The Child Who Limps

Gait

• Antalgic: caused by pain, short stride length; most of time is spent on the nonpainful limb.
• Trendelenburg: drop of the opposite side of the pelvis with weight bearing on the involved limb; seen with hip abductor weakness or hip joint pain and instability.
• Stooped: walking with increased hip flexion; appendicitis, PID, pelvic abcess.

By Age

• 1-3 year olds: congenital hip abnormalities and septic arthritis [less frequently, occult trauma, neoplasia, neuromuscular disease, diskitis].
• 4-10 year olds: leg length differences, toxic synovitis, Legg-Calve-Perthes Syndrome [less frequently, septic arthritis, osteomyelitis, diskitis, transient synovitis of the hip, JRA, trauma, neoplasm]
• 11-16 year olds: slipped capital femoral epiphyses, stress fractures, osteochondritis dessicans, hip dysplasia [JRA, leg length discrepancy, neoplasia].

History

• Age
• Trauma
• Recent immunizations
• Viral Syndromes
• Fever
• Antibiotics
• Location of pain (eg, knee)
• Chronicity of pain
• Relation to activity (eg, exacerbates the pain)
• Timing of pain
• Activities (eg, new sport)
• Shoes

Physical

• Spontaneous activity/gait on carpet barefooted and undressed (except diaper or underwear)
• Palpate nontender areas first
• Leg length: anterosuperior iliac spine to the medial malleolus
• Muscle strength, atrophy, ternderness
• Joint tenderness, effusion, range of motion, warmth, inflammation
• Deformity
• Skin rashes (HSP, Lyme disease, JRA)
• Foreign body/trauma
• Development: walks with assistance at 12 months, walks independently at 15 months, and runs at 18 months.

Labs

• CBC
• ESR (if greater than 20, needs hip aspiration)
• Plain radiograph
• Ultrasound of hip
• Bone scan

Transient Synovitis of Hip

• Most common cause of limping in young children
• Post-viral, trauma, allergic hypersensitivity
• 9 months to adolescents (peak at 6 years)
• Usually unilateral
• Low-grade or no fever
• Non-ill appearance
• ESR normal or mildly elevated
• Ultrasound to confirm effusion
• Treatment: bedrest and NSAIDs
• Duration of one week in 67%; less than 4 weeks in 88%

Toddler's Fracture

• 1-4 year olds
• Minimal history of trauma or physical findings
• Subtle findings on radiograph: distal tibia or calcaneus

Slipped Capital Femoral Epiphysis (SCFE, "skiffy")

• Slow, chronic
• Late childhood and adolescence (growth spurt): 11-13 in girls and 13-15 in boys
• Bilateral disease in 25% of cases
• Stable versus unstable
• Pain and antalgic gait; may develop Trendelenburg gait
• Pain exacerbated by activity -- often referred to the knee
• Obligatory external rotation of the hip with flexion; decreased ROM (cannot bring thigh to abdomen); acute shortening of the afffected limb
• Radiograph: AP and lateral frogleg position; draw line through superior femoral neck: should intersect less than one third of the epiphysis (ice cream cone sign)

Legg-Calve-Perthes Disease

(idiopathic avascular necrosis)

• 3-12 years of age (most commonly 5-7 year olds); boys more often than girls
• Unclear etiology (repetitive infarction and revascularization)
• May have associated coagulation defects
• Insidious onset of limp, then antalgic gait, then Trendelenburg gait
• Often referred to knee
• Loss of internal rotation and abduction of hip
• Four states of radiograph: failure of capital femoral epiphysis to grow, fragmentation, reossification, healing (with residual deformity)
• Onset at younger than 6 years of age do better.

