PED2: Evaluation of the Child with a Limp

BLOCK 6 | 23 February 2021 | Naomi Grospe-Holgado, MD, FPPS, DPSN/DPNSPr

OUTLINE • Any deviation from this gait is classified limp

I. Definition VIII. Neoplasm → Only encompasses children who can already walk, does not
II. History IX. Developmental causes includes neonates of children not able to walk yet
III. Physical Examination X. Overuse Injuries
Video transcription [Video from doc]
IV. Differential Diagnosis References TH/TG Note: Doc said she will not expect us to remember the muscles
V. Diagnostics Review Questions involved
VI. Traumatic Injuries Appendix • Initial contact
VII.Infection Summary → Hip flexion: 20 degrees
→ Knee flexion: 0 degrees
OBJECTIVES → Ankle dorsiflexion: 0 degrees
• Different presentations of a limping child • Initial contact to loading response: uses the muscle glute max/ hamstring
• Causes of limping in a child (concentric), quadriceps (eccentric), pretibial muscles (eccentric)
• Loading response:
• Diagnosis of the limping child → Hip flexion: 20 degrees
“Don’t worry, I’ll be giving easy questions for this module. Concentrate on this → Knee flexion: 20 degrees
module, you don’t have to read the book. (But if you try to read the book for → Ankle plantarflexion: 5 degrees
additional information, much better ☺) – Doc Holgado • Loading response to midstance: uses the glute max (concentric),
quadriceps (concentric), Gastrocnemius/soleus (eccentric)
I. LIMPING • Midstance
• Deviation from the normal pattern of gait → Hip flexion: 0 degrees
A. PHASES OF WALKING → Knee flexion: 5 degrees
→ Ankle dorsiflexion: 5 degrees
Table 1. Patient age and description of walking • Midstance to terminal stance: uses gastrocnemius/ soleus (eccentric)
Age Description of Walking • Terminal stance:
Toddlers • Wide base of support → Hip extension: 20 degrees
• Short asymmetric steps → Knee extension: 20 degrees
→ Ankle dorsiflexion: 10 degrees
• Occasional foot slapping • Terminal stance to preswing: iliopsoas/ Adductors (eccentric), slight
• Arm motion not reciprocal with the leg motion quad activity (eccentric), gastrocnemius/ soleus (concentric)
• Fall frequently • Preswing:
• Hands are used for balance and not for → Hip extension: 10 degrees
coordination → Knee extension: 40 degrees
→ Ankle plantarflexion: 15 degrees
3-5 years • Walk with more fluid and symmetric strides • Preswing to initial swing: iliopsoas/ Adductors (concentric), hamstrings
old • Reciprocal arm motion (arms are already (concentric), pretibial muscles (concentric)
swaying when the child is walking) • Initial swing
• Improved overall coordination of movement → Hip flexion: 15 degrees
→ Knee flexion: 60 degrees
7 years • Coordination pattern similar to adults → Ankle plantarflexion: 5 degrees
old • Longer stride lengths without being out of • Initial swing to midswing: iliopsoas/ Adductors (concentric), hamstrings
balance (concentric), pretibial muscles (concentric)
• Midswing:
B. GAIT CYCLE → Hip flexion: 25 degrees
→ Knee flexion: 25 degrees
→ Ankle plantarflexion: 0 degrees
• Midswing to terminal swing: Hamstrings (eccentric), quadriceps
(concentric), pretibial muscles (isometric)
• Terminal swing:
→ Hip flexion: 20 degrees
→ Knee flexion: 0 degrees
→ Ankle dorsiflexion: 0 degrees
• Terminal swing to initial contact: Hamstrings (eccentric), quadriceps
(concentric), pretibial muscles (isometric)

C. ABNORMAL PATTERNS OF GAIT

Table 2. Gait pattern and its description
Gait Pattern Pattern description
Figure 1. Gait cycle Antalgic • “Painful”
• 2 phases: • Shortened stance phase on the affected
→ Stance phase side
▪ Contact of the foot with the floor • To avoid weight to the affected leg
▪ Initial contact: initial contact of the heel to the ground Nonantalgic • “Painless”
▪ Midstance: Weight will now being carried by the whole • Trendelenburg and waddling gait are part
foot of nonaltalgic gait
▪ Terminal stance: in preparation for the swing phase • Proximal muscle weakness or hip
− Weigh is being carried on the toes instability
▪ Preswing: weight is balanced by both feet, almost • Equal stance phase in both the affected
→ Swing phase and unaffected side
▪ The leg is being swung to make another stance phase • Shifting of the center of gravity to the
▪ Initial swing: foot is released from the ground affected side to try to enhance more
▪ Midswing: major concern is that our weight on the affected side
opposite/contralateral leg is in single support with a small Trendelburg • Painless
base of support and thus stability is a concern [Silva & Stergiou, • Shifting of weight towards the affected hip
2020] during the stance phase
− Getting ready for the upcoming foot contact at the end • Reduces the force exerted on the weak
of our swing. abductors
▪ Terminal swing: upcoming foot contact [Silva & Stergiou, 2020]
• When one foot is in the stance phase the other foot is in the
swing phase
→ Alternating stance.. swing.. stance.. swing..

