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)