Septic Arthritis

• Early diagnosis and treatment makes a huge difference
• hip is most common site in infants and younger children
• Usually monoarticular
• usually with fever and localizing signs
• Joint limited ROM, tenderness, warmth
• ESR elevated in 90% of cases
• WBC elevated in 30-60% of cases
• Arthrocentesis is diagnostic
• Evacuate pus, and give parenteral antibiotics

Osteomyelitiis

• Most common in the first five years of life
• Femur, humerus, fibula
• Elevated ESR; less commonly, elevated WBC
• Blood cultures are positive in half of cases
• Radiographic changes only after 10-14 days
• Bone scan helpful in inconclusive cases
• Evacuate subperiosteal pus

Diskitis

• Nonspecific inflammation of the intervertebral disk
• Most common in less than 5 year olds
• Gradual onset
• Associated with back pain and paraspinal muscle spasm
• Low-grade or no fever
• Etiology unclear
• Radiograph, bone scan, CR and MRI changes
• Treatment: bed rest and immobilization -- benign course

Developmental Dysplasia of the Hip

• Formerly known as congenital dislocation of the hip
• Trendelenburg gait and decreased hip abduction
• Bilateral involvement; lordotic, swaying, waddling gait
• Assymetric skin folds
• Difference in height of knees when hips and knees are flexed in the supine position

Reflex Sympathetic Dystrophy

• Antecedant vague trauma
• Allodynia: pain associated with extreme sensitivity to light touch
• Mottling, cyanotic discoloration, swelling, skin temperature difference
• Tache cerebrale: stroke skin with blunt object to get persistent erythematous line

Osteochondritis Dessicans

• Most commonly of the knee (but also ankle, elbow, patella)
• Intermittent pain exacerbated by activity
• Segment of articular cartilate separates from underlying bone
• Radiograph is diagnostic with well-circumscribed fragment of bone

Osgood-Schlatter Disease

• Traction apophysitis of the proximal tibial tuberosity at insertion of the patellar tendon
• Caused by repetitive microtrauma
• Seen in rapidly growing, athletic adolescents
• Relieved with rest
• Promience of the tibial tuberosity
• Clinical diagnosis
• Treatment: Hamstring stretching, avoid forceful contracture of the quadriceps; immobilization

Stress Fracture

• Repetitive loading injury
• Tibia, then ffibula, then pars intraarticularis, then femur
• Radiographic changes present 1-2 weeks after the onset of symptoms
• Bone scan is abnormal sooner

Child Abuse

• Metaphyseal-epiphyseal injuries, rib fractures, vertebral fractures, finger fractures in non-ambulatory child, avulsive fractures of the clavicle and acromium process, multiple fractures, metaphyseal fractures of the long bones.

Osteoid Osteoma

• Pain which is worse at night; relieved by ASA
• May have swelling, muscular atrophy, leg length discrepancy, deformity, constractures
• Radiograph: smooth, regular, ronud, radioluscency (nidus) with surrounding sclerosis

Benign Acute Childhood Myositis

• During epidemics of Influenza
• Muscle pain, tenderness, swelling
• Resolves in 1-2 weeks

Neoplasms

• Ewing sarcoma is most common in the first decade of life (diaphysis of long bones)
• Osteosarcoma is most common in the second decade of life (metaphysis)
• Distal femur and proximal tibia
• Persistance of pain, nocturnal pain, pain at rest
• Radiograph: nonsclerotic margins, indistinct margins, onion skinning, sunburst (calcium deposits radiating perpendicularly from the tumor)

Osteochondroses

• Group of bony lesions in growing bones
• Antalgic limp and pain over involved areas
• Etiology unclear
• Kohler's disease: tarsal, navicular
• Frieberg's disease: head of the second metatarsal
• Sever's disease: heel pain, toe walking

Tarsal Coalitition

• Painful flat foot in adolescents

Non-orthopedic Causes of Limping

• Appendicitis
• CNS infection
• Stroke
• Cerebral Palsy
• Muscular Dystrophy

Best Studies

Radiograph first (sometimes, the whole extremitity)

Bone Scan

• Legg-Calves-Perthes
• Osteomyelitis
• Multifocal disease (osteomyelitis, metastases, histiocytosis)
• Osteoid osteoma

Ultrasound

• Joint effusion (septic arthritis, toxic synovitis)

CT

• Osteoid osteoma
• Tarsal coalition

MRI

• Spinal tumor
• Diskitis
• Legg-Calve-Perthes Disease
• Soft tissue tumor
• Soft tissue abcess

References

Myers, Mellissa.  "Imaging the child with a limp".  Pediatric Radiology 44(3).  June 1997.
 

Orthopedics

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