Case Presentations The Child with a Limp

Transcription

1 Case Presentations The Child with a Limp Douglas G. Armstrong, M.D. Professor, PennState Hershey College of Medicine Division Head, Pediatric Orthopaedics Dept. of Orthopaedics and Rehabilitation PennState Hershey Medical Center

2 Case 1: 11 year old girl Limping intermittently for 9 weeks c/o Right knee pain for 3 weeks

3

4 What s the most likely diagnosis? What s the next step?

5 Slipped Capital Femoral Epiphysis The most common hip disorder in adolescence incidence is increasing Proximal femoral physis weakens: epiphysis glides posteriorly & inferiorly, femoral neck rotates externally, glides upward Griffith M.J.: Ann R Coll Surg Engl 58:34, 1976

6 Anatomy of SCFE Anterior Posterior Axial

7 Slipped Capital Femoral Epiphysis Incidence: ~ 1 per 10,000 in North East U.S. Mean age: Boys 13 yrs; Girls 11 ½ yrs now trending to younger age Weight: 60% are >90th percentile Relative racial frequency: Polynesian 4.5 > Black 2.2 > White 1.0 > Indonesian-Malay 0.5 > Indo-Mediterranean 0.1 Seasonal variation: north of 40 N, more frequent in summer Loder RT, et al. Clin Orthop

8 Can you name 3 conditions for which you should have increased vigilance for SCFE? Hypothyroidism Renal failure Patient treated with HGH

9 Clinical Presentation Misdiagnosis is frequent: muscle strain Limping, often painless initially Pain in groin area with activity Pain at the Knee or Lower Thigh 23% Matava et al. J Pediatr Orthop 1999 Clinical examination is key: Observe the child s gait Check hip rotation in extension & flexion on exam table

10 Rules are meant to be broken 13 yo boy, Left Hip pain

11 SCFE Radiograms Mild slips can be missed Need a good Lateral XRay, frogleg view preferable AP: look for physeal widening & irregularity, Klein s line, remodelling of femoral neck inferiorly

12 Pinkowsky G, Hennrikus W. J Pediatr Orthop 2013

13 AP & Frogleg Bilateral Hips / Pelvis PW, male age 12y; c/o left hip pain

14 Bilateral SCFE Incidence varies by study, age, race, severity, measurement: 18% - 63% Sequential: mean is 1 yr after 1 st slip, up to 56 mos later More frequently Asymptomatic Increased Risk: Age at initial presentation 10 yrs or younger endocrine abnormality unstable SCFE

15 Natural History of Untreated SCFE 108 pts at average 41 yrs (r yr): 1/5 had good function, 2/5 poor, 2/5 moderate results declined with age Parsch K. J Pediatr Orthop(B) 1999

16 Natural History of Untreated SCFE is Poor Carney & Weinstein 1996 At least 17% displace All moderate & severe slips had developed degenerative joint disease; 5 of 14 had poor function Ordeberg G et al CORR 191: Severe slips: 28 of 35 had arthrosis

17 Natural History of Treated SCFE 41 yr follow-up: various treatments for 124 pts Acute slips: fair to poor outcomes Moderate & severe slips deteriorated In situ pinning: good to excellent 39 yr follow-up: 51 patients / 60 chronic SCFEs treated w. in situ fixation: 20 hips poor, 40 hips good Carney BT et al JBJS(A) Terjesen 2017 J Child Orthop

18

19 J.G., male, 14 yo

20 21 yr o male 8 years post pinning

21 Acute / Unstable SCFE Abrupt onset of severe pain, inability to weight bear, usually arrive by ambulance Epiphysis is mobile Exam: typical position, hip external rotation, abduction Plain Radiograms: usually gross displacement Treatment: controversial Osteonecrosis is common Outcomes: generally poor medium to long-term

22 Acute / Unstable SCFE Rate of AVN when reduction occurred Loder et al 1993: 47% (14/30) Kallio et al 1995: 3% (1/34) Kennedy et al 2001: 15% (4/27) Rattey et al 1996: 15% (4/26) Armstrong, Schwend 2000: 43% (13/30)