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 Evaluation of a Child with a Limp
• Intervertebral diskitis • Cerebral palsy
Video Transcription [Video from doc] (inflammation of the • Lower extremity
Table 3. Gait pattern, etiology, description, and common causes disks) length inequality
Gait Etiology Description Common • Malignancy
Pattern causes • Abuse
Dopamine • Shuffling gait • Not seen in
deficiency
3-10 y/o • Septic arthritis, • Developmental
and difficulty pediatric
turning around, patients
osteomyelitis, myositis dysplasia of the hip
some would • Transient synovitis • Legg-Calve-Perthes
Parkinson’s call it magnetic • Trauma Disease
gait gait as the feet • Rheumatologic • Lower extremity
are never disorders length inequality
really lifted off • Juvenile idiopathic • Neuromuscular
the ground arthritis disorder
• Early sign: arm • Intervertebral diskitis • Polio
swinging • Malignancy • Cerebral palsy
Antalgic Pain in • Short stance • Osteoarthritis • Muscular dystrophy
gait walking phase • Fractures (Duchenne)
Unstable • Pelvis tilting on • Iatrogenic
Adolescents • Septic arthritis, • Slipped capital
pelvis due to walking osteomyelitis, myositis femoral epiphyses
contralateral • Hip drop NOTE: When • Trauma (chronic, stable)
gluteal • Tilt seen in giving injections • Rheumatologic • Developmental
muscles every step in the gluteal disorder dysplasia of the hip
Trendelburg
gait
weakness muscles, target • Slipped capital femoral • Lower extremity
the superior epiphyses (acute, length inequality
lateral quadrant unstable) • Neuromuscular
of the gluteal • Malignancy disorder
muscle to avoid
this B. BASED ON MECHANISM
Unstable • Swings from • Pregnancy,
pelvis due to side to side muscular
Antalgic Gait
Waddling
bilateral (like a duck) disease Table 5. Different causes of antalgic gait
gait
gluteal muscle Type Causes
weakness
Congenital • Tarsal coalition
II. HISTORY • Legg-Calve-Perthes Disease
• Chief compliant: limping → Although it can be congenital,
Acquired
some can also be acquired
• Questions to ask:
• Slipped Capital Femoral Epiphyses
→ Can the patient bear weight on the side with pain?
→ Is there pain? • Sprains, strains, contusions
→ Pattern of limping • Fractures
→ Age of child
Trauma • Occult fractures
→ Events prior to child limping • Toddler’s fracture
→ Associated symptoms • Abuse
▪ May deal with some rheumatologic disorders that may • Unicameral bone cyst
Neoplasia (Benign)
cause limping • Osteoid osteoma
• Observe the patient while doing history • Osteogenic sarcoma
→ Try to look at the position the child is trying to assume • Ewing’s sarcoma
▪ May point on which leg may be in pain Neoplasia • Leukemia
▪ Some children would position themselves as if protecting • Neuroblastoma
the injured part • Spinal cord tumors
III. PHYSICAL EXAMINATION • Septic arthritis
• Vital signs: signs of hypotension due to bleeding in trauma • Reactive arthritis
Infectious
• HEENT: other injuries, hematomas, contusions • Osteomyelitis
• Skin: hematoma, abrasions, lacerations, rashes • Diskitis
→ Rashes may suggest systemic cause of limping • Juvenile idiopathic arthritis (JIA)
• Cardiac: pallor in case of severe bleeding, heart sounds which Rheumatologic • Hip monoarticular synovitis
could be muffled in tamponade (Transient synovitis)
• Lungs: injuries to the chest, lagging, decreased breath Trendelenburg Gait
sounds in pneumothorax Table 6. Causes of Trendelenburg gait
• GIT: hematomas, open wounds Type Causes
• GUT: injuries to the genital area Developmental • Developmental dysplasia of the hip
• Extremities and back: swelling, bleeding, hematoma, muscle • Leg-length discrepancy
symmetry, range of motion, muscle atrophy, pulses, joint
Neuromuscular • Cerebral palsy
swelling, paraspinal muscles and spinous processes
→ Given that they are not
→ Tenderness in paraspinal muscles and spinous process
paralyzed from the leg down
suggests spinal cord injury
• Poliomyelitis
• Neurologic exam: sensorium, sensory and motor problems
for CNS involvement V. DIAGNOSTICS
• In the examination of the leg injuries, manipulate the Table 7. Diagnostic modalities for children with limp
unaffected leg first Test Description
IV. DIFFERENTIAL DIAGNOSIS OF THE LIMPING CHILD • Fracture
A. BY AGE • Bone injuries
Radiologic
Table 4. Differential diagnosis by age • Periosteal reactions
(conventional x-
Age Painful causes Painless causes ray) • Neoplasms
1-3 y/o • Septic arthritis and • Developmental • Congenital and developmental
osteomyelitis dysplasia of the hip conditions
• Transient synovitis • Neuromuscular
• Occult trauma disorder • CBC
(“toddlers fracture”) • Polio Infection related
• ESR
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 Evaluation of a Child with a Limp
• CRP Table 8. Signs and symptoms of Compartment Syndrome
• Blood culture Children Adults
• Direct culture of synovial fluid • Analgesia – increased • Pain out of proportion to the
• Rheumatoid factor need for analgesics injury
Inflammatory
• ANA • Anxiety • Pain with passive stretching
markers
→ To diagnose lupus • Agitation • Paresthesias
• Assess bone abnormalities in finer • Paralysis
details • Absent peripheral pulses
CT scan • Occult fractures • Palpable swelling (tense
• Better picture of bone cysts, osteoid compartments)
osteoma, non-ossifying fibromas A. CHILD ABUSE
• Evaluates hip and joint effusion in Case of Trauma #1
septic arthritis • 2 year old male with limping
→ Can help in locating where the • Condition was noted 3 days prior when the patient tripped
needle should be punctured to on the edge of a rug causing him to fall. According to the
aspirate fluids in hip or joint witness who was the mother, he landed on his left side. He
Ultrasound
• Deep soft tissue abscesses was limping 2 days ago, but then unable to walk few hours
• Foreign bodies in the foot or knee prior to consult
→ Radiolucent foreign bodies such as • In your physical examination, you noticed bruises over the
metals can also be seen by lower back, left hip area, and both posterior upper thighs.
conventional x-ray The child refused to walk, and refused to be touched.
• Musculoskeletal infections
• Benign and malignant neoplasms
MRI • Vascular abnormalities
→ Such as avascular necrosis in
Legg-Calve-Perthes Disease
• First thing to always do is the conventional x-ray
• CT scan, MRI, and ultrasound to be done depending on
availability in your institution
→ St Luke’s has all
Most Important Causes of Limp in A Child
1. Traumatic injuries
2. Infections
3. Neoplasms
• These three are highlighted because immediate therapy is a Figure 3. X-ray of the patient. She just tripped on the rug, why is there a
must in trying to save the limb or the life of the child fracture? Why are there bruises over the lower back, left hip area, and
posterior thigh. This is a case of Child Abuse.
VI. TRAUMATIC INJURIES
• In children 5 year old and below, who have a fracture or came
• Musculoskeletal injuries
in because of a limping and you found that he has a fracture
→ Ligament sprains
on X-ray, this is one of the differential diagnosis that you really
→ Muscle strains have to rule out
→ Contusions • When will you consider child abuse?
→ Fractures → Mechanism of injury does not correlate with the history
• In cases of trauma, these diagnoses should not be missed ▪ The patient just tripped but bruises are everywhere.
→ Neurovascular compromise → Injury does not correlate with the age of the child
▪ Diminished blood flow ▪ A child that is not yet walking but he has an injury in the
− No pulse ankle
− Bluish discoloration of the skin → Lower extremity fracture in a child not yet ambulating
− Pale skin → Metaphyseal corner fractures, epiphyseal separation,
→ Open fractures multiple fractures in different stages of healing.
▪ Skin integrity is violated ▪ To look for multiple fractures in different stages of
▪ Underlying bone is exposed healing: do an X-ray of the whole body (from the head,
▪ Infections may spread to the tissue arms, chest, and legs) in order to look out for those
→ Impending compartment syndrome different fractures.
▪ Swelling or bleeding into muscle compartments creating • Management of the patient
enough pressure to inhibit adequate blood supply into or → Casting if the fracture would not be able to heal, then you
out of the compartments would have to do surgical operation
Compartment Syndrome → You would have to report to the nearest VAWC center
(Center of Violence Against Women and Children) and the
parents have to be reported.

