He Walks Funny

Jean Ivey, DSN, CRNP; Linda Wilkinson, MSN, RN, CRNP; John Killian, MD, AAOS

Disclosures

Pediatr Nurs. 2008;34(6) 

In This Article

Differentials

Trauma: A screening X-ray will reveal a fracture that was previously undetected. However, there is no history of trauma or falls in this case.

Developmental dysplasia of the hip: This problem is more frequent in children of a breech delivery. There is a genetic cause for some forms of hip dysplasia, but he has no family history that would suggest that is the case. It is usually detected at an earlier age.

Skeletal dysplasia: A screening X-ray will also detect bony abnormalities, such as coax vera.

Septic arthritis: If an infectious process is the cause of hip pain and limp, the expected course would include a history of moderate to high fever, redness, warmth, malaise, and irritability. None of these symptoms were present.

Osteomyelitis would present with point tenderness, redness, warmth, swelling, and refusal to walk or move.

Tumor: This diagnosis should be considered because of the slow onset of symptoms. X-rays might reveal/rule out this diagnosis, or a CAT scan or MRI may be required if no other cause is found.

Legg-Calve-Perthes disease: This disorder is frequently found in children 6 to 10 years of age. A radiology study to measure the acetabular head index (AHI), the slope of the acetabular roof (SAR), and the articulo-trochanteric distance (ATD) can determine the degree of limitation of movement (abduction). Treatment may be conservative, with crutches used and NSAIDs taken for a few months. There are several surgical procedures that may be chosen.

Slipped capital femoral epiphysis: This disorder is usually seen in overweight adolescents. The degree of disability can range from a limp to the inability to walk without crutches. A frog-leg lateral X-ray can detect the problem.

Juvenile arthritis (JRA): JRA may start with a refusal to ambulate or problems with only one joint. Younger children frequently have a low-grade fever and a transient rash. An elevated sedimentation rate is often the only diagnostic test that is positive, and that is non-specific. A rheumatologist would need to evaluate the child if this diagnosis is suspected.

Assessment: CBC, Differential and sedimentation rates were normal. X-rays of Peter's hips supported the diagnosis of developmental dysplasia of the hip, Group II (unilateral, no necrosis of the femoral head).

Plan: Peter will have a femoral osteotomy with open reduction and soft tissue lengthening of the involved hip. He will be in a cast for 4 to 6 weeks. Infants under 3 months of age may be successfully treated with a Pavlik™ harness, which maintains the hip in abduction. After 3 months, this method is less successful. At that point, the infant would have soft tissue lengthening and a body cast for 3 months, followed by a splint until the femoral head ossifies.

Regardless of the manner of treatment, parents must have appropriate teaching and preparation for the care of the child. They may have to change their child care arrangements, work schedule, and activities while the child is in a cast or harness. Peter's mother was able to bring his grandmother into the home to care for him while his parents were at work. Other families might need additional resources and support. Transporting the child home or anywhere else requires modification of the car seat or use of an Easy On™ harness. The care and maintenance of children wearing spica casts have been simplified; waterproof casts that allow easy diapering and cleaning to prevent skin breakdown are now available. Children who are immobile may experience other problems that require planning, including decreased appetite and the tendency to develop constipation. Older children may require homebound schooling. Primary care providers can assist the family by staying in close contact and helping them prevent problems during the treatment and follow up care.

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