Madesa Espana, MD, FAAP
Pediatric Emergency Medicine
St. Joseph’s Regional Medical Center
Paterson, New Jersey

LIMP

An uneven, jerky or laborious gait, usually caused by pain, weakness or deformity.

4/1000 visits in a pediatric ED

A CHILD WITH A LIMP

Epidemiology
– Median age: 4 years old
– Male:female ratio: 2:1
– Most common diagnosis: Transient synovitis
– Pain is present in 80% of cases
– Localization: hip and knee
– Benign cause: 77%

THE CHILD WITH A LIMP

HISTORY
– Duration
– Trauma
– Fever

THE CHILD WITH A LIMP

HISTORY
– Location of the pain
– Pain characteristics
 Constant severe pain
 Intermittent mild to moderate pain
 Bilateral pain
 Modifying factors

THE CHILD WITH A LIMP

HISTORY
– Other symptoms
 Morning stiffness
 Incontinence, weakness or sciatica
 Recent viral or bacterial illness
 Recent medications
 Endocrine and other systemic diseases

THE CHILD WITH A LIMP

PHYSICAL EXAMINATION
– General appearance
 Ill or toxic appearing
 Fever
 Obvious discomfort/pain at rest

THE CHILD WITH A LIMP

PHYSICAL EXAMINATION
– Gait evaluation
 Phases of a gait
– Stance: time when the foot is in contact with the surface
 Heel-strike to toe flat (contact)
 Foot-flat to heel-off (mid-stance)
 Heel-lift to toe off (propulsion)
– Swing: time from toe-off to heel strike

THE CHILD WITH A LIMP

PHYSICAL EXAMINATION
– Young child (<4 years) vs. adult gait
 Increased flexion of the hips, knees and ankles
 Rotation of the feet externally, wider base of support
 Faster cadence, slower velocity, shorter stride length
 Smaller percentage of the gait cycle is spent in single limb stance

THE CHILD WITH A LIMP

PYSICAL EXAMINATION
– Gait examination
 Expose the legs
 Bare feet or wearing only a pair of socks
 Listening to the gait
– Cadence
– Foot slap
– Scraping

THE CHILD WITH A LIMP

PHYSICAL EXAMINATION
– Gait examination
 Observe several gait cycles
 Includes jumping/hopping

Gait evaluation

THE CHILD WITH A LIMP

PHYSICAL EXAMINATION
– Musculoskeletal
 Muscle strength
 Muscular atrophy
 Bony tenderness
 Bony deformity

THE CHILD WITH A LIMP

PHYSCIAL EXAMINATON
– Musculoskeletal
 Active and passive ROM
 Joint swelling/tenderness
 Muscle tenderness
 Tenderness on the tendons, insertions sites

THE CHILD WITH A LIMP

PHYSICAL EXAMINATION
– Musculoskeletal
 Back and spine
 Hip
 Thigh
 Knee
 Leg
 Ankle
 Foot

THE CHILD WITH A LIMP

PHYSICAL EXAMINATION
– Musculoskeletal
 Limb length discrepancy
 Hip rotation
 Galeazzi test
 Trendelenburg test
 FABERE test

THE CHILD WITH A LIMP

PHYSICAL EXAMINATION
– Skin
 Bruises
 Rashes and other lesions
 Swelling
 Redness
 Tenderness

THE CHILD WITH A LIMP

PHYSICAL EXAMINATION
– Lymphatic
 Lymphadenopathy
– Localized vs. systemic
 Lymphadenitis
 Lymphangitis

THE CHILD WITH A LIMP

PHYSICAL EXAMINATION
– Neurologic
 Muscle strength
 Muscle tone
 DTR’s

THE CHILD WITH A LIMP

PHYSICAL EXAMINATION
– Gastroentestinal
 Abdominal tenderness
 Abdominal swelling
– Genitourinary
 Testicular or scrotal pain/swelling
 Inguinal swelling

THE CHILD WITH A LIMP

DIFFERENTIAL DIAGNOSES
– Age of the child
– Location of abnormal findings
– Duration of symptoms
– Type of gait abnormality

THE CHILD WITH A LIMP

DIFFERENTIAL DIAGNOSES
– OSSEOUS
 Fractures
– Salter-Harris or growth plate injuries
– Toddler’s: tibia, calcaneous and cuboid
– Stress
– Incomplete: buckle, greenstick
– Complete
– Plastic or bowing deformity
– Avulsion
– Child abuse: bucket-handle fractures

