redness – spread of infection beyond the metaphysis and
into the subperiosteal space
• involvement of the lower extremities, limp, or refusal to walk is seen
in approximately half of patients
• Focal tenderness over a long bone can be an important finding
Clinical Manifestation
Pelvic osteomyelitis
• can manifest with subtle findings such as hip, thigh, groin, or
abdominal pain.
Vertebral osteomyelitis
• presents as back pain with or without tenderness to palpation over the
vertebral processes
Clinical Manifestation
• Long bones are principally involved in osteomyelitis
• the femur and tibia are equally affected and together constitute almost half of
all cases.
• bones of the upper extremities account for 25% of all cases.
• Flat bones are less commonly affected
• Usually only a single site of bone or joint is involved
Clinical Manifestation
• Brodie Abscess
• subacute symptoms and focal findings in the metaphyseal area with
radiographic lucency and surrounding reactive bone.
• Typically, the contents are sterile
• Osteomyelitis due to S. aureus
• develop a deep venous thrombosis adjacent to the affected bone which can
produce septic pulmonary emboli
• these patients are often critically ill
Diagnosis
• Blood cultures should be performed in all suspected cases.
• Aspiration or biopsy of bone or subperiosteal abscess for Gram stain,
culture, PCR, and bone histology
• PCR is the most sensitive technique to detect K. kingae
Diagnosis
• There are no specific laboratory tests for osteomyelitis.
• The WBC and differential ESR and CRP are generally elevated in children
with bone infections
• nonspecific and not helpful in distinguishing between skeletal infection and other
inflammatory processes
• normal test results do not preclude the diagnosis of skeletal infection.
• Monitoring elevated CRP may be of value in assessing response to therapy or
identifying complications.
Radiographic Evaluation
• Plain Radiographs
• Within 72 hr of onset of symptoms of osteomyelitis
• displacement of the deep muscle planes from the adjacent metaphysis caused
by deep-tissue edema
• Lytic bone changes are not visible on radiographs until 30–50% of the bony
matrix is destroyed.
• important to exclude other possible causes (e.g., fracture) of the presenting
symptoms and signs.
Radiographic Evaluation
Magnetic Resonance Imaging
• more sensitive than CT or radionuclide imaging in acute osteomyelitis
• best radiographic imaging technique for identifying abscesses and for
differentiating between bone and soft tissue infection.
• provides precise anatomic detail of subperiosteal pus and accumulation of
purulent debris in the bone marrow and metaphyses for possible surgical
intervention.
Radiographic Evaluation
Whole body rapid STIR MRI
• alternative to radionuclide imaging where multiple sites of infection are
suspected or the site of infection cannot be clearly localized.
Computed Tomography
• demonstrate osseous and soft tissue abnormalities
• ideal for detecting gas in soft tissues
• has poor sensitivity for detecting the presence of osteomyelitis.
Radiographic Evaluation
• Radionuclide Studies
• May be useful if multiple foci are suspected
• Advantages: infrequent need for sedation and the ability to image the entire
skeleton for detection of multiple foci.
• Disadvantages: exposure to radiation, inability to image surrounding soft
tissues, and overall lack of detail
Treatment – Antimicrobial Therapy
In neonates
• antistaphylococcal penicillin (nafcillin or oxacillin), and a broad-
spectrum cephalosporin (cefepime)
• coverage for the methicillin-susceptible S. aureus, group B streptococcus, and
Gram-negative bacilli.
• If methicillin-resistant Staphylococcus is suspected, vancomycin is substituted
for nafcillin.
Treatment – Antimicrobial Therapy
In older infants and children
• Principal pathogens: S. aureus, K. kingae, and group A streptococcus.
• Cefazolin
• agent of choice for parenteral treatment of osteomyelitis caused by methicillin-
susceptible S. aureus
• backbone of empirical treatment for acute hematogenous osteomyelitis.
• Vancomycin: “gold standard” agent for treating invasive MRSA infections.
• Clindamycin: alternative therapy for susceptible isolates of MRSA and for
MSSA
Treatment – Antimicrobial Therapy
• Duration of antibiotic therapy
• minimal duration of antibiotics is 21-28 days, provided that:
• prompt resolution of signs and symptoms (within 5-7 days)
• CRP has normalized
• total of 4-6 wk of therapy may be required for those with slower resolution of symptoms
or normalization of CRP.
• Immunocompromised patients generally require prolonged courses of therapy,
as do patients with mycobacterial or fungal infection
Treatment – Surgical Therapy
• Indications:
• frank pus is obtained from subperiosteal or metaphyseal aspiration
or is suspected based on MRI findings
• penetrating injury and when a retained foreign body is possible.
• catheter drainage performed by an interventional radiologist
is adequate in selected cases
• surgical removal of sinus tracts and sequestrum
Treatment – Physical Therapy
• Affected extremity: in extension with sandbags, splints, or, temporary
cast
• Casts - indicated when there is a potential for pathologic fracture
• After 2-3 days, when pain is easing, passive range of motion exercises
are started and continued until the child resumes normal activity.