B. TODDLER’S FRACTURES
Case of Trauma #2
• 3 year old male, suddenly noted to be limping. The mother
recalled an incident where the child was sitting on the floor
crying, holding his left leg, so she presumed he fell. Initial
consult was done where x-ray of the leg was normal. He
Figure 2. Compartment syndrome. Red color are the inflamed muscles was prescribed with Ibuprofen. However, 10 days later, he
exerting pressure to the limb was still limping
• Severe and progressive pain due to elevated myofascial • No swell over the leg. No other injuries. The child us able to
pressures walk, though limping with pain
• There are muscle and nerve damage and loss of limb
• The extremity is opened up to release the pressure

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 Evaluation of a Child with a Limp
• Antibiotic coverage
• Surgical drainage and debridement
→ Removal of the foreign body should be done in order for the
patient to ambulate again.
VII. INFECTIONS
• Musculoskeletal infections:
▪ Local cellulitis
▪ Fasciitis
▪ Myositis
▪ Septic Arthritis
▪ Osteomyelitis
▪ Soft tissue infections
A. PYOMYOSITIS
Figure 4. X-ray of the patient. The red arrows are area of fractures Case of Infection #1
• A 5 year old female, limping for 5 days
• Usually involve the tibia
• She has been diagnosed with acute lymphocytic leukemia
• Spiral or oblique fracture
at 2 years of age, with compliance to chemotherapy
• Sometimes the initial radiograph is negative, and discovered regimens. 5 days prior, she was noted to have fever, with
10-14 days after the healing process has begun pain over the left thigh causing her to limp. Paracetamol was
→ Initially very minute until the time that more weight is put on given. 3 days prior, a mass was palpated at the upper lateral
it because of the child’s activity and it is already starting to area of her left thigh which was tender. 2 days prior redness
heal, so after 10-14 days, fracture can be seen developed over the area. A few hours prior, the child was
• Heal properly with a cast unable to tolerate the pain.
→ Some doctors will not cast these patients because they will • There was asymmetry over both thighs, the left being larger
heal spontaneously but some will prefer to put a cast in circumference than the right. You were able to palpate
→ This patient was fixed in a cast for 4 weeks and it healed the mass, about 8x5cm with erythema and warmth over the
properly. area. No other injuries were noted.
→ Prognosis is good
→ There were no injuries on other parts of the body, so the
case is most likely not due to abuse

Figure 7. (Left) A soft tissue swelling surrounding the bone. One area is
whiter than the other. You have something that is kind of suspicious in the
soft tissue area, what will you now do in a patient with fever? If your
institution can do an MRI, then an MRI has to be done. (Right) White
findings are suggestive of pyomyositis
Figure 5. Left: Toddler’s Fracture (spiral and oblique); Right: Greenstick • Infection of the muscular layer
Fracture (straight but it is still not fully broken into). → Wherein it can already be an abscess formation
C. FOREIGN BODY • Direct inoculation of the bacterial through a break in the skin
Case of Trauma #3 • Hematogenous bacterial spread
• 10 year old female with limping. She rushed out of their → Patient has ALL so she is immunocompromised
house forgetting to wear her slippers to catch their dog. She • Surgical drainage
stepped on something which caused pain over the sole of • Antibiotic therapy
her right foot. There was no bleeding, but she cleaned the • Prognosis is good but you have to be on your guard in
area with soap and water, and alcohol daily. The next day immunocompromised patients
she still felt the pain for which she took paracetamol. For 7
days there was note in increase of the intensity of pain, B. SEPTIC ARTHRITIS
causing her to limp. In the morning of the consult, there was • Diagnosis should not be missed
already redness over the area with tenderness making her • Damage to the hip cartilage and the blood supply to the femoral
walk tiptoeing. head begins within 6-12 hours of infection onset and may be
• The patient had no ankle swelling, but there was note of irreversible after 1-2 days
redness over the sole area which was markedly swollen • Diagnosis of septic arthritis is harder in the hip area because it
over the right compared to the left is much deeper.
• Kocher criteria for septic arthritis of the hip
→ Temperature >101.3°F (38.5°C)
→ White blood cell count >12,000/μL (12x10 9 /L)
→ Erythrocyte sedimentation rate >40 mm/h
→ Inability to ambulate
→ C reactive protein >2.5 mg/L (23.81 nmol/L)
▪ C reactive protein added by Caird et al; not part of the
original Kocher criteria
Figure 6. The patient stepped on a needle 10 days prior to consult causing
the pain and infection. • Differentiated from Transient Synovitis
→ Self-limited virus-related synovitis
• May appear as no injury has occurred → Viral infection (chickenpox, dengue) and after that you
→ In the case of the patient, only a needle so there is no developed pain in the hip area : Transient Synovitis
bleeding. Na-puncture lang siya. → Will not fulfill the Kocher criteria
• Consequences
→ Plantar cellulitis
→ Draining wound
→ Induration with underlying fluid collection

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 Evaluation of a Child with a Limp
C. OSTEOMYELITIS • Signs and symptoms depend on the age of the child
Case of Infection #2 → Neonates: pseudoparalysis or pain on movement (e.g.
• 8 year old male, with limping diaper change); some may not appear ill, and half may not
• Patient’s condition started 2 years prior when he developed have fever.
a wound from an accident over his right small toe. It healed → Older infants and children: pain, fever, and localizing
with home remedies of Betadine solution, but upon healing signs like edema, erythema, and warmth
it always felt itchy and the patient would scratch it, become → Limp or refusal to walk in ambulatory children
infected again. • Long bones are commonly involved.
• The toe’s swelling and redness over the skin never changed → Fibula, radius, ischium – 4%
throughout. → Phalanges, calcaneus – 5%
• The cycle of infection → healing → itching → infection, → Humerus – 13%
persisted, until day of consult. Now the patient had fever for → Tibia – 24%
5 days already and a draining wound over the right small → Femur – 25%
toe. Diagnosis
• There was erythema on the overlying skin. There was an • Diagnosis starts with clinical suspicion
open wound, draining pus over the right small toe.
• No specific laboratory tests
→ Elevated WBC count
→ Elevated ESR
→ Elevated CRP
→ Along with fever, pain, limping, induration, and swelling
▪ Consider Osteomyelitis already
→ Even if nonspecific, you should still do it
• CRP monitoring
→ May be used to assess response to therapy
Figure 8. X-ray of the foot. Compared with the other bones and joints, this • Blood culture, bone biopsy, culture of subperiosteal abscess
is lytic. parang natutunaw → Diagnostic
• Bone infection • PCR for Kingella kingae
• Early recognition is important for immediate management • X-ray
• Great risk if the growth plate is damaged → Within 72 hours → deep tissue edema, displacement of the
• May throw specific emboli and cause mortality deep muscle planes
→ To the Lungs, brain, heart → Lytic bone changes (refer to Fig. 8)
• How does it occur? ▪ Appear if 30-50% of bone matrix is destroyed
▪ Occur after 7-14 days
− If you’re dealing with a flat bone, it would take much
longer
• MRI
→ More sensitive than CT scan
→ Provides precise anatomic detail of subperiosteal pus and
accumulation of purulent debris in the bone marrow and
metaphyses
→ A CT scan is done if MRI is not available

Figure 9. Cross-section of a bone. It has vascularities in between its tissues. If

there is hematogenous spread, the infecting organisms would now try to reach
the medullary canal via these different vessels. When it reaches the medullary
canal, pus will be filling around the medulla, causing the bone to lyse. New
bone will definitely be formed still but then there is already an area of lysis.

Figure 10. Area where the pus and debris are.

