Developmental Dysplasia of the Hip - Part 1.

Developmental dysplasia of the hip (DDH) is a condition characterized by changes in joint formation within the last months of intrauterine life or the first months after birth. Developmental dysplasia of the hip presentation ranges from femoroacetabular instability to several stages of dysplasia up to complete dislocation. Early diagnosis is essential for successful treatment. Clinical screening, including appropriate maneuvers, is critical in newborns and subsequent examinations during the growth of the child. Infants with suspected DDH must undergo an ultrasound screening, especially those with a breech presentation at delivery or a family history of the condition. A hip ultrasound within the first months, followed by pelvic radiograph at 4 or 6 months, determines the diagnosis and helps follow-up. Treatment consists of concentric reduction and hip maintenance and stabilization with joint remodeling. The initial choices are flexion/abduction orthoses; older children may require a spica cast after closed reduction, with or without tenotomy. An open reduction also can be indicated. After 18 months, the choices include pelvic osteotomies with capsuloplasty and, eventually, acetabular and femoral osteotomies. The follow-up of treated children must continue throughout their growth due to the potential risk of late dysplasia.

Developmental Dysplasia of the Hip - Part 1 / Displasia do desenvolvimento do quadril - Parte 1

Abstract Developmental dysplasia of the hip (DDH) is a condition characterized by changes in joint formation within the last months of intrauterine life or the first months after birth. Developmental dysplasia of the hip presentation ranges from femoroacetabular instability to several stages of dysplasia up to complete dislocation. Early diagnosis is essential for successful treatment. Clinical screening, including appropriate maneuvers, is critical in newborns and subsequent examinations during the growth of the child. Infants with suspected DDH must undergo an ultrasound screening, especially those with a breech presentation at delivery or a family history of the condition. A hip ultrasound within the first months, followed by pelvic radiograph at 4 or 6 months, determines the diagnosis and helps follow-up. Treatment consists of concentric reduction and hip maintenance and stabilization with joint remodeling. The initial choices are flexion/abduction orthoses; older children may require a spica cast after closed reduction, with or without tenotomy. An open reduction also can be indicated. After 18 months, the choices include pelvic osteotomies with capsuloplasty and, eventually, acetabular and femoral osteotomies. The follow-up of treated children must continue throughout their growth due to the potential risk of late dysplasia.

Resumo O termo displasia do desenvolvimento quadril (DDQ) refere-se à condição na qual a articulação sofre alterações na sua formação durante os últimos meses da vida intrauterina ou nos primeiros meses após o nascimento. No espectro de apresentação, varia desde a instabilidade femuroacetabular, passando por estádios de displasia até a completa luxação. O diagnóstico precoce é fundamental para o sucesso do tratamento. A triagem através do exame clínico incluindo manobras apropriadas é imprescindível nos recém-nascidos e nas avaliações subsequentes durante o crescimento da criança. O rastreamento ultrassonográfico é indicado nos bebês sob suspeita clínica e muito mais recomendável naqueles que tiveram apresentação pélvica para o parto ou que tenham antecedentes familiares. A ultrassonografia do quadril nos primeiros meses seguida da radiografia da bacia após o 4° ou 6° mês de vida são os exames que determinam o diagnóstico e auxiliam o seguimento. O tratamento está baseado na obtenção de uma redução concêntrica e na manutenção e estabilização do quadril, propiciando a remodelação articular. Inicialmente, as órteses de flexão/abdução são a escolha; em crianças maiores pode ser necessário o uso de gesso após redução incruenta com ou sem tenotomia; redução aberta pode ser indicada e após os 18 meses as osteotomias pélvicas associadas a capsuloplastia e eventuais osteotomias acetabular e femoral. Crianças tratadas devem ser acompanhadas durante todo o seu crescimento pelo eventual risco de displasias tardias.

Percutaneous hemiepiphysiodesis using transphyseal screws for adolescent tibia vara.