• In neglected cases with flexion contractures, prolonged physical
therapy is required
Prognosis
• The improvement in signs and symptoms is rapid when pus is
drained and appropriate antibiotic therapy is given
• Failure to improve or worsening by 48-72 hr requires review of the
appropriateness of the antibiotic therapy, the need for surgical
intervention, or the accuracy of the diagnosis.
Prognosis
• Acute phase reactants may be useful as monitors
• CRP typically decreases below 2 mg/dL within 7-10 days after starting
treatment
• ESR typically rises for 5-7 days and then falls slowly, dropping sharply after 10-
14 days
• Recurrence of disease and development of chronic infection after
treatment occur in <10% of patients.
• long-term follow-up is necessary with close attention to range of motion of
joints and bone length
TRANSIENT SINOVITIS
Etiology
• The cause remains unknown
• nonspecific inflammatory condition or as a post-viral immunologic
synovitis because it tends to follow recent viral illnesses
Clinical Manifestation
• prevalent in children between 3 and 8 yr of age
• Mean age of onset: 6 yr
• ~70% of all affected children have had a nonspecific upper respiratory
tract infection the 7-14 days before symptom onset
• Symptoms often develop acutely and usually consist of pain in the
groin, anterior thigh, or knee, which may be referred from the hip.
Clinical Manifestation
• usually able to bear weight on the affected limb
• typically walk with an antalgic gait with the foot externally rotated.
• The hip is not held flexed, abducted, or laterally rotated unless a significant
effusion is present.
• often afebrile or have a low-grade fever <38°C (100.4°F).
Diagnosis
• Clinical Diagnosis
• laboratory and radiographic tests can be useful to rule out other more serious
conditions.
• ESR, CRP, and WBC counts are relatively normal
Diagnosis
• AP and Lauenstein (frog-leg) lateral radiographs of the pelvis usually
found to be normal.
• Ultrasonography of the hip is preferred to x-rays and often
demonstrates a small joint effusion
Treatment and Prognosis
• Treatment is symptomatic
• Anti-inflammatory agents and analgesics can shorten the duration of pain
• Recommended therapies:
• activity limitation
• relief of weight bearing
• Most children recover completely within 3-6 wk.
SEPTIC ARTHRITIS
Etiology
• Staphylococcus aureus: most common cause of bacterial arthritis in
all age groups
• S. pneumoniae is most likely in the 1st 2 yr of life
• but its frequency has declined since the introduction of the pneumococcal
conjugate vaccines.
• Kingella kingae: recognized as a relatively common etiology with
improved culture and polymerase chain reaction (PCR) methods in
children younger than 4 yr.
Etiology
• Gonococcus: common cause of septic arthritis and tenosynovitis,
usually of small joints or as a monoarticular infection of a large joint
(knee) in sexually active adolescents,
• Neisseria meningitidis
• septic arthritis that occurs in the first few days of illness
• reactive arthritis that is typically seen several days after antibiotics have been
initiated
• Group B streptococcus: important cause of septic arthritis in
neonates.
Etiology
• Fungal infections usually occur as part of multisystem disseminated
disease
• Candida arthritis can complicate systemic infection in neonates with
or without indwelling vascular catheters.
• Primary viral infections of joints are rare
• arthritis accompanies many viral (parvovirus, mumps, rubella live vaccines)
syndromes, suggesting an immunemediated pathogenesis.
Epidemiology
• more common in young children
• 1/2 of all cases occur by 2 yr of age
• 3/4 of all cases occur by 5 yr of age
• Adolescents and neonates: at risk of gonococcal septic arthritis
• Infection of joints can follow penetrating injuries or procedures:
• trauma, arthroscopy, prosthetic joint surgery, intraarticular steroid injection,
and orthopedic surgery
• Immunocompromised patients and those with rheumatologic joint
disease are also at increased risk of joint infection.
Clinical Manifestations
• Most septic arthritides are monoarticular
• The signs and symptoms depend on the age of the patient
• Neonates and young infants: often associated with adjacent osteomyelitis
caused by transphyseal spread of infection.
• Older infants and children:
• might have fever and pain, with localizing signs such as swelling, erythema, and
warmth of the affected joint
• involvement of joints of the pelvis and lower extremities
• limp or refusal to walk often occurs
Clinical Manifestations
• Erythema and edema of the skin and soft tissue overlying the site of
infection are seen earlier
• bulging infected synovium is usually more superficial, whereas the metaphysis
is located more deeply
• Joints of the lower extremity constitute 75% of all cases
• elbow, wrist, and shoulder joints are involved in approximately 25% of cases
Diagnosis
• Blood cultures should be performed in all cases of suspected septic arthritis
• positive in 20% or fewer cases of proven or probable septic arthritis.