23 SCFE Summary Stable slips typically present to Pediatrician first Occur during pubertal growth spurt Beware of predisposing conditions, atypical age / weight / gender Limp with or without pain at hip / groin, knee or thigh Diagnosis: history, simple physical exam Xrays: AP & Frogleg bilateral hips MRI not necessary

24 Case 2 6 ½ year old boy limping for 6 weeks Limp is intermittent, worse with activity No history of trauma ADHD Pain at inner aspect of thigh / knee

25

26 Physical Examination Short statured Walks with a lurching gait to the right Right hip is stiff, some pain with internal rotation

27 XRay

28 Legg-Calve Perthes Disease Incidence Ranges from 1:1200 to 1:12,500 Usually presents between 4 and 8 years, however reported in ages 2 to 12 years Boys: Girls = 4 to 5: 1 More common in Caucasians, Asians Bilateral in 10% of cases Can be familial May be related to disorders of thrombophilia

29

30 Disease Course Initially, avascular episodes are silent As bone of femoral epiphysis dies, it is revascularized, Osteoclasts remove dead bone while osteoblasts lay down new bone on dead trabeculae (creeping substitution). During this phase, femoral epiphysis is weak Fragmentation and collapse may occur causing geometric flattening and deformity

31 Legg Calve Perthes Disease: a long disease course Fragmentation: 1 year Reossification: 3 to 5 years remodeling and improvement of femoral head shape may occur until maturity Long term prognosis depends on shape of head at maturity

32 Radiographic Progression

33 LCPD: Clinical Presentation - History Usually between ages 4 and 8 years Boys >> Girls ADHD Small stature c/o limp - varying duration Pain usually activity related and localized to groin, anterior thigh, or knee at-risk factors age > 6 yrs; obesity; female; marked stiffness

34 Clinical Presentation Physical Exam Antalgic or Trendelenburg gait May have hip flexion contracture of degrees Limited motion, notably decreased Internal Rotation and Abduction May have leg length inequality Atrophy of thigh, calf, or buttock musculature

35 Differential Diagnosis Toxic synovitis Infection / septic arthritis Juvenile rheumatoid arthritis Tumor Sickle cell, thalassemia, hemophilia, ITP, etc. Leukemia In bilateral cases: skeletal dysplasia (spondyloepiphyseal dysplasia), endocrinopathies, some genetic syndromes.

36 LCPD: Diagnosis height, weight (typically short-statured) Gait Hip ROM Trendelenburg test; measure limb lengths Laboratory studies usually not needed

37 LCPD: Imaging AP and frog-lateral views both are necessary Determine extent of femoral epiphysis involvement Femoral epiphysis may collapse and extrude from the acetabulum Determine femoral head coverage & containment on frogleg view MRI may be useful in select cases, not typically the first step

38 AP and Frog-Lateral

39 LCPD Imaging MRI may be useful for diagnosis in difficult cases As a prognostic tool - not clear

40 Lateral Pillar Classification Femoral head can collapse over time Extent of collapse varies with severity of osteonecrosis Shape of the femoral head at maturity determines outcome, longevity of the hip A B C

41 Prognosis & Treatment Age at onset is a main determinant of outome < 6 yrs: 80 % do well Age 6 to 8: surgery may help some Age > 8 yrs: surgery often helpful Physical Therapy: not helpful Bracing: in selected patients Surgery: In selected children Soft tissue releases to improve Range of motion, Bone operations to improve coverage

42

43 Case 3 1 yr 5 month old girl Just started walking Walking on tiptoe on right No pain No h/o trauma No fever

44 Physical Examination

45

46 Developmental Dysplasia of the Hip Is this the Pediatrician s fault?

47 Developmental Dysplasia of the Hip (DDH) A Group of disorders of the hip in which the head of the femur is unstable or incongruous in relation to the acetabulum. Untreated hip dysplasia results in degenerative arthrosis; age at onset varies: subluxated hips develop rapid, severe OA in young adulthood