THE CHILD WITH A LIMP

DIFFERENTIAL DIAGNOSES
– OSSEOUS
 Apophysitis
– Sinding-Larsen-Johnson disease
– Kohler disease
– Sever disease
– Freiberg disease
– Osgood-schlater disease

THE CHILD WITH A LIMP

DIFFERENTIAL DIAGNOSES
– OSSEOUS
 Vasoocclussive crisis of SCD
 Slipped capital femoral epiphysis
 Legg-Calve-Perthes disease

THE CHILD WITH A LIMP

DIFFERENTIAL DIAGNOSES
– TUMORS
 Leukemia
 Lymphoma
 Spinal cord tumor
 Osteogenic sarcoma
 Ewing’s sarcoma
 Osteoid sarcoma
 Metastatic neuroblastoma

THE CHILD WITH A LIMP

DIFFERENTIAL DIAGNOSES
– ARTICULAR
 Transient synovitis of the hip
 Septic arthritis
 Osteochondritis dessicans
 Acute rheumatic fever
 Juvenile rheumatoid arthritis

THE CHILD WITH A LIMP

DIFFERENTIAL DIAGNOSES
– ARTICULAR
 Serum sickness
 Discitis
 Developmental dysplasia of the hip
 Chondromalacia of the patella
 Hemarthrosis: traumatic, hemophilia

THE CHILD WITH A LIMP

DIFFERENTIAL DIAGNOSES
– ARTICULAR
 Henoch-Schonlein purpura
 Lyme disease
 SLE
 Patellar dislocation

THE CHILD WITH A LIMP

DIFFERENTIAL DIAGNOSES
– SOFT TISSUE
 Contusion
 Muscle strain
 Sprain
 Tendonitis
 Viral myositis
 Foreign body

THE CHILD WITH A LIMP

DIFFERENTIAL DIAGNOSES
– SOFT TISSUE
 Cellulitis
 Abscess
 Pyomyositis
 IM vaccination
 Insect envenomation
 Plantar warts

THE CHILD WITH A LIMP

DIFFERENTIAL DIAGNOSES
– SOFT TISSUE
 Bunion
 Ingrown toenail
 Baker’s cyst rupture
 Myositis ossificans
 Bursitis
 Benign hypermobility syndrome

THE CHILD WITH A LIMP

DIFFERENTIAL DIAGNOSES
– NEUROLOGICAL
 Meningitis/Intracranial abscess
 Cerebral palsy
 Peripheral neuropathy
 Epidural abscess
 Spinal cord tumor
 Complex regional pain syndrome (reflex sympathetic dystrophy)

THE CHILD WITH A LIMP

DIFFERENTIAL DIAGNOSES
– INTRA-ABDOMINAL
 Appendicitis
 PID
 Pelvic abscess
 Psoas abscess
 Perirectal abscess
 Iliac adenitis

THE CHILD WITH A LIMP

DIFFERENTIAL DIAGNOSES
– GENITO-URINARY
 Incarcerated inguinal hernia
 Testicular torsion
 STD’s

THE CHILD WITH A LIMP

DIFFERENTIAL DIAGNOSES
– PSYCHIATRIC
 Conversion disorder
 Malingering

THE CHILD WITH A LIMP

DIFFERENTIAL DIAGNOSES
– DERMATOLOGIC
 Erythema multiforme
– VASCULAR
 Henoch-schonlein purpura

THE CHILD WITH A LIMP

DIFFERENTIAL DIAGNOSES
LIFE OR LIMB-THREATENING CAUSES OF
LIMP IN CHILDREN
Septic arthritis SCFE
Osteomyelitis
Tumors
Testicular torsion
Meningitis
Fracture
Appendicitis
Discitis
Epidural abscess
Developmental dysplasia of the hip


CAUSES OF LIMP IN CHILDREN
OF ALL AGES
ACUTE
– Contusion
– Foreign body
– Fracture
– Osteomyelitis
– Reactive arthritis
– Septic arthritis
– Transient synovitis
– Lyme arthritis
– Poor shoe fit

CHRONIC
– Rheumatic disease
 JRA
 Acute rheumatic fever
 SLE
 Inflammatory bowel disease

THE CHILD WITH A LIMP

SEPTIC ATHRITIS
– Clinical signs/symptoms
 Fever
 Pain
 Decreased ROM
 Minor trauma

