Limping Age Specific Conditions and Algorithm

Age-Based Diagnostic Algorithm

Timeline Overview (1-15 years)

Age-based prevalence of conditions:

• DDH (Developmental Dysplasia of the Hip): Years 1-3
• Perthes Disease: Years 4-9
• SCFE (Slipped Capital Femoral Epiphysis): Years 10-13
• Growing Pains: Years 10-12
• Infections: Years 10-14
• Trauma: Years 10-15

Detailed Chronological Distribution

Timeline (years): 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15

Conditions associated with specific ages:

• DDH (Developmental Dysplasia of the Hip) - Early childhood
• Growing Pains - School age
• Septic Arthritis - Variable
• Perthes Disease - Early school age
• Osteomyelitis - Variable
• SCFE (Slipped Capital Femoral Epiphysis) - Adolescence
• Trauma - Increasing with age

Age-Specific Conditions

Different diseases occur more commonly at specific age groups:

Age 1-4 Years

Developmental Dysplasia of the Hip (DDH)

Risk Factors:

• Female gender
• Breech presentation
• Family history
• Swaddling practices
• Associated conditions: torticollis, metatarsus adductus, calcaneovalgus

Physical Findings:

• Asymmetrical gluteal folds
• Limited hip abduction
• Apparent limb shortening
• Positive Trendelenburg sign

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Age 3-6 Years

Transient Synovitis

• Presentation: Limping, painful movement
• Lab findings: May have slightly elevated WBC, fever, or ESR
• Course: Resolves within days without treatment

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Septic Arthritis

• Presentation: Limping, refusal to walk
• Diagnostic criteria:
  • Fever > 38.5°C
  • WBC > 12,000
  • ESR > 40 mm/h
• Management: Joint aspiration if diagnosis uncertain

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Legg-Calve-Perthes Disease

Definition: Idiopathic avascular necrosis of the femoral head

Epidemiology:

• Age: Usually 4-8 years
• Gender: Boys 4× more common than girls
• Pathophysiology: Peculiar blood supply dependent on lateral epiphyseal vessels which may be easily occluded

Clinical Presentation:

• Limping (painful or painless)
• May present with knee or thigh pain
• Early stage: Limitation of all hip movements with pain and muscle spasm on passive motion
• Late stage: Limitation of abduction and internal rotation
• Positive Trendelenburg sign

Radiographic Stages:

1. Initial/ Bone Death Stage

   • May initially appear normal on x-ray
   • Increased density followed by collapse
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2. Revascularization and Repair Stage

   • Reduced density and fragmentation on x-ray
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3. Distortion and Remodeling Stage

   • Distortion, flattening (coxa plana)
   • Enlargement (coxa magna) with partial uncoverage

Radiological Progression:

Progression: Sclerosis → Collapse → Fragmentation → Remodeling

Imaging Examples:

Treatment:

• Conservative:
  • Rest
  • Physiotherapy: abduction and rotation exercises
  • Containment using abduction splint
• Surgical:
  • Containment procedures: To improve femoral head coverage
    • Acetabuloplasty
    • Femoral varus osteotomy
  • Late procedures: For residual deformity or problems

Prognosis: Depends on:

• Age at onset: Earlier onset = better prognosis
• Extent of head involvement: Complete head involvement = worse prognosis

Complications:

• Hip stiffness (related to deformed femoral head)
• Secondary osteoarthritis

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Age 10-15 Years

Slipped Capital Femoral Epiphysis (SCFE)

Definition: Antero-lateral slippage of the femoral metaphysis relative to the epiphysis

Epidemiology:

• Occurs around puberty
• Risk factors:
  • Male gender
  • Overweight/obesity
  • Hypogonadism
  • Tall stature or gonadal underdevelopment
• Pathophysiology: Hormonal imbalance between gonadal and growth hormones

Clinical Presentation:

• Limping
• May present with thigh or knee pain
• Types: Acute slip vs. chronic slip

Physical Examination Findings:

• Overweight body habitus
• Hypogonadism signs
• Hip positioning:
  • Externally rotated hip at rest
  • Loss of internal rotation
  • Obligatory external rotation on hip flexion
• Bilateral involvement: Occurs in 1/3 of patients

Imaging:

• Required views: AP and Frog lateral pelvis
• Key finding: Slippage of femoral epiphysis

Radiographic Examples:

Comparative views showing slipped vs. normal hip: (Source: Apley’s System of Orthopedics and Fractures)

Clinical examination findings: (Source: Apley’s System of Orthopedics and Fractures)

Physical examination demonstration:

X-ray Diagnosis:

View	Slipped Hip	Normal Hip
AP		-
Frog Lateral		-

Treatment:

• Critical principle: Manipulation to reduce the slip may cause avascular necrosis (AVN)
• Surgical management:
  • Fixation in situ (without reduction)
  • Prophylactic fixation: Consider fixing the contralateral hip (1/3 will develop slip on other side)

Complications:

• Avascular necrosis (AVN)
• Coxa vara
• Slippage of opposite hip
• Secondary osteoarthritis

(Source: BMJ Best Practice)

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Age 3-12 Years

Acute Osteomyelitis

• Presentation: Constitutional symptoms with localized bone pain
• Diagnostic workup:
  • Laboratory: WBC, CRP, ESR
  • X-ray: May initially be normal
  • MRI: Gold standard for early diagnosis

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Age 5-18 Years

Trauma

Pattern of traumatic injuries varies by age:

• Household injuries - Early childhood
• Playground injuries - Childhood
• School and sports injuries - Older children and teenagers
• Road traffic accidents - Teenagers

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Foreign Body Injuries

• Prick or splinter in sole of foot

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Growing Pains

• Diagnosis: By exclusion of all other diseases
• Location: Pain in legs, not at joints
• Age groups: 3-5 years and 8-12 years
• Diagnostic criteria (MUST meet all 3):
  1. Bilateral leg pain
  2. Pain occurs only at night
  3. No limping nor pain symptoms during the day

Clinical Examples: (Source: KidsHealth.org)

⚠️ Warning: Inaccurately diagnosing a limping child with “growing pains” risks missing significant disease

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