approach to patient

Approach to a child with limping


  • The pattern of how a person walks
  • A dynamic & repetitive performance
  • Occurs with a definite rhythmic sequence of events that takes during a gait cycle
  • Normal walking is relatively effortless, performed with minimum expenditure of energy


  • The walking sequence requires that the non weight bearing leg moves forward while weight is shifted smoothly from one leg to another
  • The period of time from one heel-ground contact to the next heel-ground contact of the same foot is one gait cycle
  • 2 phases
    • Stance phase
    • Swing phase


    • Normal gait begins with the stance phase
    • The foot is in contact with the floor & the lower limb is bearing all or part of body weight.
    • Begins when the heel strikes the floor & when the toes rise off the floor
    • Occupies 60% of the duration of the cycle


    • The foot is not touching the floor & body weight is borne by the opposite limb
    • Begins immediately the toe leaves the ground until the heel contacts ground
    • Occupies 40% of the gait cycle


    • Any deviation from a normal gait pattern for the child's age
    • Any asymmetric deviation from a normal gait pattern
    • It is a common complaint in childhood, accounting for 4 per 1000 visits in one pediatric emergency department (literature review -August 2007- Mark C Clark)


    • Children complain of pain frequently, but limping is almost always in the context of true organicity
    • The cause of a limp can range from a life-threatening bone tumor to a pebble in a shoe
    • Plain radiographic assessment should be the initial study as 20% of children have unsuspected fractures


    • CNS
    • Spine
    • Hip
    • Knee
    • Ankle
    • Foot
    • Mechanical defects affecting the pelvis, hips, or legs
    • Pain in pelvis, any of the bones, joints, muscles, or other structures of the lower limbs
    • Disorders of the pyramidal or peripheral nervous systems or muscle
    • Disorders of the vestibular structures e.g. vertigo
    • Psychological disturbances
    • Miscellaneous
      • Foot conditions-plantar warts, pressure ulcers
      • Toxic reactions - alcohol, drug,
      • Neoplasms


    • Trauma
      • Fracture
      • Stress fracture
      • Toddler's fracture (minimally displaced spiral fracture of the tibia)
      • Soft tissue
      • Contusion
      • Ankle sprain
      • Child abuse
    • Tumor
      • Spinal cord tumors
      • Tumors of bone
        Benign: osteoid osteoma, osteoblastoma
        Malignant: osteosarcoma, Ewing's sarcoma
      • Lymphoma
      • Leukemia
    • Inflammatory
      • Juvenile rheumatoid arthritis
      • Transient synovitis
      • Systemic lupus erythematosus
    • Congenital
      • Developmental dysplasia of the hip
      • Sickle cell
      • Congenitally short femur
      • Clubfoot
    • Developmental
      • Legg-Calvé-Perthes disease
      • Slipped capital femoral epiphysis
      • Tarsal coalitions
      • Osteochondritis dissecans (knee, talus)
    • Neurologic
      • Cerebral palsy
      • Hemiparesis
      • Hereditary sensory motor neuropathies


    • Age of Onset
      • Developmental dysplasia of the hip and congenital limb length discrepancy - children younger than 3 years
      • Toxic synovitis and Legg-Calvé- Perthes disease - 4 to 10 years of age
      • Adolescence - slipped capital femoral epiphysis