Hemiepiphysiodesis around the knee is becoming the mainstay procedure in adolescents for a wide range of aetiological deformities, when considering adolescent tibia vara (ATV), the published series have variable results. The purpose of this study was to review our experience with the percutaneous transphyseal screw (PETS) in these patients followed until bone maturity. We analysed the charts from 13 patients (20 knees) that underwent lateral tibial hemiepiphysiodesis using PETS. The radiographs were accessed before surgery, at implant removal, when occurred, and at the final follow-up. The clinical evaluation noted if there were complaints regarding pain or range of motion, and the radiographic assessment included: the femorotibial angle, the mechanical axis zone, the anatomic lateral distal femoral angle, and medial mechanical proximal tibial angle. There was one overcorrection, and after the screw removal (14 knees), rebound was observed in two knees modifying the result from excellent to good in all three knees. No bone bars and no implant breakage were observed. At the last appointment, all patients had normal knee range of motion, and two patients had unilateral alignment complaints, one of whom referred to occasional pain. Overall, the surgery was excellent in 12 knees (60%), good in six knees (30%), and poor in two knees (10%). This technique is indicated to be well tolerated and effective for treating ATV. When a complete correction cannot be obtained, in our opinion, it is advantageous to at least stabilise the deformity and postpone osteotomies until after skeletal maturity. Level of Evidence: Level IV - Case Series, Therapeutic Study.

Chronic slipped capital femoral epiphysis: a radiographic evaluation of the Southwick osteotomy.

The aim of this study was to evaluate the radiographic correction and the complications in Southwick osteotomy for slipped capital femoral epiphysis (SCFE) on the basis of radiographic evaluation. We retrospectively analyzed the charts of 37 patients with chronic, unilateral, moderate, or severe SCFE, who underwent the procedure, verifying Southwick angles, articulotrochanteric distance, and the articular narrowing on preoperative, postoperative periods, and in the last follow-up evaluation, using the contralateral, healthy hip, for comparison. Southwick's angle changed from 117.8 to 147.3° on average (front) and from 56.9 to 19.1° (Lauenstein view). Articulotrochanteric distance changed from 11.3 to 24.1 mm (normal distance 22.1 mm). Joint space changed from 4.3 mm preoperatively to 3.84 mm. Chondrolysis was diagnosed in five cases before and eight cases after surgery. There was no case of avascular necrosis. Southwick osteotomy effectively corrected SCFE deformity. There was a tendency toward excessive valgism.

Flexible intramedullary nails with traction versus plaster cast for treating femoral shaft fractures in children: comparative retrospective study.

CONTEXT AND OBJECTIVE Femoral fractures are common in children between 2 and 12 years of age, and 75% of the lesions affect the femoral shaft. Traction followed by a plaster cast is universally accepted as conservative treatment. However, in some situations, a surgical approach is recommended. The objective here was to compare treatments for femoral shaft fractures using intramedullary nails (titanium elastic nails, TEN) versus traction and plaster casts in children. The hypothesis was that TEN might provide better treatment, with good clinical results in comparison with plaster casts. DESIGN AND SETTING This retrospective comparative study was conducted in a public university hospital. METHODS Sixty children with femoral fractures were evaluated; 30 of them underwent surgical treatment with TEN and 30 were treated conservatively using plaster casts. The patients' ages ranged from 5 to 13 years (mean of 9 years). RESULTS The mean duration of hospitalization was nine days for the surgical group and 20 days for the conservative group. The incidence of overgrowth in the patients treated with TEN was 60.0% and, for those treated conservatively, 13.3%. Partial weight-bearing was allowed after 3.5 weeks in the surgical group and after 9.6 weeks in the conservative group. New hospitalization was required for 90.0% in the surgical group and 16.7% in the conservative group. Patients treated with plaster casts presented higher incidence of complications, such as loss of reduction. CONCLUSIONS The surgical method presented better results for children.

Flexible intramedullary nails with traction versus plaster cast for treating femoral shaft fractures in children: comparative retrospective study / Hastes intramedulares flexíveis com tração versus aparelho gessado para o tratamento de fraturas diafisárias do fêmur em crianças: estudo comparativo retrospectivo

Femoral fractures are common in children between 2 and 12 years of age, and 75% of the lesions affect the femoral shaft. Traction followed by a plaster cast is universally accepted as conservative treatment. However, in some situations, a surgical approach is recommended. The objective here was to compare treatments for femoral shaft fractures using intramedullary nails (titanium elastic nails, TEN) versus traction and plaster casts in children. The hypothesis was that TEN might provide better treatment, with good clinical results in comparison with plaster casts.