• Aspiration of the joint fluid provides the optimal specimen to confirm the
diagnosis
• Multiplex bacterial PCR panels appear to have a yield around 50% from joint
fluid specimens
Diagnosis
• Multiplex bacterial PCR panels appear to have a yield around 50% from joint
fluid specimens
• PCR is rarely necessary but can detect Borrelia burgdorferi in joint aspirate
specimens in cases of Lyme arthritis
• Synovial fluid analysis for cell count, differential, protein, and glucose has limited
utility in diagnosing infectious arthritis.
• Joint fluid white blood cell counts >50,000 cells/mm3 suggest bacterial infection as the most likely
etiology (neither sensitive nor specific)
• Monitoring elevated CRP may be of value in assessing response to therapy or
identifying complications
Radiographic Evaluation
Plain Radiographs
• widening of the joint capsule, soft tissue edema, and obliteration of
normal fat lines.
• exclude other causes of joint pain such as fractures.
• Plain films of the hip
• medial displacement of the obturator muscle into the pelvis (the obturator
sign)
• lateral displacement or obliteration of the gluteal fat lines
• elevation of Shenton’s line with a widened arc
Radiographic Evaluation
Ultrasonography
• helpful in detecting joint effusion and fluid collection in the soft tissue
and subperiosteal regions
• highly sensitive in detecting joint effusion, particularly for the hip
joint
• plain radiographs are normal in more than 50% of cases
• serve as an aid in performing hip aspiration
Radiographic Evaluation
Magnetic Resonance Imaging and Computed Tomography
• confirm the presence of joint fluid in patients with suspected
osteoarthritis infections but are not routinely indicated.
• MRI is useful in evaluating for adjacent osteomyelitis or pyomyositis
but is typically reserved for cases when the index of suspicion for
these conditions is high.
Radionuclide Imaging
• not routinely indicated
• more sensitive than plain radiographs in providing supportive
evidence of the diagnosis of septic arthritis;
• may be positive within 2 days of the onset of symptoms
Antimicrobial Therapy
Neonates
• Anti-staphylococcal Penicillin (Nafcillin or Oxacillin) + broad-spectrum
cephalosporin (Cefepime)
• for the S. aureus, group B streptococcus, and Gram-negative bacilli
• If MRSA is a concern, Vancomycin is selected instead of nafcillin or oxacillin.
Older infants and children
• empirical therapy to cover for S. aureus, streptococci, and K. kingae includes
cefazolin or nafcillin
• In areas where methicillin resistance is noted, adding an antimicrobial that is
effective against local CA-MRSA isolates is suggested
• Vancomycin is preferred in patients who are ill-appearing, suspected to be bacteremic, or if
local clindamycin resistance is more than 10–15%.
Antimicrobial Therapy
Immunocompromised patients
• Combination Therapy
• vancomycin and ceftazidime, cefepime, or piperacillin/ tazobactam, with or
without an aminoglycoside.
• Adjunct Therapy with dexamethasone for 4 days with antibiotic
therapy
• decrease the duration of fever
• promote a more rapid decline in inflammatory markers
Antimicrobial Therapy
• Empirical antimicrobials are narrowed to targeted therapy when the
pathogen is identified
• If a pathogen is not identified and is improving, therapy is continued with the
antibiotic selected initially
• If a pathogen is not identified and is not improving,
• consideration should be given to the need for reaspiration, the presence of an
extraarticular infection requiring surgical debridement or the possibility of a
noninfectious etiology.
• MRI may be performed to assist with subsequent management decisions
Antimicrobial Therapy
• Duration of antibiotic therapy:
• 10-14 days - streptococci, S. pneumoniae, and K. kingae
• 3 weeks - may be needed for S. aureus and Gram-negative infections
• 4 weeks - concomitant osteomyelitis, extensive disease, or slow response to
treatment
• Oral antibiotics - used to complete therapy once the patient is afebrile
for 48-72 hours and is clearly improving
Surgical Therapy
• Infection of the hip is generally considered a surgical emergency
• vulnerability of the blood supply to the head of the femur.
• Daily aspirations of synovial fluid may be required for joints other
than the hip
• In general, one or two subsequent aspirations suffice
• If fluid continues to accumulate after 4-5 days, arthrotomy or video-assisted arthroscopy
is needed.
• At the time of surgery, the joint is flushed with sterile saline solution.
• Antibiotics are not instilled because they are irritating to synovial tissue, and adequate
amounts of antibiotic are achieved in joint fluid with systemic administration.
Prognosis
• Septic arthritis can lead to numerous long-term sequelae in children
• including leg-length discrepancy or angular deformity from growth arrest
• limitations in range of motion due to chondral damage
• avascular necrosis of the femoral head from septic arthritis of the hip.
• The overall rate of these sequelae with current therapies is <5%
Thank You!