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1 Evaluation of a child with a limp / Slipped Capital Femoral Epiphysis (SCFE) Lee S. Segal, MD Chief, Division of Pediatric Orthopedics American Family Children s Hospital Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health Madison, WI Evaluation of a child with a limp / Slipped Capital Femoral Epiphysis (SCFE) I have no financial relationships related to disclose common presentation to pediatric orthopaedic office limp can be caused by pain, weakness, or mechanical factors requires thorough history and physical examination Introduction Evaluation of the limping child narrow differential dx based upon 1. Gait 2. Location 3. Age Toddler (<4y) Child (4-10y) Adolescent (>10y) 4. Pain Normal gait Abnormal gait Trendelenburg equinus (toe- walking) circumduction/ vaulting steppage 1

2 Non- antalgic gait Equinus: CP, congenitally tight heel cord, LLD, clubfoot Trendelenberg: LCP, DDH, SCFE, Muscular dystrophy Circumduction/Vaulting: CP, LLD, any stiffness of ankle/knee Steppage: CMT, CP, Spina Bifida History Is limp associated with or without pain? PQRST- characterize pain Provokes, Palliates Quality Radiate, Referred Severity Timing PMH Family history Physical examination gait table- top exam (supine, prone) Take age of child into consideration with exam radiographs (comparison, oblique) bone scan ultrasound CT MRI Imaging CBC with Diff ESR / CRP Lyme titer rheum (ANA, RF) joint aspiration (cell count, etc) Lab tests Critical Questions Flynn J, Widmann RF: The Limping Child: Evaluation and Diagnosis. JAAOS 2001 Is the limp due to pain? Did the pain occur suddenly or gradually, or has it always been there? Is the child systemically ill? Does the child exhibit a specific gait pattern? Can the pain be localized? 2

3 Toddler s fracture DDH osteomyelitis, septic arthritis JA, Lyme tumor (benign/ malignant) Non- accidental trauma Toddler (<4y) DDH: 3+8 month old In toddler, not uncommon to present with a LLD and limp Risk Factors 4 F s : Breech, +FH, 1 st born, female (6:1) Uterine compression syndrome Associated structural abnormalities Ethnic groups * majority of infants with DDH don t have a risk factor * safe swaddling Treatment depends on age of presentation 0-6 months Pavlik harness 6-18 months Hip arthrogram, +/- adductor tenotomy, closed/open reduction and hip spica cast for weeks > 3 years late discovery DDH open reduction with femoral shortening + pelvic osteotomy Pediatric bone and joint infection / synovitis Legg- Calve- Perthes fracture OCD Foreign body Tumor Lyme disease Child (4-10y) Transient synovitis Septic arthritis Osteomyelitis 3

4 Transient Synovitis Hip joint most often affected Mild pain, fever, stiffness, lab abnormalities (T<101, ESR< 50, WBC< 15,000) Tolerate movement of hip if done cautiously U/S shows minimal fluid in joint TX- Rest and NSAIDS Improvement is usually within a few days to 2 wks Wax and wane, recurrence Septic arthritis hip joint commonly involved Child appears toxic, irritable Severe pain with joint ROM U/S demonstrate joint effusion Neonate often has multiple joint involvement, may not mount inflammatory response (fever, ESR, WBC) Don t want to miss septic hip, severe sequelae Confirm with aspiration fluid normal Transient synovitis vs septic arthritis of hip Prediction of septic arthritis is 93% with 3 or more of the following (Kocher criteria) Fever NWB ESR >40 WBC >12,000 * Does not replace the clinical exam Septic arthritis of the hip Infant with septic arthritis of the left hip Hip held rigidly in the classic position of flexion, abduction, and external rotation position that maximizes capsular volume Infant relatively comfortable as long as the hip remains immobile in this position Septic Arthritis Diagnosis is made via hip joint aspiration (US or in OR) Treatment is drainage and irrigation, followed by antibiotics Early treatment is important for a good result Identify the cause, determine which antibiotic, duration, route Legg Calve- Perthes Disease Most common in children 4 to 8 yrs old Males > females affected Insidious limp is most common presentation Limited hip abduction and internal rotation on exam 4

5 LCP - etiology Unknown source of frustration, 2 prevailing theories Perthes Disease temporal classification - xray Initial Fragmentation Reossification Healed 9 Mo 32 Mo 10 yr (1) disruption of blood supply * disturbance clotting mechanism * hyperviscosity Factor Leiden V, Protein S and C deficiency (2) underlying systemic disorder primary disorder of epiphyseal cartilage? delayed skeletal maturation, shorter stature, ADHD Extent of involvement Catterall Lateral Pillar classification prognosis Age at presentation (<6 years) Extent of involvement Perfusion MRI Duration of disease process Clinical ROM Treatment principles goal maintain sphericity femoral head Maintain ROM (PT, NSAID, petrie casts) Containment (bracing vs surgery) If >6 yo or lateral pillar B/C, hip subluxation, other treatment may be considered (femoral or pelvic osteotomy) Long term prognosis depends on residual femoral head deformity Adolescent (>10 yrs) CITMAT Sports - related stress fractures (overuse, repetitive), OCD Transitional: SCFE, tarsal coalition, Osgood- Schlatter Inflammation: Juvenile arthritis, Infection: Osteomyelitis, Lyme disease Tumor 5

