Limp

Question 1

What questions should be asked in a focused hx for limp?

Answer 1

1. Trauma
2. Recent infection
3. Fever?
4. Creche?
5. Timing
6. Is it painful
7. Severity
8. Any local findings (bruising, swelling, redness)
9. Walking normally up to this point?
10. Family hx or past medical hx
11. Normal development up to this point?
12. Is he sick? Any other symptoms?
13. Vaccinated?
14. Birth hx
15. Risk factors:
    - Eczema, chicken pox = septic arthritis/osteomyelitis
    - Sickle cell disease = Avascular necrosis of femoral head
    - Weight (overweight) = slipped epiphysis (chronic cause)

Question 2

What should we be looking for on examination of a child with a limp?

Answer 2

1. Watch - see what can/can’t do
2. ROM at hip - may just have to observe
3. Bony point tenderness (osteomyelitis)
4. Imaging if can’t examine
5. Look for risk factors - eczema (source of infection); organomegaly, lymphoedema, pallor (malignancy)
6. HR, temp, cap refill
7. CVS/Resp/CNS

Question 3

What is the position of comfort for septic arthritis?

Answer 3

Flexed and externally rotated

Question 4

What is the differential diagnosis for limp with a fever?

Answer 4

1. Transient synovitis
2. Osteomyelitis
3. Septic arthritis
4. Intra-abdominal abscess
5. Appendicitis
6. Psoas abscess

Question 5

What is the differential diagnosis for limp without a fever?

Answer 5

1. Fracture
2. Reactive arthritis
3. Monoarticular arthritis
4. Polyarticular arthritis
5. Bone tumour
6. Haematological malignancy
7. Slipped capital femoral epiphysis
8. Avascular necrosis (Perthe’s disease)
9. Sickle cell crisis
10. DDH

Question 6

What investigations should be done in a child that presents with limp?

Answer 6

Bloods:

1. FBC - esp. WCC; platelets esp if WCC decreased, Hb
2. CRP
3. ESR
4. Blood cultures (if child definitely febrile)
5. Add things if hx suggestive:
   - Blood film for malignancy
   - Serology if suspected reactive arthritis

Radiology:

1. Plain film - trauma, septic arthritis, Perthes, SCFE, malignancy
2. US - septic arthritis, DDH (only up to 5mths)
3. MRI - osteomyelitis, Perthes, SCFE, malignancy
4. CT - SCFE, malignancy

Question 7

How should limp be managed?

Answer 7

• Fever + limp = always admit
• Normal exam + limp = imaging and baseline investigations
• Transient synovitis = rest + observation
• Septic arthritis = EMERGENCY!! Aspirate + IV Abx
• Osteomyelitis = IV Abx (whole course = 4wks but may not be entirely IV)
• DDH - depends on age of Dx

Question 8

What is transient synovitis?

Answer 8

• Paediatric condition
• Mild illness
• Inflammation of joint synovium
• Generally self limiting
• Follows or is accompanied by viral infection

Question 9

What is reactive arthritis?

Answer 9

• Have had an illness and couple of weeks later present with joint problem
• Group A strep, parvovirus, mycoplasma, lyme disease
• Tx = NSAIDs

Question 10

List the causes of limp in the 1-3yrs age group

Answer 10

Acute painful limp:

1. Infection
   - SA
   - Osteomyelitis
2. Transient synovitis
3. Trauma
4. Malignant disease
   - Leukaemia
   - Neuroblastoma

Chronic and Intermittent Limp:

1. DDH
2. Talipes
3. Neuromuscular (e.g. CP)
4. JIA

Question 11

List the causes of limp in the 3-10yrs age group

Answer 11

Acute painful limp:

1. Transient synovitis
2. SA/osteomyelitis
3. Trauma and overuse injuries
4. Perthe’s disease (acute)
5. JIA
6. Malignant disease
7. Complex regional pain syndrome

Chronic and intermittent limp:

1. Perthe’s disease (chronic)
2. Neuromuscular disorders
3. JIA
4. Tarsal coalition

Question 12

List the causes of limp in the 11-16yrs age group

Answer 12

Acute painful limp:

1. Mechanical
2. SCFE
3. Avascular necrosis of femoral head
4. Reactive arthritis
5. JIA
6. SA/osteomyelitis
7. Osteochondritis dissecans of the knee
8. Bone tumours and malignancy
9. Complex regional pain syndrome

Chronic and intermittent limp:

1. SCFE
2. JIA
3. Tarsal coalition

Question 13

What is Perthe’s disease?

Answer 13

• Avascular necrosis of the capital femoral epiphysis of the femoral head due to interruption of blood supply ]. followed by revascularisation and reossification over 18-36mths
• More common in boys
• 5-10yrs
• X-ray of both hips
• Early signs = increased density in femoral head

Question 14

What is the management for Perthe’s disease?

Answer 14

• Rest
• Physiotherapy
• Traction
• Plaster casts
• Surgery

Question 15

Define Juvenile idiopathic arthritis (JIA)

Answer 15

Persistent joint swelling >6wks, presenting before 16yrs of age in absence of infection or any other defined cause

Question 16

How is JIA classified?

Answer 16

Clinical - based on the number of joints involved:

• > 4 = polyarthritis
• =4 = oligoarthritis
• Systemic

Question 17

How does JIA present?

Answer 17

• Gelling (stiffness after periods of rest)
• Morning stiffness
• Pain
• Intermittent limp
• Deteriorating behaviour or mood
• Avoidance of previously enjoyed activities
• last 3 = young children
• Need to consider possibility of connective tissue disorder
• If systemic features = consider sepsis or malignancy

Question 18

What are the complications of JIA?

Answer 18

1. Chronic anterior uveitis:
   - Usually asymptomatic in early stages
   - Can lead to severe visual impairment
   - Regular ophthalmological screening indicated
2. Flexion contractures of the joints:
   - Joint destruction
   - Need for joint replacement (in chronic untreated)
   - Preventable with early dx and tx
3. Growth failure:
   - Leg length discrepancy may be present
   - Preventable with early dx and tx
4. Constitutional problems:
   - Anaemia of chronic disease
   - Delayed puberty
5. Osteoporosis:
   - Reduce risk by dietary supplements, regular weight bearing exercise and minimise oral corticosteroid use
6. Amyloidosis:
   - Rare
   - Proteinuria and renal failure
   - High mortality

Question 19

How is JIA managed?

Answer 19

• Specialist paediatric rheumatology MDT
• Education and support for child and family
• Medical management:
  1. NSAIDs and analgesics - symptom relief
  2. Joint injections (steroids) - first line
  3. Physical therapy to maintain joint function
  4. Methotrexate - polyarthritis; early use decreases joint damage; weekly dose with regular blood monitoring required (LFTs and marrow suppression)
  5. Systemic corticosteroids - avoid if possible
  6. Cytokine modulators and other immunotherapies

Question 20

What is the prognosis in JIA?

Answer 20

• Most can expect good control and QOL
• Significant morbidity if good control not achieved
• Joint replacements sometimes required in adulthood