• Brodie Abscess
→ An abscess in the bone but the patient does not have that
much symptoms
→ Subacute symptoms
→ Focal findings in the metaphyseal area (tibia)
→ Contents are usually sterile

Figure 10. Microorganisms isolated from patients with osteomyelitis and their
clinical associations.
• Most frequently it is caused by S. Aureus – whether it be the
susceptible one or the one resistant to methicillin
• For patients younger than 4 years old, think of another bacteria
(Kingella Kingae)
• Early signs may be subtle or nonspecific
Figure 11. Brodie abscess

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 Evaluation of a Child with a Limp
Management
• Rapid improvement in signs and symptoms with surgical
debridement and antibiotic therapy
• Antimicrobial management
Table 9. Antimicrobial management
Agent Antibiotic
Staphylococcus Oxacillin
Cefazolin for methicillin susceptible
MRSA Vancomycin or Clindamycin
To include Gram Cefepime
negative bacilli
Figure 12. Imaging of Case #1. Left: Xray. Red arrow shows the medullar
Kingella kingae Cefazolin part of your bone. You might see something white covering the medulla. It
→ Duration looks sclerotic or fibrotic. If you cannot see it on x-ray, consider another
▪ If responsive, 21-28 days imaging modality. Do CT scan to detect bone problems. (if soft tissue
▪ If not, 4-6 weeks problem, MRI is better). Right: CT Scan. A different area, but just try to
imagine that it is the same area. CT scan will show a hole. This is a cyst
→ Monitoring through the use of CRP with area of sclerosis.
→ At the back of your mind, the most common bacteria is
staphylococcus. • Benign tumor
▪ So even before getting the cultures, you can start already • Epidemiology
with oxacillin and cefazolin already while waiting for the → Most common in 5-20 years of age
cultures to come → Male > female
▪ Failure to respond within 48-72 hours → right antibiotic? • Clinical Manifestations
(Wala ka pang result ang culture) → Limp, atrophy or weakness of the involved extremity
− Culture usually take 5-7 days → Pain is worse during activity, and also at night
− If after 48-72 hours patient is still febrile, better change • Imaging
the antibiotic (e.g. from staphylococcus to MRSA- give
→ X-ray would show usually cortical thickening
vancomycin instead)
→ CT scan shows the nidus
▪ Try to check also for ESR
• Management
− It can also give you a sign if the patient is improving
or not → Since the nidus is causing pain, it has to be removed
▪ via Percutaneous radiofrequency ablation, cryoablation
− Technically, even if you’re just starting therapy, it will
still rise slowly within 5-7days, but with the response → Open surgical resection, if the lesion is close to articular
to your antibiotic, it will drop sharply after 10-14 days cartilages or neovascular structures, to prevent further
▪ CRP titer trauma to other surrounding structures
− Decreases below 2 mg/dL within 7-10 days after
starting treatment
− By the time that CRP decreased, you already have the
results of your culture
o If CRP still did not decrease by the 7th day, culture
is already in, you have to change.
• Surgical therapy
→ Frank pus obtained from subperiosteal or metaphyseal
aspiration
→ Removal of foreign body
• Physical therapy Figure 13. Left: Conventional radiograph of patient with osteoid osteoma
You may be able to visualize the cyst itself, which is the nidus
→ Preventive
→ Casting or immobilization if at risk for fracture B. OSTEOSARCOMA
→ Prevention of flexion contractures Case of Neoplasm #2
VIII. NEOPLASMS • 12 year-old female seen due to limping and swelling of the
left lower leg
• Pain, worst at night
• About 2 months prior, a dictionary the size of Nelson’s
→ Hallmark of many musculoskeletal
Textbook in Pediatrics accidentally fell on her thigh, above
• Insidious pain with activity
the knee. This was followed by tolerable pain with
• Visible, and palpable masses tenderness, relieved with mefenamic acid. After this event,
A. OSTEOID OSTEOMA she started walking with a limp
Case of Neoplasm #1 • 2 weeks prior, she felt a hard mass over the area, still with
• 15 year old female with limping tenderness. Her limping persisted.
• One year prior, she complained of on and off pain over the • There was gradual enlargement of the mass with the pain
right lower leg usually at night. There was no palpable mass, now also waking her up at night and no longer relieved by
no history of trauma. analgesics.
• The pain was worse when she was exercise activity at home • The left thigh is larger in circumference compared to the
and was relieved by intake of Mefenamic acid 250mg as right. There was a hard, palpable mass over the anterior
needed for pain, part, about 12 x 8 cm, with tenderness over the area. There
was no change in the color of the overlying skin. No
• The pain was initially tolerable, however, she noted it to be
hematoma formation.
more steady and increase in its intensity from 5/10 to 9/10
• Radiography was performed with the following results
• There was no visible or palpable mass over the right leg. No
change in the color of the skin.
• Muscle testing showed that the motor strength of the right
leg was 3/5 with ankle dorsiflexion

Figure 14. X-ray results of mass, showing sunburst pattern

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 Evaluation of a Child with a Limp
• Most common bone sarcoma • Radiosensitive tumor
• Highest risk for development is during the adolescent growth → Risk of radiation-induced secondary malignancies
spurt ▪ If you give a patient with Ewing’s sarcoma a shot of
→ Association between rapid bone growth and malignant radiotherapy, the patient may develop osteosarcoma
transformation → Failure of bone growth in skeletally immature patients
• Sunburst pattern on x-ray • Prognosis
• May occur alone or together with other syndromes → Small and non-metastatic → 75% cure rate
→ Hereditary retinoblastoma → Worst outcome for pelvic tumors
→ Li-Fraumeni Syndrome → Bone and bone marrow metastasis on diagnosis → < 30%
→ Rothmund-Thomson Syndrome survival
• Four pathologic subtypes of high-grade osteosarcoma D. OTHER MALIGNANCIES THAT MAY CAUSE LIMPING
→ With regards to prognosis, technically all are the same. But • Leukemia and lymphoma
according to them, chondroblastic osteosarcoma carries • Bone metastases
a poorer prognosis • Soft tissue sarcomas of the leg
→ Osteoblastic • That’s why if your patient is limping, your x-ray is very
→ Fibroblastic important to rule out bone involvement
→ Chondroblastic → If findings are clear, you will now use CT scan or MRI
→ Telangiectatic
IV. DEVELOPMENTAL CAUSES
• Diagnostic Work-up
• Three most common hip conditions in children and
→ MRI
adolescents causing limping
▪ Evaluate proximity of the mass to vessels and nerves
▪ MRI is helpful since we’re dealing with a tumor and trying → Developmental dysplasia of the hip
to evaluate soft tissue structures → Slipped capital femoral epiphyses
→ Chest CT Scan → Legg-Calve-Perthes Disease
▪ Check for lung metastases A. DEVELOPMENTAL HIP DYSPLASIA
→ Radionuclide bone scanning • Abnormality in the formation (dysplasia) of the acetabulum and
▪ Check for bone metastases in other bones femoral head
→ PET
▪ Check for overall metastasis
• Management
→ Limb salvage surgery
▪ Curative for low parosteal osteosarcoma
▪ If the limb cannot be salvaged, we have to take it out
→ Chemotherapy
→ Lung metastases may be cured by excision of nodules, but
it is a very risky procedure
• Extremely poor prognosis
→ Widespread lung and bone metastases Figure 16. Normal hip joint vs. Dysplastic Hip Joint. Look at the size of the
→ While it is quite ironic, even if it is a bone tumor, it can also acetabulum. For the dysplastic hip joint, the size of both the acetabulum
and femoral head is smaller, resulting in hip instability, dislocation and
metastasize to other bone areas painless limp
C. EWING’S SARCOMA • Manifestations
• Involves extremities and central axis → Hip instability
→ Central axis → Dislocation
▪ Pelvis → Painless limp (nonantalgic gait)
▪ Spine → Leg-length discrepancy
▪ Chest wall (Askin tumor) ▪ Leg on the side of the hip dislocation appears 1-3 cm
• Manifestations shorter
→ Pain and swelling, limitation on motion, tenderness → Activity-related hip pain
→ Respiratory distress, if the mass is located at the chest wall → Trendelenburg gait
→ Cord compression, if the mass is located in the spine ▪ Wide-based waddling gait pattern
→ Often associated with systemic symptoms ▪ Non-antalgic gait
▪ Fever → Hop over the longer normal leg, and walk on his toes on the
▪ Weight loss affected leg
▪ Elevated inflammatory markers • Diagnosis
• Imaging Findings → Since this is developmental dysplasia, they may already be
→ X-ray: onion-skinning diagnosed during the neonatal period using Ortolani and
Barlow’s examination, which have to be done together
→ Barlow maneuver: done to see if you can actually displace
the hip joint
→ Ortolani maneuver: done to bring it back
→ These maneuvers are easily done in the neonate because
you can feel the hip joint at that time
How to Test for Newborn Hip Dysplasia (Video)
(https://www.youtube.com/watch?v=Qy3uSkDhMZs)
Hip Dysplasia
• Congenital deformation or misalignment of the hip joint
Figure 15. Radiograph of patient with Ewing’s sarcoma with characteristic • More common in infants if:
onion skinning due to periosteal elevation because of the mass → Family history of hip dysplasia
(Parang umangat yung periosteum of the bone – parang numipis and there is → Female
a mass underneath)
→ Breech presentation in utero
• Management Barlow Maneuver
→ Limb salvage surgery: curative in some cases 1. Adduct the hip by bringing the thigh toward the midline
→ Chemotherapy 2. Apply a gentle posterior pressure to the knee