48 Developmental Dysplasia of the Hip Acetabular dysplasia is characterized by an immature, shallow acetabulum. Normal acetabular development is dependent upon concentric reduction of the femoral head But - Dysplasia may sometimes exist without associated instability: primary acetabular dysplasia may present later, even in adulthood Severity of dysplasia correlates with age of onset of symptoms and disability

49 Screening for DDH Typically performed by primary care providers Primary screening tool is physical exam & history The screening tool is relatively reliable, and is cost effective Early treatment can prevent disability and degenerative arthrosis of the hip, i.e., prevents significant disease burden

50 Epidemiology Incidence: 1 in 100 live births have hip instability, 1 per 1000 have a dislocation Left 3 X > Right (?) due to fetal position Females : males = 4.6:1 Family History: If 1 parent & 1 sib have DDH then 36% will have it Race: Native American > White > Black However, The Majority of DDH patients Have No Risk Factors 1 in 5,000 children have DDH that presents late, like this one

51 Etiology Mechanical: Breech Maternal hormone-induced ligamentous laxity Genetics role remains unclear

52 Risk factors for DDH Vertex: Girls: 2/1000; Boys 0.5/ 1000 First born: effect is small Positive family history: RR = 1.7; 3.2 % girls Breech especially Frank breech Female Breech: 12 % have DDH Associated packaging disorders

53 What to do Screening at Newborn and at Periodic examinations until age 1 year After age 1, if clinically indicated Refer to Orthopedic surgery if exam positive 2 week exam suspicious : U/S at 1 month or referral Breech: U/S at 6 weeks or Radiogram at 4-6 months Suspicious, up to 12 mos: refer, U/S or XRay

54 Diagnosis: age 3 months or less Ortolani test Elevation/abduction produces relocation clunk of a dislocated hip (not a click) Barlow test: (no longer considered reliable) Adduction/depression dislocates or subluxates a dislocatable or subluxable hip Ultrasound : sensitivity / specificity better at 1 month of age than as newborn; not recommended if patient > 5 months old; controversial HIP XRAY

55 Ortolani

56 Barlow

57 Diagnosis: age 3 to 12 months Ortolani/Barlow become unreliable ** Limitation of Abduction ** Foreshortening of femur (Galeazzi sign) Beware bilateral DDH

58 Clinical Signs Assymmetric skin folds: not always reliable Hip abduction can be close to symmetric Worst case scenario: bilateral DDH & loose ligaments: present with waddling gait & hyperlordosis

59 Age 12 months and older Delayed walking Toe walking if unilateral Limping Limb length discrepancy

60 AP Pelvis Dislocated head above horizontal line (Hilgenreiner) and lateral to perpendicular (Perkins)

61 Treatment: 6 to 18 months or if failed nonoperative measures Closed reduction & Spica casting Arthrography is often useful Adductor tenotomy Open reduction as necessary Spica for 4 months with cast changes X-rays or CT scans or MRI to check reduction

62 Open Reduction & Salter Osteotomy: one of the most successful operations: % good to excellent results at 45 years follow up!

63 DDH follow-up There is a wide spectrum of disease Prognosis is good for hips treated early but Many patients can develop abnormal hips during late childhood or adolescence Contralateral normal hip can develop dysplasia up to age 12 years old Orthopedic follow-up throughout growing years is recommended

64 Summary DDH Routine physical examination by pediatrician will find many but not all cases 1 in 5000 present at 12 mos or older Shaw B, Segal L. Clinical Report: Evaluation and Referral for DDH in Infants. Pediatrics Dec Best Practices Examine the hips at periodic visits up to 6 9 months of age Consider ultrasound to clarify suspicious findings on physical examination after 3 to 4 weeks of age or to detect clinically silent DDH in the high-risk infant from 6 weeks to 4 to 6 months of age

65 Thank You 65