Evaluation of Imaging Study Results in Limping Patients Related to Hip

Adil Hasan Ali Akbar,Osamah Ayad Abdulsattar,Hasanain Ahmed Al-Bayati
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Keywords : Imaging study; CT; MRI; limping; Hip
Medical Journal of Babylon  14:1 , 2017 doi:1812-156X-14-1
Published :16 July 2017

Abstract

Limping is a common chief complaint among children while presenting to the orthopaedic clinics need medical attention and essential consultation from orthopaedic surgeon. To evaluate the imaging study findings of limping patients and their associated risk factors and causes related to hip joint. 80 patients with limping who referred from orthopaedic clinics to radiological clinic in Al-Hilla Teaching Hospital for imaging study of hip joints, between December 2010 and December 2015 were included in this study. Report information of the patient regarding name, age, sex, address, medical and family history and short examination of gait, hip joints and lower limbs. Then imaging study for hip joints done. Clinically (26.3%) of patients had pain, meanwhile, (22.8%) of patients had unilateral pain. (78.8%) of patients had equal leg length and (75.0%) of patients had normal daily activity. (81.3%) had normal range of motion. (81.3%) of limping patients had positive findings by CT scan and MRI. (35.4%) of limping patients with positive finding had perthes disease. Majority of limping patients related to hips appear positive finding by imaging studies, which lead to definitive diagnosis. In addition, the most common cause of limping related to hip joints in this study was perthes disease. Imaging studies (C-T scan, MRI) are good tools for diagnosis of limping patients related to hip causes

Introduction

Refusal to walk or limping is a common chief complaint among children while presenting to the orthopaedic clinics need medical attention and essential consultation from orthopaedic surgeon [1]. Limping might result from pain, weakness or deformity and there is a wide range of causes that may produce a limp in childhood ranging from simple unfitted shoe to the first manifestation of life-threatening neoplasm [2, 3]. In order to confirm limping diagnosis we need to differentiate limping from physiologic and anatomical deformities that may lead to abnormal gait [4]. Although normal gait is a process of functional and healthy joints, muscles and bones as well as normal neurological system, however, majority of children who limp follow a benign course [1-3]. In a study done by Fischer and Beattie reported that 0.2% of children present to the emergency department ororthopaedic clinic complaint from limping each year. Two third of limping children were boys and majority of limping were unilateral [4]. Although, majority of limping children have been received in orthopaedic clinics after 2 to 3 days of their complaining from pain or refusal to walk. However, after performing an appropriate systematic history, a comprehensive physical examination and necessary laboratory testing and diagnostic imaging most of limping children are discharged without further adverse event [5]. The main concerns related to limping children are the wide spectrum of differential diagnosis for limping child which can range from slight pain due to sprains to neoplasm changes, therefore, orthopaedic surgeon are facing challenge about how to evaluate and manage limping child [5]. There are many serious diseases mimic in their presentations to simple causes of limping around hip joint which might include bone or joint septic arthritis, primary or metastatic tumours of bone, Perthes’ disease and slipped femoral capital epiphysis (SFCE) as well as trauma [1-10]. Although, the importance of limping in children and its challenges to clinicians and parents, however, there is no information on the magnitude of limping and evaluating diagnosis and management. This study has been carried out to evaluate the imaging study findings of limping patients and their associated risk factors and causes related to hip joint.