This retrospective comparative study was conducted in a public university hospital.

Sixty children with femoral fractures were evaluated; 30 of them underwent surgical treatment with TEN and 30 were treated conservatively using plaster casts. The patients' ages ranged from 5 to 13 years (mean of 9 years).

The mean duration of hospitalization was nine days for the surgical group and 20 days for the conservative group. The incidence of overgrowth in the patients treated with TEN was 60.0% and, for those treated conservatively, 13.3%. Partial weight-bearing was allowed after 3.5 weeks in the surgical group and after 9.6 weeks in the conservative group. New hospitalization was required for 90.0% in the surgical group and 16.7% in the conservative group. Patients treated with plaster casts presented higher incidence of complications, such as loss of reduction.

The surgical method presented better results for children. .

Fraturas femorais são comuns em crianças entre 2 e 12 anos de idade, e 75% das lesões acometem a diáfise. Tração seguida de aparelho gessado (“gesso”) é universalmente aceita como tratamento conservador. Entretanto, em algumas situações o tratamento cirúrgico é recomendado. O objetivo foi comparar o tratamento de fraturas diafisárias do fêmur com hastes intramedulares (titanium elastic nails, TEN) com tração e gesso em crianças. A hipótese era de que TEN pode ser melhor tratamento, com bons resultados clínicos em comparação com o gesso.

Este estudo retrospectivo e comparativo foi conduzido num hospital público universitário.

Sessenta crianças com fraturas de fêmur foram avaliadas, 30 delas foram submetidas a tratamento cirúrgico com TEN e 30 foram tratadas de forma conservadora usando gesso. A idade dos pacientes variou de 5 a 13 anos (média de 9 anos).

O tempo médio de internação foi de 9 dias para o grupo cirúrgico e 20 dias para o grupo conservador. A incidência de crescimento excessivo nos pacientes tratados com TEN foi de 60,0% e, para aqueles tratados de forma conservadora, 13,3%. Sustentação parcial de peso foi permitida após 3,5 semanas no grupo cirúrgico e após 9,6 semanas no grupo conservador. Houve 90,0% de novas internações no grupo cirúrgico e 16,7% no grupo conservador. Pacientes tratados com gesso apresentaram maior incidência de complicações, tais como perda de redução.

Radiographic evaluation in epiphysiolysis: possible predictors of bilaterality?

OBJECTIVE: To identify anatomical changes and skeletal maturity through radiographic analysis, allowing more accuracy for indication of surgical management of non-slipped hips in patients with epiphysiolisys. METHOD: A retrospective study of the radiographs of 61 patients followed until the end of skeletal growth, assigned to two groups: 37 patients with unilateral epiphysiolysis, and 24 patients with contralateral epiphysiolysis diagnosed during follow-up. The skeletal maturity was evaluated using pelvis radiographs (Oxford method) and compared between the groups for patients of the same gender. In addition, the Southwick angle (in anteroposterior and in Lauenstein view), physeal sloping angle and physeal posterior sloping angle were compared as well. RESULTS: Skeletal maturity showed a statistically significant difference between the two groups for both genders. It was observed that the lateral view of the Southwick angle is mathematically equal to the physeal posterior sloping angle, and were the only ones to show relevant differences between the groups. CONCLUSION: The Oxford method and the Southwick angle in Lauenstein view can be utilized as parameters to help the physician to better indicate the prophylactic surgical treatment of the contralateral hip, in patients with slipped capital femoral epiphysis (SCFE). Level of Evidence III, Diagnostic Study.

Avaliação radiográfica na epifisiolise: possíveis preditores de bilateralidade? / Radiographic evaluation in epiphysiolysis: possible predictors of bilaterality?

