Pediatric Limp

Asymmetric deviation from normal gait pattern (i.e. antalgic: stance phase shortened in the painful limb with a resultant increase in the swing phase)

Differential Diagnosis of a Pediatric Limp by age

  • All ages
    • Neoplastic
    • Infectious: osteomyelitis, septic arthritis, Lyme disease
    • Trauma
  • 1 – 3 years
    • Trauma: toddler’s fracture
    • Developmental: developmental dysplasia of the hip, leg length discrepancy
    • Neuromuscular: CP
  • 4 – 10 years
    • Vascular: Legg-Calve-Perthes disease (AVN femoral head)
    • Inflammatory: juvenile idiopathic arthritis, transient synovitis
  • 11 – 16 years
    • Orthopedic/Degenerative: slipped capital femoral epiphysis, Osgood-Schlatter (tibial tuberosity apophysitis)
    • Trauma: overuse syndromes

History

  • Pain vs painless: onset, location, duration, nocturnal, severity, characteristic, allev/aggrav factors, radiation, symptoms associated (weight loss, fevers, rash, arthralgia, back pain, void/stool problems)
  • Limp: acute/chronic, course since onset, course throughout day (worse in morning?), unilateral, history trauma, prior episodes, limited activity
  • Recent illness
  • Antibiotic exposure
  • Sports activity
  • Ability to weight bear
  • Past medical history, surgeries, allergies, medications, family history

Physical exam

  • Vital signs
  • Skin
  • Spine – abnormal curvature (kyphosis and scoliosis), flexion and extension, midline abnormalities (e.g. hair tuft, dimple)
  • Neurological – tone, deep tendon reflexes (DTR’s)
  • Musculoskeletal
    • Muscle strength
    • All joints – swelling, erythema, atrophy, asymmetry, deformity, skin changes, temperature, effusion, tenderness, crepitus, ROM, Faber’s
    • Limb length (measured from the anterior superior iliac spine to the medial malleolus), Galeazzi test
    • Standing position
      • Genu varum (bowing of the tibias normal until 2-3 years old)
      • Genu valgum (knock knees normal until 2-4 years old)
      • Flat foot
      • Trendelenburg maneuver (assess level of hips while pt stands on affected leg)
      • Pain with weight bearing
    • Gait – remove shoes, socks, pants

Investigations

  • Bloodwork
    • Infectious markers, ESR, CRP
  • Imaging
    • Xrays (trauma, Legg-Calve-Perthes, neoplasm)
    • Bone scan (infectious, neoplasm)
    • US (septic arthritis)
    • CT/MRI (infectious)
  • Aspiration (septic arthritis, osteomyelitis)

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