THE CHILD WITH A LIMP

SEPTIC ARTHRITIS
– Clinical signs/symptoms
 Toxic or ill appearance
 Painful ROM
 Joint effusion
 Warmth/erythema

THE CHILD WITH A LIMP

SEPTIC ARTHRITIS
– Laboratory findings
 Elevated WBC count with left shift
 Elevated ESR
 Elevated CRP
 Positive blood culture

THE CHILD WITH A LIMP

SEPTIC ARTHRITIS
– Laboratory findings
 Synovial fluid analysis
– Volume > 3.5 ml
– Clarity: opaque
– Color: yellow to green
– WBC: > 100,000/mm3, >75% PMN’s
– Gram stain/Culture: positive
– Total protein: 3 – 5 g/dl
– Glucose: <25 mg/dl
– LDH: variable compared to blood level

THE CHILD WITH A LIMP

SEPTIC ARTHRITIS
– Common organisms
 Staphylococcus aureus
 Beta hemolytic streptococcus
 Group A strep
 Hemophilus influenzae
 Neisseria gonorrhea

THE CHILD WITH A LIMP

SEPTIC ARTHRITIS
– Radiologic findings
 Plain films:
– Soft tissue swelling
– Widened joint space
– Periosteal reaction of the adjacent bone, suggestive of osteomyelitis

THE CHILD WITH A LIMP

SEPTIC ARTHRITIS
– Radiologic findings
 Ultrasonography
– Increased joint space and amount of joint fluid
– Increased vascularity
 CT scan
– Joint effusion
– Increased vascularity
– Erosion of the cartillage
– Periosteal reaction or osteomyelitis

THE CHILD WITH A LIMP

SEPTIC ARTHRITIS
– Radiologic findings
 MRI
 Radionuclide studies


CAUSES OF LIMP IN PRE-
SCHOOL CHILDREN
ACUTE
– Fractures
 Abusive injuries
 Toddler’s fracture
 Salter I fractures
– Hemarthrosis
– HSP
– Septic hip
– IM shots
– Toxic synovitis

CHRONIC
– Blount disease
– Cerebral palsy
– Developmental dysplasia of the hip
– Discitis
– Kohler disease
– Leg length discrepancy
– Vertical talus


CAUSES OF LIMP IN SCHOOL-
AGE CHILDREN
ACUTE
– Fractures
– Myositis

CHRONIC
– Legg-calve-Perthes disease
– Baker cyst
– Kohler disease
– Leukemia
– Spinal dysraphism
(tethered cord)
– Tarsal coalition

THE CHILD WITH A LIMP

LEGG-CALVE-PERTHES DISEASE
– Idiopathic vascular necrosis of the femoral head
– More common in boys
– Common in 5 – 9 years old, may affect 2 – 11 years old
– Transitional stage of development of the vascular anatomy of the femur

THE CHILD WITH A LIMP

LEGG-CALVE-PERTHES DISEASE
– Preceding history of minor trauma
– Predisposing factors
 SCD
 Steroid use
 Hip dysplasia

THE CHILD WITH A LIMP

LEGG-CALVE-PERTHES DISEASE
– Radiologic studies
 Plain films
 Radioisotope studies
 MRI

THE CHILD WITH A LIMP

KOHLER DISEASE
– Affects more boys than girls
– Most common in 5 – 10 years old, as early as
2 years old
– Impaired perfusion to the navicular bone of the talus
– Inflammatory changes over the navicular bone

THE CHILD WITH A LIMP

KOHLER DISEASE
– Treatment
 Weight bearing with below the knee cast followed by arch support


CAUSES OF LIMP IN
ADOLESCENTS
ACUTE
– Sprain
– Strain
– Tendonitis

CHRONIC
– Arthritis
– Herniated disc
– SCFE
– Scoliosis
– Spinal dysraphism
– Spondylolisthesis
– Chondromalacia
– RSD
– Osgood-Schlatter

THE CHILD WITH A LIMP

OSGOOD-SCHLATTER DISEASE
– Over use injury affecting the insertion site of the patellar tendon on the anterior tibial tubercle
– Inflammatory changes over the tubercle
– Treatment goal: decrease the stress on the tubercle
 Rest
 Cast
 Excision of an ossicle