OBJETIVO: Identificar radiograficamente alterações anatômicas e da maturidade esquelética em paciente com epifisiólise do quadril, que auxiliem na indicação do tratamento cirúrgico profilático dos quadris não escorregados, no mesmo paciente. MÉTODOS: Foi realizada uma avaliação radiográfica retrospectiva com 61 pacientes, acompanhados até o final do crescimento, divididos em dois grupos: 37 com escorregamento unilateral e 24 com escorregamento bilateral, diagnosticados durante o acompanhamento. A maturidade esquelética foi avaliada nas radiografias da bacia (método de Oxford) e comparada entre os grupos, nos pacientes do mesmo sexo. Além disso, diversos ângulos descritos para a região proximal do fêmur foram medidos e comparados: ângulo de Southwick (nas incidências ântero-posterior e Lauenstein), ângulo de inclinação da fise e ângulo de sloping posterior da fise. RESULTADOS: A maturidade esquelética mostrou diferença estatisticamente significante entre os grupos, em ambos os sexos. Com relação aos ângulos avaliados, o de Southwick no perfil mostrou-se matematicamente igual ao de "sloping " posterior, os únicos a mostrar diferenças relevantes. CONCLUSÃO: O método de Oxford e o ângulo de Southwick no perfil podem ser utilizados como parâmetros para uma melhor indicação do tratamento profilático do quadril contralateral em pacientes com epifisiolise. Nível de Evidência III, Estudo Diagnóstico.

OBJECTIVE: To identify anatomical changes and skeletal maturity through radiographic analysis, allowing more accuracy for indication of surgical management of non-slipped hips in patients with epiphysiolisys. METHODS: A retrospective study of the radiographs of 61 patients followed until the end of skeletal growth, assigned to two groups: 37 patients with unilateral epiphysiolysis, and 24 patients with contralateral epiphysiolysis diagnosed during follow up. The skeletal maturity was evaluated using pelvis radiographs (Oxford method) and compared between the groups for patients of the same gender. In addition, the Southwick angle (in anteroposterior and in Lauenstein view), physeal sloping angle and physeal posterior sloping angle were compared as well. RESULTS: Skeletal maturity showed a statistically significant difference between the two groups for both genders. It was observed that the lateral view of the Southwick angle is mathematically equal to the physeal posterior sloping angle, and were the only ones to show relevant differences between the groups. CONCLUSION: The Oxford method and the Southwick angle in Lauenstein view can be utilized as parameters to help the physician to better indicatethe profilatic surgical treatment of the contralateral hip, in patients with slipped capital femoral epiphysis (SCFE). Level of evidence III, Diagnostic Study.

Coxa vara do desenvolvimento / Developmental coxa vara

OBJETIVO: Avaliar os aspectos clínicos e radiográficos observados após o tratamento operatório de pacientes portadores de coxa vara do desenvolvimento (CVD), além de revisar sua epidemiologia e história natural. MÉTODOS: Foram selecionados 19 pacientes (26 quadris) portadores de CVD submetidos à osteotomia valgizante subtrocantérica, com tempo médio de quatro anos e 10 meses e mínimo de 12 meses de seguimento. Foram analisadas a amplitude de movimento dos quadris, o sinal de Trendelenburg e a discrepância de comprimento dos membros inferiores. Na avaliação radiográfica, foi medido o ângulo epifisodiafisário (ED) e a distância articulotrocantérica (DAT) em diferentes momentos. RESULTADOS: Observou-se elevação média de 21º da amplitude de abdução dos quadris, assim como desaparecimento do sinal de Trendelenburg. Na avaliação da discrepância de comprimento, 72,2 por cento dos 18 pacientes analisados foram equalizados, considerando uma diferença residual de até 0,5cm entre os membros. A variação da DAT apresentou médias de -0,34cm no período pré-operatório, 2,18cm no pós-operatório imediato e 1,35cm na última avaliação, o ângulo ED apresentou uma média de 91º no pré-operatório, 142º no pós-operatório imediato e 133º na última avaliação. CONCLUSÃO: A osteotomia valgizante subtrocantérica, levando a ângulos epifisodiafisários próximos a 140º, foi eficiente ao longo do tempo na correção das deformidades.

