Limp
Evaluation of limp in a child can be very difficult. The differential is very wide, and the history is often nonspecific. Physical examination may likewise be unremarkable or nonspecific. Limp may be the herald sign of a systemic condition, so treatment may be directed at the underlying cause rather than at the affected extremity.
Differential Diagnosis
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Transient synovitis: Etiology unknown; may be viral, postviral, or traumatic; occurs in preschool children, M>F; presents with limp or refusal to walk
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Malignancy: Neuroblastoma, leukemia, sarcoma (Ewing, osteogenic), rhabdomyosarcoma
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Osteochondritis dissecans: Necrosis of the articular surfaces due to repetitive stress
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Fracture
–Stress fracture of foot, subtle ankle, foot fractures, patellar avulsion fracture, toddler's fracture of the tibia
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Musculoskeletal injury
–Knee and ankle injuries are most common in school-age and adolescents during athletics or vigorous activity
–Meniscal and ligamentous injuries to the knee are increasingly common
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Spine: Compression fracture, herniated disc, diskitis
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Rheumatologic: JRA, ankylosing spondylitis, SLE
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Legg-Calvé-Perthes disease (LCP): Vascular insult to the proximal femoral epiphysis leading to osteonecrosis
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Slipped capital femoral epiphysis (SCFE): Result of weakness of the perichondral ring, leading to slippage through the hypertrophic zone in the growth plate of the proximal femoral epiphysis
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Osgood-Schlatter (OSD): Repetitive small avulsion injuries at the tibial tuberosity
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Infectious
–Septic arthritis of hip: Fever, hip pain, refusal to walk, limp
–Septic arthritis of knee: Swelling, usually
fever, well-localized pain
–Lyme arthritis
–Cellulitis
–Soft-tissue abscess
–Osteomyelitis (pelvis, femur, knee, foot,
ankle)
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Duchenne muscular dystrophy
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Charcot-Marie-Tooth disease (CMT)
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Non-accidental trauma (NAT)
–Musculoskeletal injury in a child who is not developmentally capable of an action that would cause such an injury is very suspicious
Workup and Diagnosis
- History
–Pain: Musculoskeletal is worse in the evening and after activity; malignancy may present with pain at night, early morning pain may be transient synovitis or JRA
–Duration of symptoms: Long-term is more alarming
–Malaise, fever, activity
–Exposure to STD, ticks
–Location of pain
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Physical exam
–Areas of tenderness, muscle weakness or atrophy
–ROM of spine, extremities
–Spine abnormalities, tenderness, SI joint
–Symmetry
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Labs
–ESR, CBC
–Blood culture if osteomyelitis or septic joint is
suspected
- Studies
–Plain films, including special views as directed by H&P; tunnel view for osteochondritis dissecans; frog-leg view to evaluate the joint space of the hip
–Bone scan is best for osteomyelitis, may be positive in
malignancy
–CT for benign bony lesions
–MRI for soft-tissue lesions and sarcomas
Treatment
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Transient synovitis: Resolves with supportive care
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Malignancy: Referral to oncologist
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Osteochondritis dissecans: Rest, immobilization, or surgical debridement and fixation
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Musculoskeletal injury: Variable depending on degree and location of injury; options include supportive care, physical therapy, surgical reconstruction
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Fractures: Variable depending on degree and location of injury: options include traction, casting, surgical pins
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Rheumatologic: Generally treated with NSAIDs, steroids, immunosuppressives
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LCP: Rest, traction, bracing, surgery
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SCFE: Non-weight bearing, percutaneous pinning
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Infectious: Appropriate antibiotics for cellulitis, septic arthritis, osteomyelitis, diskitis
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OSD: Resolves with decreased activity, rest, NSAIDs
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Duchenne MD and CMT: Progressive neurologic deterioration; physical therapy may help
Book Source Details
- Book Title: In A Page: Pediatric Signs and Symptoms
- Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
- Year of Publication: 2007
- Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Limping
Read excerpts from these other book chapters related to Limping:
Medical Books Excerpts
- Limp
- "In A Page: Pediatric Signs and Symptoms" (2007)
- [ read ]
- Limp
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
More About Causes of Limping
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More About This Book:
Title: In A Page: Pediatric Signs and Symptoms
Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 1-4051-0427-9
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» Next page: Limp (The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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