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 Evaluation of a Child with a Limp
C. LEGG-CALVE-PERTHES (LCP) DISEASE
• Idiopathic avascular necrosis of the femoral head
→ No other reason that may cause the avascular necrosis
• Epidemiology
→ 2-12 years old, commonly between 6-8 years
→ Male > female
Figure 17. Barlow Maneuver • Manifestations
Ortolani Maneuver → Painful limp
1. Flex the infant’s knees to a 90 degree position → Limited hip motion
2. Abduct the knees by folding the thigh outwards • Can produce premature osteoarthritis of the hip
• Management
→ Anti-inflammatory medications
▪ Given most of the time due to the pain
→ Protected weight-bearing physical therapy
→ Limited activities

Figure 18. Ortolani Maneuver

TG Note: Barlow: adduction (BAdduction), Ortolani: abduction

B. SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)
• Abnormality of the physis
→ Structurally weakened leading to displacement or slipping
• Conditions that may present with SCFE
→ Hypothyroidism
→ Renal osteodystrophy
• Excessive or abnormal mechanical stresses can also cause
SCFE
→ Exacerbates the weakness that is already present Figure 21. X-ray of Legg-Calves-Perthes Disease
congenitally If you try to compare both of the hips in this patient, the femoral head on the
• Epidemiology encircled area is slowly disappearing.
→ Usually found in 10-14 years old X. OVERUSE INJURIES
→ Obese A. OSGOOD SCHLATTER DISEASE
→ Males > females
• Stable SCFE Case of Overuse Injuries #1
→ Good prognosis for long-term hip function • 10 year old male, with limping
→ Non-antalgic gait • Happened pre-pandemic
• Unstable SCFE • Patient’s condition started 2 months prior to consult, where
he noted right knee pain which occurred upon coming home
→ May lead to severe avascular necrosis, and more problems
from school. There was no joint swelling, no fever. Pain was
for the patient
on-and-off and tolerable (3/10). I advised Paracetamol as
→ Antalgic; in 10%, the type of pain is simulating hip fracture
need for the pain.
• In the interim, pain continued to be on-and-off. Then 2
weeks prior, the patient noted increase in intensity of the
pain at 8/10, still on-and-off, occurring more at home and
when at rest. Paracetamol was continued, affording slight
relief, so I advised mefenamic acid as needed and advised
them for consult.
• They came after 2 weeks. The patient was limping in the
clinic with pain over the right knee.
• The child is a basketball varsity player in school and
Figure 19. Stable SCFE: with minimal dislocation in physeal site
Unstable: with dislocation at physeal site
practices for 4 hours, 3x a week. Then he was enrolled in
taekwondo, which lasts for 2 hours per session, 3x a week.
• Hallmark: limitation of the internal rotation of the affected hip Apart from this were the practice sessions for basketball
• Imaging and taekwondo that he does at home.
→ X-ray • There was no swelling, but there was tenderness over the
▪ Anteroposterior view of the pelvis right knee. There was full range of motion. There were no
▪ Frog lateral view of the hips rashes, or abnormal heart sounds (to rule out rheumatic
fever)

Figure 20. Anteroposterior view of the pelvis showing separation from the
physis
• Management Figure 22. Left: X-ray findings of patient. Right: Normal x-ray of the knee
→ Surgical correction for both stable and unstable SCFE The tibial tubercle of the patient is uplifted from the bone (arrow)

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 Evaluation of a Child with a Limp
• Epidemiology • Epidemiology
→ 9-14 years old → 7-9 years old
→ Male > female • Manifestations
• Manifestations → Limp with toe walking due to heel pain, which worsens with
→ Slight limp activity
→ Pain worsening with activity → Painful ankle dorsiflexion
→ Tnderness or swelling of tibial tubercle → Tender heel points on PE
→ Tenderness to palpation

Figure 26. Sever’s Disease

Achilles tendon is trying to pull the calcaneal tubercle upwards, causing friction
and pain when walking.
• Imaging
Figure 23. Tibial tubercle swelling. The pain would happen because the tibial
tubercle is where the patellar tendon is attached. With every movement of the
gastrocnemius muscle and when it contracts, it would pull up the patellar
tendon including your tibial tubercle.