OBJECTIVE: To evaluate the clinical and radiographic findings observed after surgical treatment of patients with developmental coxa vara (DCV) and review its epidemiology and natural history. METHOD: We selected 19 patients (26 hips) with DCVthat underwent subtrochanteric osteotomy with a mean follow-up period of four years and ten months and a minimum of 12 months of follow-up. We analyzed the range of motion of the hips, the Trendelenburg sign, and the discrepancy of the length of the lower limbs.In the radiographic evaluation, we measured the epiphyseal-diaphyseal (ED) angle and articulo-trochanteric distance (ATD) at different times. RESULTS: We observed an average increase of 21º in the amplitude of hip abduction, as well as the disappearance of theTrendelenburg sign. In assessing the length discrepancy, 72.2 percent of the 18 patients studied were equalized, witha residual difference of up to 0.5cm between the limbs. The rangeof the ATD showed an average of -0.34 cm in the preoperative period, 2.18 cm in the immediate postoperative period, and 1.35 cm in the last evaluation.The ED angle had an average valueof 91º preoperatively, 142º in the immediate postoperative period, and 133º in the last evaluation. CONCLUSION: The subtrochanteric valgus osteotomy, leading to epiphyseal-diaphyseal angles close to 140º, was effective in the correction of deformitiesover time.

Osteocondrite de Van Neck-Odelberg: relato de 4 casos / Van neck-odelberg osteochondritis: report on 4 cases

A osteocondrite de Van Neck-Odelberg é uma doença rara, que acomete a sincondrose isquiopúbica. Foram avaliados quatro crianças em idade escolar com queixa de dor súbita no quadril esquerdo. As radiografias mostravam alteração da sincondrose isquiopúbica. Os casos foram confirmados com ressonância magnética. Todos os casos foram tratados com marcha sem carga no membro acometido por duas a quatro semanas com melhora completa do quadro.

The Van Neck-Odelberg osteochondritis is a rare disease that affects the ischiopubic synchondrosis. We evaluated four school-age children with complaints of acute pain in the left hip. Radiographs showed a change in the ischiopubic synchondrosis. The cases were confirmed with MRI. All cases were treated with walking withno weight bearing on the affected limb for two to four weeks with complete improvement of symptoms.

Complicações osteoarticulares da analgesia congênita / Osteoarticular complications of congenital analgesia

Os autores apresentam dois irmãos com diagnóstico de analgesia congênita, com suas características clínicas e evolução. Essa doença é rara, apresenta alta morbidade e gera complicações osteoarticulares de difícil solução. O objetivo dos autores foi ressaltar a importância do diagnóstico tanto para o tratamento de suas afecções secundárias, quanto para seu aspecto jurídico.

The authors present two brothers with congenital pain insensitivity, with their clinical characteristics and evolution. This disease is rare, has high morbidity and originates complex osteoarticular complications. The aim of the authors was to emphasize the value of the diagnosis for a better treatment and to avoid legal problems to the parents.

Short hospitalization period with elastic stable intramedullary nails in the treatment of femoral shaft fractures in school children.

PURPOSE: To evaluate the safety and period of hospitalization of the treatment of femoral shaft fractures with titanium elastic nails (TEN) in the age range 5 to 14 years. The hypothesis was that TEN might be a low-cost treatment, with good clinical results and short length of hospitalization. METHODS: Thirty children with femur fractures were surgically treated with TEN. RESULTS: The patients spent an average of 9.4 days in hospital. The average period for the healing process was 7.7 weeks. Partial weight bearing was permitted 3.3 weeks after surgery. The incidence of overgrowth was 60%, with an average of 0.40 cm. CONCLUSIONS: The surgical method brings few complications and results in good limb alignment, with a short period of hospitalization and early return to daily activities and school.

EVOLUTION OF SLIPPED CAPITAL FEMORAL EPIPHYSIS AFTER NONSURGICAL TREATMENT.

UNLABELLED: To evaluate the efficacy of conservative treatment of patients with slipped capital femoral epiphysis (SCFE) and the complications due to the progression of the disease. METHODS: 18 patients (26 hips) seen consecutively from December 1996 to August 2006 at the Orthopedics Service of Santa Casa de Misericórdia de São Paulo, who had been referred from other services with a diagnosis of SCFE and were treated without surgery, were retrospectively analyzed. RESULTS: Slip progression occurred in 19 hips (73%). Among the mild cases, eight remained mild, four became moderate and one became severe, according to the Southwick classification. Four out of the six originally moderate cases became severe and the two already severe cases worsened. CONCLUSION: Although today there is a consensus regarding the indication of surgical treatment for SCFE to prevent progression, some cases with confirmed diagnoses are still being treated conservatively. This is a major error, since it implies increased morbidity of the disease.