    • Birth to 3 years
      • Septic arthritis
      • Osteomyelitis
      • Fractures
      • Developmental dysplasia of the hip
      • Congenital limb length discrepancy
    • Ages 4 to 10 years
      • Septic arthritis
      • Osteomyelitis
      • Transient synovitis
      • Fractures
      • Legg-Calvé-Perthes disease
      • Juvenile rheumatoid arthritis
      • Leukemia
    • Ages 11 to 18 years
      • Slipped capital femoral epiphysis
      • Avascular necrosis of femoral head
      • Overuse syndromes
      • Tarsal coalitions
      • Gonococcal septic arthritis
    • Sex
      • Developmental dysplasia of the hip -common in girls
      • Legg-Calvé- Perthes disease and slipped capital femoral epiphysis - common in boys
    • Onset of the Limp
      • An acute onset - trauma or infection.
      • A gradual onset with progression of the limp - neuromuscular disorder, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis, rheumatic disease, or malignancy.
      • A chronic limp - mechanical or psychogenic in nature.
    • Recent Trauma or Strenuous Exercise
      • May be difficult to obtain in very young children
      • Obvious trauma in the absence of a consistent history raises the question of child abuse
      • Limping after strenuous activity suggests a musculoskeletal etiology
    • Associated Symptoms- PAIN
      • Exact location and character; severity;localized - fractures, dislocations, osteomyelitis, and septic arthritis
      • Referred pain -hip pathology may present as knee pain and pain from the lower back can be referred to the lateral thigh
      • A painful limp without localization or with migratory bone pain - sickle cell disease or leukemia
      • Limping with bilateral leg pain localized to the calf muscles - myositis
    • Associated Symptoms
      • Severe pain out of proportion to the history of injury - reflex sympathetic dystrophy
      • Painless limp- limb length discrepancy, developmental dysplasia of the hip, or a neuromuscular disease.
      • Muscle pain - more aching in nature
      • Nerve pain - burning or tingling in nature
      • Increasing pain with joint motion - joint problem
      • Fever - infection or inflammation
      • Recurrent fever, rash and joint pain- juvenile rheumatoid arthritis
      • Low grade fever, weight loss, and malaise- with occult malignancy
      • Unexplained bruising in the lower extremities, joint pain, and abdominal pain - Henoch-Schönlein purpura
      • A deterioration of gait or loss of acquired motor skills is suggestive of a neuromuscular disease
    • Precipitating or Relieving Factors
      • Worse in the morning & morning stiffness -juvenile rheumatoid arthritis
      • Worsens with activity - soft tissue strain, stress fracture, overuse injury
      • Relieved by aspirin- osteoid osteoma
      • Pain that worsens throughout the day is typical of muscle fatigue
    • Past History
      • juvenile rheumatoid arthritis,leukemia,TB
    • Family History
      • hemophilia ,sickle cell disease
    • Birth history
      • Prematurity & birth complications-hypoxic brain damage- cerebral palsy
      • Neurological impairment present since birth or early infancy-non progressive cerebral palsy

    Type of Gait

    • Dragging of foot- Hemiplegia, foot drop
    • Dragging of both feet & scissor like gait-Cerebral diplegia


    • Observation of gait
      • Without shoes or socks
      • Walk along a straight line
      • Walking on the balls of the feet, flat footed, or the heels & relative stability of pelvis
      • Associated movements of arms & hand-fingers & hands may flex associated with infolding of the thumbs—corticospinal tract dysfuction
    • General examination
      • weight
      • Height
      • vital signs
    • Poor growth -chronic disorder, neuromuscular disorder or rheumatic disease
    • Fever - infection or inflammation
    • Examination of shoes- for unusual wear, asymmetry, and point of initial foot strike
    • Examination of foot for foreign bodies and calluses
    • Ecchymosis and puncture –trauma
    • Pallor, fever, an appearance of being ill, generalized lymphadenopathy, and hepatosplenomegaly -malignancy, chronic infection, or rheumatic disease
    • A photosensitive rash – systemic lupus erythematosus or juvenile dermatomyositis
    • Musculoskeletal Examination
      • Gait pattern
      • Skin- color, warmth, tenderness
      • Joint-Soft tissue/joint swelling, joint laxity, muscle strength, range of motion and symmetry: Hyperextensibile -benign hypermobility syndrome, Stiff- chronic joint inflammation
      • Measurement of limb lengths - from the patient's anterior superior iliac spine to the medial malleolus
      • Point tenderness over a bone may indicate a fracture or osteomyelitis
      • Muscle atrophy suggests a neuromuscular disorder
      • A stiff, tender spine suggests diskitis
      • A positive FABER test-signifies sacroiliac joint pathology
    • Sensation
    • Deep tendon reflexes
    • Tone
    • Hyperreflexia and spasticity - cerebral palsy
    • Tightness of the hamstring muscles with a limited straight-leg raise - spinal problem