• Diagnosis
→ X-ray
▪ Shows lifting of tibial tubercle (see figure from case)
• Management
→ Ice to area after activities
→ Anti-inflammatory medications
Figure 27. Left: Normal x-ray findings of the foot in a child. Right: X-ray of
→ Restriction of activities (let the leg rest) patients with Sever’s Disease. You can see dysregularity of growth plate,
→ PT for stretching the muscle and strengthening the tendon fissures and a more sclerotic bone for calcaneal area
→ Surgical repair is very rare • Management
▪ Done via uniting the tibial tubercle to the tibia → Limit workouts on hard surfaces
• Prognosis → Symptomatic relief, with ice and anti-inflammatory
→ Spontaneous resolution in 1-2 years, for most cases medications
→ Some resolve after closure of the growth plate at 14-15 → Rest
years old, when the growth plate closes and the area is XI. POINTS TO REMEMBER
ossified • Infectious processes, trauma, and neoplastic processes
▪ Between 14-15 years old resolution once the tibial have to be considered and ruled out in the child with a limp.
tubercle will close
→ Early institution of treatment is necessary for limb salvage.
→ May leave a nontender bony prominence over the knee at
• Take note of the differential diagnoses per age of a limping
adulthood
child. Infectious processes such as septic arthritis and
osteomyelitis are considered in all age groups, who present
with signs and symptoms as such.
• Developmental bone conditions may appear as nonpainful
initially, but may become painful as the disease progresses.
• In cases wherein infections are entertained:
→ Start with the empiric antibiotic therapy needed for
infectious conditions while awaiting for the culture results if
they need to be changed.
Figure 24. Immature vs. Mature Bone. In the immature bone, you can see the → The CRP is a good monitoring tool to evaluate the
growth plate, compared to the mature bone where the growth plate is just a effectiveness of your therapy. The need to change the
line. Thus, for immature bones, you are still able to pull up the tibial tubercle in antibiotic may be explained by:
cases of injury.
▪ Non-improvement in symptoms within 48-72 hours
▪ Increasing or non-decreasing CRP and ESR titer within
7 days
• Pre-adolescents or adolescents may have overuse injuries
which are not serious conditions. These resolve spontaneously
with rest
• Though the child with limping problems initially come to the
general pediatrician for consultation, do not forget to involve
the orthopedic subspecialty if necessary (which is almost
always necessary)
Figure 25. Left: Calcification of Tibial Tuberosity. When healing occurs,
especially if the growth plates will fuse, the tibial tuberosity will know be Then Peter said, “Silver and gold I do not have, but what
calcified. Right: Non-union, resulting to persistence of pain. However, there I do have I give you: In the name of Jesus Christ of
are instances wherein the tibial tuberosity does not calcify and is still replaced Nazareth, rise up and walk.”
by cartilage, resulting to a non-union of the tibial tuberosity with that of the
tibia. This results in non-resolution of Osgood Schlatter Disease and Acts 3:6
persistence of pain.
When you are dealing now with your patients, especially
B. SEVER DISEASE when you get to the clinics, do not forget to pray for
• Apophysitis of the calcaneal tubercle them, and do not forget always, to think that miracles do
→ Basically the same mechanism of Osgood Schlatter still happen. - Doc Holgado
involving growth plate in the calcaneus
TG Note: Osgood-Schlatter: knee; Sever: foot

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 Evaluation of a Child with a Limp

REFERENCES d. Rhesus
Doc Holgado’s video 2. What do you call the phase of the gait cycle where the
leg just started lifting off the ground?
NEO-LMS QUIZ a. Preswing
1. A 2 year-old who just started to walk started to have a b. Terminal stance
painful limp after falling from bed. Physical exam showed c. Terminal swing
multiple bruises over the chest, back, buttocks and d. Initial swing
thighs. The x-ray showed a fracture over the right femur 3. Which of the following is not a painless gait
and right tibia. What would be your suspicion in this a. Waddling
case? b. Nonantalgic
a. Osgood-Schlatter Disease c. Parkinson’s gait
b. Osteomyelitis d. Antalgic
c. Child Abuse 4. A 3 year old male fell and was seen sitting on the floor,
d. Toddler’s fracture crying and holding his left leg. Which of the following
2. The sunburst pattern on x-ray is diagnostic of: are correct about this patient?
a. Osteoid osteoma a. This usually involve the fibula
b. Ewing’s sarcoma b. Most likely a spiral fracture
c. Osteosarcoma c. Most likely a straight fracture
d. Osteomyelitis d. A and B
3. What long bone is most commonly affected in e. A and C
osteomyelitis? 5. The following statements regarding septic arthritis are
a. Tibia true EXCEPT
b. Humerus a. Damage to the hip cartilage and the blood supply to the
c. Ischium femoral head begins within 6-12 hours of infection onset
d. Femur b. Damage may be irreversible after 24-48 hours
4. Fractures in children present with what type of gait? c. It is related to self-limited viruses
a. Trendelenburg d. Temperature, WBC count, ESR and CRP are included in
b. Waddling the kocher criteria
c. Non-antalgic 6. A 9 y/o female was limping and on history taking, she
d. Antalgic reported a cyclic history of infection, healing, itching,
5. The following cause of a painful limp can be observed in and infection again 1 year prior. What can you tell your
all age groups: patient about her disease?
a. Slipped capital femoral epiphysis (stable) a. The most common cause is S. Aureus but you will have to
b. Septic arthritis wait for the culture result to start treatment
c. Rheumatologic disorders b. Medical treatment is given for 4-6 weeks if the patient is
d. Developmental dysplasia of the hip responsive
6. An 8-year-old male came in due to a painful limp after c. Physical therapy is not needed
falling from his bicycle. The x-ray showed a fracture over d. If she does not respond to the antibiotic after 3 days, you
the left distal tibia. In cases of trauma, what important will stop treatment and wait for the culture result
condition among the choices will you look out for? e. None of the above
a. Compartment syndrome 7. Which of the following imaging findings is incorrectly
b. Development of a neoplasm matched?
c. Ability to bear weight a. Osteoid osteoma: cortical thickening on x-ray
d. Closure of the growth plate b. Osgood-Schlatter Disease: uplifting of tibial tubercle
7. The following condition may present with a c. Sever Disease: disintegrating femoral head
Trendelenburg gait: d. Ewing’s sarcoma: onion-skinning
a. Septic arthritis 8. This condition is characterized by abnormality of the
b. Developmental dysplasia of the hip epiphysis, making it prone to displacement or slipping.
c. Osteosarcoma Patients often present with hypothyroidism, and have a
d. Sever disease non-antalgic gait.
8. The organism frequently isolated in osteomyelitis: a. Stable Slipped Capital Femoral Epiphysis
a. Burkholderia cepacia b. Unstable Slipped Capital Femoral Epiphysis
b. Staphylococcus aureus c. Legg-Calve-Perthes Disease
c. Enterobacter cloacae d. Developmental Hip Dysplasia
d. Pseudomonas aeruginosa 9. Patient presented with painful ankle dorsiflexion, toe
9. The finding of onion skinning in a limb on x-ray is walking, and tender heel points on PE due to this
diagnostic of: condition characterized by apophysitis of the calcaneal
a. Osteosarcoma tubercle.
b. Ewing’s sarcoma a. Osgood-Schlatter Disease
c. Osteoid osteoma b. Sever Disease
d. Osteomyelitis c. Osteosarcoma
10. The diagnostic modality to look for a fracture d. Unstable SCFE
a. Ultrasound 10. In cases of infections, this is a good monitoring tool to
b. MRI monitor effectiveness of empiric antibiotic therapy.
c. X-ray a. X-ray
d. CT scan b. Hematocrit
c. WBC count
ANSWERS:
1. C p. 3, IV-A 6. A p. 3, VI d. CRP
2. C p. 7, VIII-B 7. B p. 2, IV-B
3. D p. 5, VII-C 8. B p. 5, VII-C ANSWERS:
4. D p. 2, I-C 9. B p.7, VIII 1. B p. 3, V 6. E p. 5, VII-C
5. B p. 9, XI 10. C p. 2, V 2. D p. 1, I-B 7. C p. 8, IX-A
3. D p. 1, I-C 8. A p. 9 X-B
REVIEW QUESTIONS 4. B p. 4, VI-B 9. B p. 9, X-B
5. C p. 5, VII-B 10. D p. 9, XI
1. Which of these is an inflammatory marker used to look
for the cause of limping
a. WBC per HPF
b. ANA
c. Growth factor

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Evaluation of a Child with a Limp
SUMMARY
DEFINITION
A. PHASES OF WALKING
Age Description of walking
Toddlers • Wide base of support
• Short asymmetric steps
• Occasional foot slapping
• Arm motion not reciprocal with the leg motion
• Fall frequently
Hands are used for balance and not for coordination
3-5 years old • Walk with more fluid and symmetric strides,
• Reciprocal arm motion
Improved overall coordination of movement
7 years old coordination pattern similar to adults, longer stride lengths
B. GAIT CYCLE