Evolução do escorregamento epifisário proximal do fêrmur após tratamento não cirúrgico / Evolution of slipped capital femoral epiphysis after nonsurgical treatment

OBJETIVO: Avaliar a eficácia do tratamento conservador em pacientes com epifisiólise proximal do fêmur (EEPF) e as complicações devidas à evolução da doença. MÉTODOS: Foram analisados, retrospectivamente, 18 pacientes (26 quadris) consecutivamente atendidos no período entre dezembro de 1996 e agosto de 2006 no Serviço de Ortopedia da Santa Casa de Misericórdia de São Paulo, encaminhados por outros serviços com diagnóstico de EEPF e tratados de forma não cirúrgica. RESULTADOS: A progressão do escorregamento aconteceu em 19 quadris (73 por cento), sendo que, dos quadris com escorregamento leve, oito permaneceram leves, quatro progrediram para moderados e um tornou-se grave pela classificação Southwick. Dos seis quadris classificados como moderados, quatro evoluíram para grave e os dois graves acentuaram-se um pouco mais. Conclusões: Apesar de a indicação cirúrgica ser hoje consenso no tratamento do EEEP para evitar a progressão do escorregamento, há ainda pacientes com diagnóstico confirmado que são tratados de forma conservadora, e isto representa um grande erro, pois implica no aumento da morbidade da doença.

OBJECTIVE: To evaluate the efficacy of conservative treatment of slipped capital femoral epiphysis (SCFE) and the complications due to the progression of the slip. METHODS: 18 patients (26 hips) seen consecutively from December 1996 to August 2006 at the Orthopedics Service of Santa Casa de Misericórdia de São Paulo, referred from other services with a SCFE diagnosis and treated without surgery were retrospectively analyzed. RESULTS: Slip progression was observed in 19 hips (73 percent). Among the mild cases, 8 remained mild, four turned moderate and one became severe according to Southwick classification. Four out of the six originally moderate cases became severe and the two already severe cases worsened. Conclusion: Despite there being a consensus regarding the use of surgical treatment to prevent SCFE progression, some cases are still being treated conservatively. This represents a grave error, since it increases the morbidity of the disease.

Fraturas da diáfise da tíbia em crianças / Tibial diaphyseal fractures in children

As fraturas da diáfise da tíbia nas crianças e adolescentes são lesões relativamente comuns e geralmente têm boa evolução com os métodos clássicos de tratamento conservador. Sua elevada frequência se deve ao alto grau de exposição da criança nas suas atividades físicas e também pela anatomia e topografia da tíbia, expondo-a ao trauma direto ou indireto. Algumas particularidades devem ser consideradas e respeitadas na sua abordagem, que compreendem aspectos atinentes à faixa etária, local de acometimento (se proximal ou distal), tipo de fratura e de terapêutica instituída. A vantagem anatômica do periósteo mais espesso e a relativa flexibilidade na acomodação de impactos angulares podem proporcionar na criança de menor idade, maior estabilidade e consequente tendência ao melhor prognóstico. Nas crianças maiores e nos adolescentes o grau de exposição a traumas de maior energia, a maior gravidade e complexidade das lesões têm tornado mais comum a estabilização cirúrgica. Complicações encontradas nessas fraturas nos adultos como infecção, retarde de consolidação e pseudartrose são muito menos frequentes nas crianças, mas o risco de instalação de síndromes compartimentais é uma eventualidade que requer atenção, principalmente nas condutas incruentas com imobilizações gessadas.

