The Limping Child
Wendalyn King MD, MPH
Walking

2 phases
 Stance
 Swing
Both feet in contact with ground only 20%
of gait cycle
 Developmental process

– short, rapid steps
 Adult gait pattern present around age 3
 Toddlers
Limp

Antalgic gait
 Pain
leads to shortened stance phase on affected
side
 Most common acute presentation of limp

Trendelenberg
 Underlying
proximal muscle weakness or hip
instability
 Equal stance phase, but trunk shifts over affected
extremity
 Usually non-painful
 “waddling” gait if bilateral process
Differential Diagnosis

Trauma
 Acute
 Repetitive


SCFE, AVN
Infectious/inflammatory
 Septic
arthritis
 Inflammatory arthritis
 Osteomyelitis
 Diskitis

Neoplastic
 Leukemia
 Primary
and
metastatic bone
lesions
By Age

Toddler (1-3yr)




Infection
Occult trauma
Neoplasia
Child (4-10)






Infection
Transient synovitis
LCPD / AVN
Rheumatologic disorder
Trauma
Neoplasm

Adolescent (11+)
 SCFE
 Rheumatologic
disorder
 Trauma
Evaluation

History
 Onset
of symptoms
 Fever, systemic symptoms
 History of trauma


Often present, may be misleading
Physical examination
 Inspection
 Observe
gait
 Range of motion (feet, knees, hips)
Evaluation
Xray
 Labs

 CBC,
ESR, CRP may be helpful in some
instances

Other imaging
 Ultrasound
 CT
/MRI
 Bone scan
(hips)
Case #1
18 month old with acute onset limp
 Afebrile, otherwise no complaints
 Happy and playful until stands up

 Fussing,

resists weight bearing on R
Normal examination
Toddler Fracture




Spiral fracture of distal 1/3 of tibia
Usually simple fall while running or stepping on
object
May occur up to 6 yr age (peak 2-4yr)
May not be visible on normal AP/Lat film
 Oblique
film
 Repeat films


Callous formation within 1-2 week
Splint/cast
 Healing
within 3-4 weeks
Case #2





2yo male with 1 week of progressive limp and
leg pain
Xray at beginning of symptoms negative
Splinted for presumptive fracture
Low grade fever, increasing fussiness, now
“dragging leg” and refusing to walk
Exam
 Fussy,

?tender to palpation distal L leg
CRP, ESR elevated
Osteomyelitis


Most common in children <10
Usually hematogenous seeding of bone
 Trauma


(even minor) may predispose
Usually begins in metaphaseal region of long
bone
Inflammatory exudate collects in marrow, cortex,
subperiosteal space
 Ischemia
leads to infarction and pain
 Form area of necrotic bone called sequestrum

Eventually separates to form free body or may be reabsorbed
Osteomyelitis

Common organisms
 Staph
aureus most common
 Group B strep in neonates
 H. flu, Strep pyogenes, Salmonella,
Pseudomonas, Kingella kingae

May be difficult to localize
 Neonates
 Spine,
pelvis
Osteomyelitis

Diagnosis
 Radiographs
 May be normal or nonspecific for 10-14 days
 Bone scan, CT, MRI may be needed
 Acute phase reactants
 WBC normal initially in 60% cases
 CRP rises in 8 hours, peaks 2 days, normalizes over 1 week
 ESR normal in 25% new onset cases, may be useful for
monitoring therapy
 Blood
culture positive 50-60% cases
 Bone aspiration or biopsy
 Treatment is 3-6 weeks of antibiotic therapy
Case #3
4 year old female with worsening limp and
leg pain. Tactile fever at home
 Recent URI, otherwise healthy
 Exam

 Uncomfortable,
approached
lying in bed, cries when
Septic Arthritis

Usually hematogenous seeding
 Extension
of osteomyelitis
 Direct inoculation into joint from penetrating trauma

Etiology
 Staph
aureus
 (H. flu historically)
 Kingella kingae
 Neonates: E. coli, Candida, GBS
 Adolescents: N. Gonorrhea
Septic Arthritis