Figure 1. Gait cycle

• Technically, there are only 2 phases:

→ Stance phase
▪ Contact of the foot with the floor
▪ Initial contact: initial contact of the heel to the ground
▪ Midstance: Weight will now being carried by the whole foot
▪ Terminal stance: in preparation for the swing phase
− Weigh is being carried on the toes
▪ Preswing: weight is balanced by both feet, almost
→ Swing phase
▪ The leg is being swung to make another stance phase
▪ Initial swing: foot is released from the ground
→ When one foot is in the stance phase the other foot is in the swing phase
C. ABNORMAL PATTERNS OF GAIT
Gait Pattern Pattern description
Antalgic • “Painful”
• Shortened stance phase on the affected side
• To avoid weight to the affected leg
Nonantalgic • “Painless”
• Trendelenburg and waddling gait are part of nonaltalgic gait
• Proximal muscle weakness or hip instability
• Equal stance phase in both the affected and unaffected side
• Shifting of the center of gravity to the affected side
Trendelburg • Painless
• Shifting of weight towards the affected hip during the stance phase
• Reduces the force exerted on the weak abductors
• Unstable pelvis due to contralateral gluteal muscles weakness
• Tilt seen in every step
• Common cause: iatrogenic
Waddling • Unstable pelvis due to bilateral gluteal muscle weakness
• Swings from side to side
• Common causes: Pregnancy, muscular disease
II. HISTORY
• Chief compliant: limping → Age of child
• Questions to ask: → Events prior to child limping
→ Can the patient bear weight on the side with pain? → Associated symptoms
→ Is there pain? • Observe the patient while doing history
→ Pattern of limping
III. PHYSICAL EXAMINATION
• Vital signs: signs of hypotension due to • Cardiac: pallor in case of severe • Extremities and back: swelling, bleeding,
bleeding in trauma bleeding, heart sounds which could be hematoma, muscle symmetry, range of
• HEENT: other injuries, hematomas, muffled in tamponade motion, muscle atrophy, pulses, joint
contusions • Lungs: injuries to the chest, lagging, swelling, paraspinal muscles and
• Skin: hematoma, abrasions, lacerations, decreased breath sounds in spinous processes
rashes pneumothorax
• Git: hematomas, open wounds
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Evaluation of a Child with a Limp
→ Rashes may suggest systemic cause • Gut: injuries to the genital area → Tenderness in paraspinal muscles
of limping • Neurologic exam: sensorium, sensory and spinous process suggests spinal
and motor problems for CNS cord injury
involvement • In the examination of the leg injuries,
manipulate the unaffected leg first
DIFFERENTIAL DIAGNOSIS OF THE LIMPING CHILD
A. BY AGE
Age Painful causes Painless causes
1-3 y/o • Septic arthritis and osteomyelitis • Developmental dysplasia of the hip
• Transient synovitis • Neuromuscular disorder
• Occult trauma (“toddlers fracture”) • Polio
• Intervertebral diskitis (inflammation of the disks) • Cerebral palsy
• Malignancy • Lower extremity length inequality
• Abuse
3-10 y/o • Septic arthritis, osteomyelitis, myositis • Developmental dysplasia of the hip
• Transient synovitis • Legg-Calve-Perthes Disease
• Trauma • Lower extremity length inequality
• Rheumatologic disorders • Neuromuscular disorder
• Juvenile idiopathic arthritis • Polio
• Intervertebral diskitis • Cerebral palsy
• Malignancy • Muscular dystrophy (duchenne)
Adolescents • Neuromuscular disorder • Slipped capital femoral epiphyses (chronic, stable)
• Trauma • Developmental dysplasia of the hip
• Rheumatologic disorder • Lower extremity length inequality
• Slipped capital femoral epiphyses (acute, • Neuromuscular disorder
unstable)
• Malignancy
B. BASED ON MECHANISM
Type Causes Type Causes
• Tarsal coalition • Osteogenic sarcoma
• Ewing’s sarcoma
Congenital Neoplasia • Leukemia
• Neuroblastoma
• Spinal cord tumors
• Legg-Calve-Perthes Disease • Septic arthritis
→ Although it can be • Reactive arthritis
Antalgic Gait congenital, some can also • Osteomyelitis
Acquired Infectious
be acquired • Diskitis
• Slipped Capital
• Femoral Epiphyses
• Sprains, strains, contusions • Juvenile idiopathic arthritis
• Fractures (JIA)
Trauma • Occult fractures Rheumatologic • Hip monoarticular synovitis
• Toddler’s fracture (Transient synovitis)
• Abuse
Trendelenburg Developmental • Developmental dysplasia of Neuromuscular • Cerebral palsy
the hip • Poliomyelitis
• Leg-length discrepancy
V. DIAGNOSTICS
• First thing to always do is the conventional x-ray
• CT scan, MRI, and ultrasound to be done depending on availability in your institution
V. MOST IMPORTANT CAUSES OF LIMP IN A CHILD
1. Traumatic injuries A. TRAUMATIC INJURIES Compartment syndrome
2. Infections • Musculoskeletal injuries • Severe and progressive pain due to elevated
3. Neoplasms • In cases of trauma, these diagnoses should not myofascial pressures
be missed • There are muscle and nerve damage and loss of
→ Neurovascular compromise limb
▪ Diminished blood flow • The extremity is opened up to release the pressure
− No pulse • Symptoms include
− Bluish discoloration of the skin • Analgesia – increased need
− Pale skin • Anxiety
→ Open fractures • Agitation
▪ Skin integrity is violated
▪ Underlying bone is exposed
▪ Infections may spread to the tissue
→ Impending compartment syndrome
▪ Swelling or bleeding into muscle
compartments creating enough pressure to
inhibit adequate blood supply into or out of
the compartments
Child Abuse • In children 5 year old and below, who have a fracture or came in because of a limping and you found that he
has a fracture on X-ray, this is one of the differential diagnosis that you really have to rule out
• When will you consider child abuse?
→ Mechanism of injury does not correlate with the history
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Evaluation of a Child with a Limp
→ Injury does not correlate with the age of the child
→ Lower extremity fracture in a child not yet ambulating
→ Metaphyseal corner fractures, epiphyseal separation, multiple fractures in different stages of healing.
• Management of the patient
→ Casting if the fracture would not be able to heal, then you would have to do surgical operation
Toddler’s Fracture • Usually involve the tibia
• Spiral or oblique fracture
• Sometimes the initial radiograph is negative, and discovered 10-14 days after the healing process has
begun
→ Initially very minute until the time that more weight is put on it because of the child’s activity and it is
already starting to heal, so after 10-14 days, fracture can be seen
• Heal properly with a cast
Foreign body • May appear as no injury has occurred
• In the case of the patient, only a needle so there is no bleeding. Na-puncture lang siya.
• Consequences
→ Plantar cellulitis
→ Draining wound
→ Induration with underlying fluid collection
• Antibiotic coverage
• Surgical drainage and debridement
B. INFECTIONS
• Musculoskeletal infections:
▪ Local cellulitis
▪ Fasciitis
▪ Myositis
▪ Septic Arthritis
▪ Osteomyelitis
▪ Soft tissue infections
Pyomyositis • Infection of the muscular layer
• Direct inoculation of the bacterial through a break in the skin
• Hematogenous bacterial spread
• Surgical drainage
• Antibiotic therapy
Septic Arthritis • Diagnosis should not be missed
• Damage to the hip cartilage and the blood supply to the femoral head begins within 6-12 hours of infection
onset and may be irreversible after 1-2 days.
• Kocher criteria for septic arthritis of the hip
→ Temperature >101.3°F (38.5°C)
→ White blood cell count > 12,000/μL (12x109 /L)
→ Erythrocyte sedimentation rate >40mm/h
→ Inability to ambulate
→ *C reactive protein >2.5 mg/L (23.81 nmol/L)
• Differentiated from Transient Synovitis
→ Self-limited virus related synovitis
Osteomyelitis • Bone infection
• Early recognition is important for immediate management
• Great risk if the growth plate is damaged
• May throw specific emboli and cause mortality
• How does it occur? If there is hematogenous spread, the infecting organisms would now try to reach the
medullary canal via these different vessels. When it reaches the medullary canal, pus will be filling around
the medulla, causing the bone to lyse. New bone will definitely be formed still but then there is already an
area of lysis.
• Sign and symptoms
→ Neonates: pseudoparalysis or pain on movement (e.g. diaper change); some may not appear ill, and half
may not have fever.
→ Older infants and children: pain, fever, and localizing signs like edema, erythema, and warmth
→ Limp or refusal to walk in ambulatory children
• Long bones are commonly involved
→ Fibula, radius, ischium – 4%
→ Phalanges, calcaneus – 5%
→ Humerus – 13%
→ Tibia – 24%
→ Femur – 25%
• Diagnosis
→ Diagnosis starts with clinical suspicion
→ No specific laboratory tests
• Elevated WBC count
• Elevated ESR
• Elevated CRP
→ CRP monitoring may be used to assess response to therapy
→ Blood culture, bone biopsy, culture of subperiosteal abscess
→ PCR for Kingella kingae
→ 72 hours → deep tissue edema, displacement of the deep muscle planes
→ Lytic bone changes appear if 30-50% of bone matrix is destroyed
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Evaluation of a Child with a Limp
→ Lytic changes in long bones occur after 7-14 days
• If you’re dealing with a flat bone, it would take much longer
→ MRI is more sensitive than CT scan
• Brodie Abscess
→ An abscess in the bone but the patient does not have that much symptoms
→ Subacute symptoms
→ Focal findings in the metaphyseal area (tibia)
→ Contents are usually sterile
• Treatment
→ Antimicrobial management
- Staphylococcus → Oxacillin, cefazolin for methicillin susceptible
- MRSA → Vancomycin or Clindamycin
- To include Gram negative bacilli →Cefepime
- Kingella kingae → Cefazolin
- How long? If responsive, 21-28 days. If not, 4-6 weeks. Monitor with CRP.
→ Surgical therapy
- Frank pus obtained from subperiosteal or metaphyseal aspiration
- Possibility of a foreign body
→ Physical therapy
- Preventive
- Casting or immobilization if at risk for fracture
- Prevention of flexion contractures
→ Rapid improvement in signs and symptoms with surgical debridement and antibiotic therapy
→ If after 48-72 hours patient is still febrile, better change the antibiotic (e.g. from staphylococcus to
MRSA- give vancomycin instead)
- Culture usually take 5-7 days
→ ESR: rises slowly within 5-7days, then drops sharply after 10-14 days
→ CRP titer: Decreases below 2 mg/dL within 7-10 days after starting treatment
→ If CRP still did not decrease by the 7th day, culture is already in if not same, you have to change.