Surface Anatomy of the Knee

Saggital view of the knee

THE CHILD WITH A LIMP

SINDING-JOHANSSON-LARSEN DISEASE
– Traction tendinitis of the proximal attachment of the patellar tendon (inferior pole of the patella)
– Boys more than girls
– Age of presentation: 10 –16 years old
– Overuse injury, athletes

THE CHILD WITH A LIMP

SINDING-JOHANSSON-LARSEN DISEASE
– Radiologic findings
 Irregular calcification of the inferior pole of the patella
– Treatment
 Rest
 Cast

THE CHILD WITH A LIMP

SLIPPED CAPITAL FEMORAL EPIPYSIS
(SCFE)
– Epiphyseal dislocation in superolateral displacement and external rotation of the femoral metaphysis, Salter I injury
– Causes kinking of the epiphyseal vessels that leads to compromised blood to the epiphysis

THE CHILD WITH A LIMP

SCFE
– Incidence
 10/100000
– Boys: 13.5, Girls 8.5/100000
 Regional and seasonal variation
 Initial presentation 20% bilateral hip
– 20 – 40% eventually develop bilateral involvement within 18 months of initial presentation

THE CHILD WITH A LIMP

SCFE
– Radiologic classification
 I: < 33%
 II: 33 – 50%
 III: > 50%
 Displacement in relation to the femoral neck

THE CHILD WITH A LIMP

Treatment
– Depends on the onset of symptoms and grade
– Internal fixation with single cannulated screw
– Prophylactic fixation of the unaffected hip
– Osteomy of the proximal femur

SCFE radiographs

THE CHILD WITH A LIMP

LABORATORY STUDIES
– Blood tests
 CBC, differential
 ESR
 CRProtein
 Blood culture
 Lyme studies
 ANA
 ASO

THE CHILD WITH A LIMP

LABORATORY STUDIES
– Normal synovial fluid characteristics
 Highly viscous
 Clear
 Essentially acellular
 Protein concentration is 1/3 of plasma protein
 Glucose concentration is similar to plasma

THE CHILD WITH A LIMP

LABORATORY STUDIES
– Components of synovial fluid analysis
 Clarity
 Color
 Viscosity
 Glucose content
 Protein content

THE CHILD WITH A LIMP

LABORATORY STUDIES
– Components of synovial fluid analysis
 Microscopic examination
– WBC count
– Crystal search
– Gram satin
 Culture
– Routine bacterial culture
– GC culture
– Unusual organisms

THE CHILD WITH A LIMP

RADIOLOGIC TESTS
– Plain radiographs
 Affected site
 Comparison views
 Skeletal survey

THE CHILD WITH A LIMP

RADIOLOGIC TESTS
– MRI
– Radionuclide studies
– Ultrasonography
– CT scan

THE CHILD WITH A LIMP

DISPOSITION
– In-patient
 IV antibiotics
 Diagnostic work-up
 Surgical intervention
– Out-patient
 Observation with close follow up
 NSAID’s
 Sub-specialty referrals

THE CHILD WITH A LIMP

DISPOSITION
– Consultation
 Orthopedic
– Joint aspiration
– Surgical intervention
 Hematology-Oncology
– Bone marrow aspiration
– Chemotherapy

THE CHILD WITH A LIMP

DISPOSITION
– Consultation
 Gynecologic
– Pelvic examination
– Surgical intervention
 Urology
– Surgical intervention

THE CHILD WITH A LIMP

DISPOSITION
– Consultation
 Neurosurgery
 Pediatric or general surgery
– Surgical intervention
 Infectious disease
– Choice of antibiotics
– Length of treatment

THE CHILD WITH A LIMP

DISPOSITION
– Consultation
 Rheumatology
 Pain specialist
 Psychiatry
 Physiatry
– Physical/occupational therapy
– Orthotics

THE CHILD WITH A LIMP

DISPOSITION
– Diagnoses that require immediate intervention
 Septic arthritis
 Osteomyelitis
 Meningitis
 Epidural abscess

THE CHILD WITH A LIMP

DISPOSITION
– Diagnoses that require immediate intervention
 Fractures
 Dislocated patella
 SCFE
 Developmental dysplasia of the hip

THE CHILD WITH A LIMP

DISPOSITION
– Diagnoses that require immediate intervention
 Neoplasms/tumors
 Testicular torsion
 Appendicitis
 PID with tuboovarian abscess
 Discitis