Presentation
 Acute


joint inflammation
Swelling, redness, pain
“Pseudoparalysis”
 Joint
held in position to maximize intra-articular space
and minimize pressure and pain




Hip – flexion, abduction, external rotation
Knee - partial flexion
Shoulder – adduction and internal rotation
Elbow – midflexion
 Often
have fever and ill appearance
Septic Arthritis

Diagnosis




Blood culture positive 30-40%
Elevated CRP, ESR
Arthrocentesis
Imaging



Widening of joint space, soft tissue swelling
Ultrasound useful for hip effusion
Treatment



Antibiotic
Irrigation and drainage
Prompt surgical drainage of hip (and often shoulder) needed to
reduce intra-articular pressure and avoid avascular necrosis of
femoral head
Diagnostic Dilemmas

Transient synovitis of hip (“toxic synovitis”)
Non-infectious, inflammatory condition
 Usually children 3 – 8yrs
 May follow viral URI
 Mild fever, limp, fussiness
 Minimal limitation of range of motion
 ESR, CRP, WBC usually normal
 Managed with rest, NSAIDs, close follow up

Diagnostic Dilemmas
Overlying cellulitis vs Septic Arthritis
 Other causes of acute arthritis

 HSP
 Serum
sickness
 JRA, lupus
 Tick borne illness
Case #4
4 yo male with 3d h/o limp and thigh pain
 No fever
 Some improvement with ibuprofen
 Active and playful
 Uncomfortable with rotation of hip

Avascular Necrosis
Legg-Calve-Perthes Disease
 Usually occurs 2 – 12 yrs (avg 7)
 Males > female
 May be secondary to repeated microtrauma
 Recurrent episodes of hip irritability
common

AVN

Risk of later degenerative arthritis
 Worse
prognosis with older age (>10) and
extensive femoral head deformity
 Very good prognosis in children <5

Treatment
– rest, pain meds
 Observation for children <6
 Surgery for older children with severe
involvement
 Symptomatic
Case #5




5yo female with several days of leg and back
pain, decreased appetite and activity and
?weight loss
Xrays pelvis at outside facility negative 2 d
before
Pt alert, thin, ill and uncomfortable appearing.
Cries with manipulation of hips/legs. ? Firmness
to palpation in upper abdomen
CBC, chemistry normal
Neoplastic
Leukemia
 Neuroblastoma
 Primary bone tumors

 Benign
Unicameral bone cyst
 Osteoid osteoma

 Malignant


Ewing and osteogenic sarcomas
Spinal tumors
Case #6
12yo male with chief complaint of knee
pain
 Present for a couple weeks, acutely
worsened after playing basketball
 No fever, no other symptoms
 Exam: walks with limp

– no swelling, no tenderness, normal
range of motion
 Knee
Slipped Capital Femoral Epiphysis
(SCFE)



Most common adolescent hip disorder
Type of epiphyseal fracture
Common in obese adolescents
(also in tall, thin kids after growth spurt)


May present with chronic limp, acute pain or
combination
Hold leg in slight external rotation and have
limited internal rotation
SCFE

Xray
 Need
both hips for comparison
 Need frog-leg radiograph
 Earliest sign is widening of epiphysis

“pre-slip” condition
 Line
drawn along outer aspect of femoral
neck should intersect the femoral capital
epiphysis
Case #7
15 yo male brought in by EMS for sudden
onset severe hip and leg pain
 Was running 40 yard dash for football
tryouts when developed severe pain and
difficulty ambulating
 Exam: very uncomfortable, pelvis stable
but painful to palpation, pain with hip
movement, especially hip flexion

Avulsion


Probably secondary to repetitive
stress/microfracture
3 common sites (at major muscle insertions)
 Anterior
inferior iliac spine
 Superior iliac crest
 Ischial tuberosity


Initial therapy is rest, crutches, pain meds
Outpatient orthopedic follow up
Summary

Many causes of acute limp
 Range
from trivial (new shoes) to life
threatening
 Thorough history and physical important
 Liberal use of imaging studies
 Keep in mind common conditions for each
age group
 Close follow up if diagnosis in doubt
Questions???