    • TLC,DLC ,ESR, Platelet (Platelet count may be low, or the white cell count elevated in the child with leukemia)
    • CRP (elevated earlier than the ESR and is considered more sensitive for an infectious process; a baseline ESR and CRP helps monitor clinical improvement during antibiotic treatment)
    • Peripheral blood film
    • Blood cultures
    • RA factor, ANA, HLA typing
    • When examined together, the combination of an ESR greater than 20 and a temperature above 37.5°C (99.5°F) identified septic arthritis of the hip in 97 percent of patients presenting with a limp (Del Beccaro MA, Champoux AN, Bockers T, Mendelman PM. Septic arthritis versus transient synovitis of the hip: the value of screening laboratory tests. Ann Emerg Med 1992;21:1418-22)
    • Septic Arthritis- joint aspirate
      • White cell count
      • Gram stain
      • Anaerobic and aerobic cultures
      • Protein and glucose analyses
    • Significant overlap of synovial white cell counts in infection and inflammatory conditions, a white blood cell count above 50,000 per mm3 (50 3 109 per L) should be presumed to be an infection.
    • A septic joint partially treated with antibiotics may have a lower-than-expected white cell count
    • A negative culture does not rule out a septic joint, in about 33 percent of cases, the joint aspirate does not recover an organism (Herndon WA, Knauer S, Sullivan JA, Gross RH. Management of septic arthritis in children. J Pediatr Orthop 1986;6:576-8)
    • If the joint in question is the knee in a sexually active patient, the fluid should be cultured for gonorrhea (Renshaw TS. The child who has a limp. Pediatr Rev 1995;16:458-65)


    • Plain films of the affected area
    • In the nonverbal patient, presenting with a limp- a screening of antero-posterior film from hips to feet identifies a fracture in one fifth of patients (Oudjhane K, Newman B, Oh KS, Young LW, Girdany BR. Occult fractures in preschool children. J Trauma 1998;28:858-60)


    • Plain X-rays
      • At least 2 views
      • Oblique, AP, Lateral views for minimally displaced tibial (Toddler’s) fracture
      • AP & frog lateral view of the pelvis for hip patholgy
    • USG
      • Joint effusion or abscess
      • developmental dysplasia of the hip
      • more sensitive than plain films- identify an effusion in two thirds of a series of 500 children with normal plain films (Miralles M, Gonzalez G, Pulpeiro JR, Millan JM, Gordillo I, Serrano C, et al. Sonography of the painful hip in children: 500 consecutive cases. AJR Am J Roentgenol 1989;152:579-82)
    • Radioisotope uptake scan
      • When the cause of a child's limp cannot be localized by history or physical examination, a bone scan is an excellent way to help localize pathology (Aronson J, Garvin K, Seibert J, Glasier C, Tursky EA. Efficiency of bone scan for occult limping toddlers. J Pediatr Orthop 1992;12:38-44)
      • Perthe’s disease, septic arthritis & osteomyelitis, chronic recurrent multifocal osteomyelitis, stress fracture & osteoid osteoma
    • CT
      • Bone - to demonstrate tarsal coalition, spondylolisthesis/ spondylolisis & osteoid osteoma
    • MRI
      • If soft tissue malignancy or infection is suspected
      • Spinal cord
      • Early diagnosis of Perthe’s disease
      • CT best delineates bone structure, whereas MRI best highlights areas of pathology in the soft tissues, as well as inflammation of bone If soft tissue malignancy or infection is suspected
      • Spinal cord
      • Early diagnosis of Perthe’s disease
      • CT best delineates bone structure, whereas MRI best highlights areas of pathology in the soft tissues, as well as inflammation


    • Depends on the specific cause
    • Besides medical & surgical management, acute & long term rehabilitation are also important.
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