6 The limping child Common musculoskeletal presentation Determine gait pattern, associated with or without pain, age of child, and localization Establish differential DX, choose appropriate studies to confirm diagnosis Be familiar with treatment with relation to condition Slipped Capital Femoral Epiphysis (SCFE) the unsolved adolescent hip disorder Most common adolescent hip disorder Missed or delay in diagnosis Asymptomatic, chronic SCFE tilt deformity Etiology remains unknown etiology remains unknown Missed or delay in diagnosis endocrine trauma mechanical genetic inflammatory Kocher et al Pediatrics 2004 Median delay 8 weeks Significant relationship: delay in dx à increase slip severity Matava JPO 1999 Isolated distal thigh or knee pain common presentation Leads to higher rates of missed dx, unnecessary x- rays, and more severe slips Silent slip Silent slip 6

7 Silent slip Silent slip à tilt / pistol grip deformity Clinical presentation May complain of hip, thigh, or knee pain (Hilton s Law) Extremity externally rotated + roll test +/- ability to WB ** Any older child or adolescent with knee pain has a SCFE until proven otherwise Preventing progression of the slip Promote closure of the growth plate Minimizing risks of AVN / chondrolysis Prophylactic pinning of contralateral hip controversial in NA Treatment goals Narrow age range at presentation Males yrs Females yrs Beyond this range (+/- 2 yrs) consider endocrine or systemic disorder (atypical) Atypical SCFE Below 10 th percentile for height for chronologic age Bilateral presentation Juvenile Consider associated endocrine disorder : hypothyroidism (esp. if < 10) pituitary and parathyroid abnormalities VDRR Radiation exposure GH treatment Renal osteodystrophy 7

8 smooth k- wires/semitubular plate (1996) Epidemiology kidney transplant (2005) Incidence - 2/100,000 Ethnic variation Seasonal variation Geographic variation (40 o latitude) Bilateral 25% (?) 40 o Traditional (temporal) Acute, acute on chronic, chronic Physeal stability Severity of slip classification Onset < 3 weeks Epiphyseal displacement without remodeling High risk AVN >15% Acute SCFE Physeal stability pathophysiology Loder et al JBJS 75A, 1993 Clinical evaluation Unstable - patient presents with severe hip pain, and is unable to walk with or without crutches, regardless of the duration of symptoms Fluoroscopic evaluation *prognostic importance Direction of slip True posterior Hypertrophic zone of physis 8

9 Torsional basis / SCFE torsional basis of SCFE Both coronal + sagittal planes of shear loading Displacement of CFE resolved by common torsional force radiographs AC ** must obtain both AP and frog- lateral x- rays of the pelvis AP radiograph - Difficult to recognize minimal slip Clues Klein s line Decreased epiphyseal height Blanch sign AC Goals of Treatment (older) Prevent further slip* Promote premature physeal closure* Minimize risks associated with SCFE Evolving concepts with SCFE FAI femoral acetabular impingement 9

10 treatment Always consider dx Don t send home Differentiate stable vs. unstable Do not allow further ambulation Surgical urgency standard of care North America : in- situ single screw fixation NORTH AMERICA CANNULATED SCREW FIXATION/single B/L INCIDENCE 25% OBSERVE CONTRALATERAL HIP GERMANY K WIRE FIXATION B/L INCIDENCE 75% STABILIZE CONTRALATERAL HIP Entry site different than pinning hip fracture 10

11 9/7/14 11

12 risks AVN chondrolysis Unstable Slip severity Iatrogenic Segmental vs global pitfalls c. Pin in situ for severe SCFE In past used to consider osteotomies to compensate for deformity a. b. a. Growth disturbance / premature closure b. Subtrochanteric fracture c. Strip screws upon attempt to remove C osteotomies A New concepts Contralateral hip prophylactic stabilization Femoral acetabular impingement (FAI) AVN risk higher closer to deformity Open surgical hip dislocation 12

13 Femoral Acetabular Impingement (FAI) Open surgical hip dislocation Preserve blood supply CAM FAI Surgical hip dislocation protects blood supply to femoral head summary Any adolescent with knee pain is a SCFE until proven otherwise Always obtain x- ray of pelvis Always obtain 2 views (AP/Frog) Surgical urgency don t send home Delay in Dx increases risk of slip severity Thank you 13