Materials and methods

Study design/Study Location
This hospital-based cross-sectional study was carried out in a General Teaching Hospital.
Study population
80 patients with limping who received in radiological clinics referred cases from orthopaedic clinic for imaging study of hip joints, between December 2010 and December 2015 were included in this study. We report information of the patient regarding name, age, sex, address, medical history (specially the pain site, time, type, duration), family history and short examination for gait, hip joints and whole lower limbs. Then we did imaging study for hip joints.
All procedures performed in study involving human participants were in accordance with the Declaration of Helsinki in observing human rights.
Instruments and procedures
CT protocol for pelvis:
A)    Whole pelvis (for any case that does not specify the SI joints)
“FAI” add oblique reformats, parallel to femoral necks. reformat slices 3mm Thick at 3mm Intervals in all 3 planes.
1) Straight Axial Reformats
2) Straight Coronal Reformats
3) Straight Sagittal Reformats
B) Judet Views (For every case with Acetabulum Fracture)
C) SI Joints: reformat 3mm thick at 3mm intervals
1) Oblique Coronal Reformats
2) Oblique Axial Reformats
MRI protocol for pelvis:
1-    T1 TSE coronal 3 mm
2-    T2 STIR coronal 3 mm
3-    T1 TSE axial 3 mm
4-    T2 STIR axial 3 mm
5-    T2 TSE sagittal SFOV affected side.
6-    PD fat sat axial oblique 3 mm SFOV affected side.
Statistical Analysis
Statistical analysis was carried out using SPSS version 20. Categorical variables were presented as frequencies and percentages. Continuous variables were presented as means with their 95% confidence interval (CI). The Pearson s chi-square test (x2) test was used to determine the associations between categorical variables. A p-value of ? 0.05 was considered as statistically significant.




Results

80 patients with limping have been referred from orthopaedic clinics to radiological clinic of teaching hospital for imaging study of hip joints. The overall mean age of patients was (14.95±4.33) years old, (31.3%) of patients were older than 16 years (Figure 1). (61.3%) of patients were males, meanwhile, (42.5%) of patients were from urban areas. Distribution of Patients with Limping by Medical History Table 1 shows the distribution of patients with limping by medical history. (36.3%) of patients had family history of neurological and musculoskeletal abnormalities, meanwhile, (31.3%) of patients had history of rickets. Only (25.0%) of limping patients had history of abnormal gait. (21.2%) and (26.3%) of limping patients had history of neuromuscular problems and history of structural abnormalities, respectively.

Discussions

Limping is the presentation of a hidden cause and a challenge for orthopaedic surgeons that may happen at any age, and the definitive diagnosis by careful history, physical examination and the use of imaging techniques is recommended. Many cases of limping children will pass with no diagnosis due to absence of severe illness and spontaneous resolution, meanwhile, worsen limping might be happened if there is delay in careful follow up and diagnosis [1, 4]. Limping can be a cause of previous trauma, infection, inflammation, tumour as well as congenital anomalies. However, determining the definitive pathology is the cornerstone in treating a limping child. This study has found that the limping was increased at adolescent age group and more boys than girls were affected which reflect their more predispositions to trauma and other illness. However, it is difficult for young children to remember trauma and the time of injury as well as localization and development of pain tend to be unclear [11]. Majority of limping patients appeared to have positive radiological finding by CT scan and MRI. Although, most of limping patients experienced no pain, difficult to localized the pain and have no sleep disturbance due to pain as well as appeared normal leg length with normal daily activity and wide range of motion but with duration of limping for more than two years duration. It is attributed to fact that, most of limping children presented on the day when symptoms started, meanwhile, significantly many cases of limping appeared a notable delay and late presentation to hospital due to absence of serious illness [12]. Furthermore, there were significant associations of CT scan and MRI Finding by pain, sleep disturbance and pain location which indicated that the feeling and site of pain is not a reliable indicator of the site of pathology. Although, there were significant associations of CT scan and MRI finding by histories of rickets, gait, neuromuscular problems and structural abnormalities of limping patients. However, majority of limping patients had no family history of neurological and musculoskeletal abnormalities as well as no history of neuromuscular and structural abnormalities or rickets and appeared normal gait. There are several pathologies related to hip joint responsible for limping in children. This study reported that, (35.4%) of limping patients with positive finding had perthes, although its uncommon disease. However, it misdiagnosed with different causes of limping including trauma and developmental, inflammatory, and coagulation abnormalities [9]. Meanwhile, only (3.1%) of patients had developmental dysplasia of hip. Therefore, differentiating of normal developmental changes from disease states represents a difficulty in the diagnosis for orthopaedic surgeon.

Conclusions

1- Majority of limping patient related to hips appear to have positive finding by imaging studies which lead to definitive diagnosis. 2-most of limping patient presented for imaging studies in late stages of the disease because of absence of serious symptoms early. 3- the most common cause of limping related to hip joint in this study is perthes disease. 4- imaging studies (C-T scan, MRI) are a good tools for diagnosis of limping patients.

References

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