Tibial diaphyseal fractures in children and adolescents are relatively common injuries and often evolve with good results when treated through traditional methods of conservative treatment. Their elevated frequency is due to the high degree of exposure of children in physical activities and also to the topographic location, exposing them to direct or indirect trauma. The approach used should consider and respect some features regarding age, place of affection (whether proximal or distal), type of fracture and therapy. The anatomical advantage of a thicker periosteum and flexibility when submitted to angular impacts can provide younger children with greater stability and, consequently, increases their chances of a better prognosis than older children and adolescents. In the latter, the degree of exposure to high-energy trauma and the greater complexity and severity of injuries have caused the recent trend towards stabilization surgery to become more common. Frequent complications in the evolution of fractures in adults such as infection, delayed union and non-union are much less common in children, although the risk of occurrence of compartment syndrome is an event that requires attention, especially with plaster.

LIMPING IN CHILDREN.

Limping in children is a common complaint at pediatric, pediatric orthopaedic offices and in emergency rooms. There are several causes for this condition, and identifying them is a challenge. The older the patient, the better the anamnesis and more detailed the physical examination will be, enabling an easier medical assessment for searching the source of the disorder. In order to make the approach easier, three age groups can and should be considered. Among infants (1 to 3 years old), diagnosis will most likely be: transitory synovitis, septic arthritis, neurological disorders (mild brain palsy (BP) and muscular dystrophy), congenital hip dislocation (CHD), varus thigh, juvenile rheumatoid arthritis (JRA) and neoplasias (osteoid osteoma, leukemia); in the scholar age group, between 4 and 10 years old, in addition to the diagnoses above, Legg-Calvé-Perthes disease, discoid meniscus, inferior limbs discrepancy and unspecific muscular pain; in adolescents (11 to 15 years old): slipped capital femoral epiphysis, congenital hip dislocation, chondrolysis, overuse syndromes, dissecans osteochondritis, and tarsal coalition. The purpose of this study is to provide an update on how to approach pediatric patients presenting with limping, and to discuss its potential causes.

Claudicação na criança / Limping in children

A claudicação na criança é uma queixa frequente nos consultórios dos pediatras, dos ortopedistas pediátricos e nos pronto-socorros. Diversas são as causas para essa condição e identificá-las torna-se um desafio. Quanto maior a idade do paciente, melhor é a coleta da anamnese e mais completo se torna o exame físico, facilitando o raciocínio médico na busca da origem do distúrbio. Para facilitar a abordagem, três grupos etários podem e devem ser considerados. No grupo etário infantil, de um aos três anos de idade, os diagnósticos mais prováveis incluem: sinovite transitória, artrite séptica, desordens neurológicas (paralisia cerebral (PC) branda e distrofia muscular), displasia do desenvolvimento do quadril (DDQ), coxa vara, artrite reumatoide juvenil (ARJ) e neoplasias (osteoma osteoide, leucemia); no grupo etário escolar, dos quatro aos 10 anos de idade, além dos diagnósticos acima, doença de Legg-Calvé-Perthes, menisco discoide, discrepâncias de comprimento dos membros inferiores e "dor do crescimento"; nos adolescentes, dos 11 aos 15 anos de idade: epifisiólise, DDQ, condrólise, síndromes de overuse, osteocondrite dissecante e coalizão tarsal. A proposta deste trabalho é atualizar o leitor em relação à abordagem do paciente pediátrico que apresenta claudicação e discutir as suas prováveis causas.

Limping in children is a common complaint at pediatric, pediatric orthopaedic offices and in emergency rooms. There are several causes for this condition, and identifying them is a challenge. The older the patient, the better the anamnesis and more detailed the physical examination will be, enabling an easier medical assessment for searching the source of the disorder. In order to make the approach easier, three age groups can and should be considered. Among infants (1 to 3 years old), diagnosis will most likely be: transitory synovitis, septic arthritis, neurological disorders (mild brain palsy (BP) and muscular dystrophy), congenital hip dislocation (CHD), varus thigh, juvenile rheumatoid arthritis (JRA) and neoplasias (osteoid osteoma, leukemia); in the scholar age group, between 4 and 10 years old, in addition to the diagnoses above, Legg-Calvé-Perthes disease, discoid meniscus, inferior limbs discrepancy and unspecific muscular pain; in adolescents (11 to 15 years old): slipped capital femoral epiphysis, congenital hip dislocation, chondrolysis, overuse syndromes, dissecans osteochondritis, and tarsal coalition. The purpose of this study is to provide an update on how to approach pediatric patients presenting with limping, and to discuss its potential causes.