NEOPLASMS
DESCRIPTION MANIFESTATIONS DIAGNOSIS MANAGEMENT
Osteoid • Most common in 5-20 • Limp, atrophy or • X-ray: cortical • Removal of nidus through
Osteoma years weakness thickening percutaneous
• Male > female • Pain worsens during radiofrequency ablation or
activity or at night cryoablation
• Surgery if close to articular
cartilages/neovascular
structures
Osteosarcoma • Most common bone • X-ray: sunburst • Limb salvage surgery
sarcoma pattern (curative: low parosteal
• Highest risk for dev’t: • MRI: evaluate osteosarcoma)
adolescent growth spurt proximity to vessels • Chemotherapy
• Four pathologic and nerves
subtypes • Chest CT: lung
→ Osteoblastic metastases
→ Fibroblastic • Radionuclide bone
→ Chondroblastic: scanning: bone
poorer prognosis metastases
→ Telangiectatic • PET: overall
metastases
Ewing’s • Extremities and central • Pain and swelling, • X-ray: onion- • Limb salvage
sarcoma axis limitation on motion, skinning • Chemotherapy
tenderness • Radiosensitive (but with
• Respiratory distress risk of secondary
• Cord compression malignancy secondary to
• Systemic symptoms radiation)
• Worst outcome: pelvic
tumors
Other malignancies that may cause limping • Leukemia and lymphoma
• Bone metastases
• Soft tissue sarcomas of the leg
DEVELOPMENTAL CAUSES
DESCRIPTION MANIFESTATIONS DIAGNOSIS MANAGEMENT
Developmental • Abnormality in the • Hip instability and • Barlow: adduction;
hip dysplasia formation of the dislocation done to determine if
acetabulum and femoral • Painless limp with hip can be displaced
head activity-related hip • Ortolani: abduction;
pain done to return to
• Leg-length position
discrepancy
• Trendelenburg gait
• Non-antalgic gait
Slipped Capital • Abnormality of the • Limitation of internal • X-ray: • Surgical correction for both
Femoral physis rotation of affected hip anteroposterior view stable and unstable SCFE

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Evaluation of a Child with a Limp
Epiphyses • Associated with of the pelvis, frog
(SCFE) hypothyroidism and lateral view of the
renal osteodystrophy hips
• 10-14 y/o, obese, male >
female
• Stable SCFE: minimal
dislocation, non-antalgic
• Unstable SCFE: with
dislocation, may lead to
severe avascular
necrosis, antalgic
Legg-Calve- • Idiopathic avascular • Painful limp and • X-ray: femoral head • Anti-inflammatory
Perthes Disease necrosis of femoral head limited hip motion disappearance medications
• Most common: 6-8 y/o, • Can produce • Protected weight-bearing
male > female premature activities
osteoarthritis of hip • Limited activity
OVERUSE INJURIES
DESCRIPTION MANIFESTATIONS DIAGNOSIS MANAGEMENT
Osgood • 9-14 y/o, males > • Slight limp, pain • X-ray: lifting of tibial • Ice to area after activities
Schlatter females worsening with tubercle • Anti-inflammatory
Disease • Spontaneous resolution activity, tenderness or medications
in 1-2 years swelling of tibial • Restriction of activities
• Some resolve after tubercle • PT for stretching the
closure of the growth • Tenderness to muscle and strengthening
plate at 14-15 years old palpation the tendon

Sever Disease • Apophysitis of • Limp with toe walking • X-ray: dysregularity • Limit workouts on hard
calcaneal tubercle due to heel pain, which of growth plate, surface
worsens with activity fissures and a more • Symptomatic relief
• Painful ankle sclerotic bone in • Rest
dorsiflexion calcaneal area
• Tender heel points on
PE

Trans # 6.04 PED2 TG14: Baobao, Lavin, Serrano | TH: Tarrazona 15 of 15