Limp

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Chapter 29 LIMP

Timothy J. Horita

General Discussion

Most children begin walking unassisted between the ages of 12 and 36 months. There is wide variation within this age range and how an individual child progresses. Strength, balance, vision, coordination, and anticipation are only a few of the skills to be mastered for normal gait to be achieved. Shorter steps and a wider shifting of weight from side to side are considered normal compared with that of adults. However, certain patterns of gait abnormalities can provide critical information in detecting common pathology.

Gait is divided into swing and stance phases. The most common form of limp, an antalgic gait, is caused by pain. The time in stance phase is shortened in the painful limb, with a resulting increase in the swing phase. An acute limp implies an underlying pathology that causes disruption of the usual gait pattern.

The older patient may be able to localize a painful joint or area of pain, but referred pain patterns must also be considered. The clinician must consider the spine, pelvis, and lower extremities for a possible cause in a child with a limp. A helpful clinical “pearl” to remember is that knee pain in a child is hip pathology until proven otherwise. Because hip pathology may manifest as knee or thigh pain, the hip must always be considered in patients with knee or thigh pain. The very young child rarely is able to verbalize the location of the pain. If a previously ambulatory child prefers to crawl on his or her knees, foot pathology is more likely.

The differential diagnosis in an acutely limping child can be divided into broad categories of causes, such as traumatic, infectious, inflammatory, neoplastic, congenital, neuromuscular, and developmental. Pain that is worse in the morning suggests a rheumatologic process. Pain at night that awakens a child from sleep is worrisome for a malignant process. If a child has multiple fractures or a fracture of a suspicious nature, child abuse should be considered.

A diagnosis of growing pains must meet three criteria: (1) the leg pain is bilateral; (2) the pain occurs only at night; and (3) the patient has no limp, pain, or symptoms during the day.

A delay in diagnosis can be devastating in some processes, particularly a septic joint. A septic process may result in damage to the cartilaginous surface of a joint. A septic hip may result in avascular necrosis of the femoral head.

Causes of Abnormal Gait

Congenital Problems and Bone Disorders

• Clubfoot

• Congenitally short femur

• Developmental dysplasia of the hip

• Genu valgum

• Leg-length discrepancy

• Osteogenesis imperfecta

• Sickle cell disease

• Spondylolisthesis

• Tibial or femoral anteversion

Developmental

• Legg-Calvé-Perthes disease

• Osteochondritis dessicans

• Slipped capital femoral epiphysis

• Tarsal coalitions

Hematologic

• Hemophilia with hemarthrosis

• Sickle cell disease

Infection

Inflammatory

• Henoch-Schönlein purpura

• Inflammatory bowel disease

• Juvenile rheumatoid arthritis

• Serum sickness

• Systemic lupus erythematosus

• Transient synovitis

Muscular disease

• Muscular dystrophies (many types)

Neurologic or Neuromuscular

Tumor

• Benign bone tumors

Osteoblastoma

Osteoid osteoma

• Malignant bone tumors

Trauma and Overuse

Other

• Hysteria/conversion

• Mimicry

Key Historical Features

Time of onset of limp or abnormal gait

Duration of the limp

Getting better, getting worse, or staying the same

Time of day when the pain occurs

Recent trauma

Painful versus painless limping

Fever or chills

Unexplained weight loss or lack of appropriate growth

Recent viral illness

Past trauma to the lower extremity or back

Myalgias

Morning stiffness or pain

Back pain

Nocturnal pain

Missing school or change in normal activity

Tinnitus or vertigo

Symptoms better with rest or worse with strenuous activity

Relative increase or decrease in physical activity

Clumsiness or lack of coordination

Past medical history

• Seizures

• Inflammatory or infectious disease

• Recurrent fractures or dislocations

Family history of connective tissue disease

Review of systems, especially fever, weight loss, rash, and gastrointestinal (GI) symptoms

Key Physical Findings

Observation of gait and stance

Symmetry of in-toeing, out-toeing, or toe walking

Complete palpation of leg musculature for focal tenderness

Examination of each joint in the legs for swelling, erythema, warmth, or tenderness

Palpation of the spine for local tenderness

Observation of the spine in forward flexion to evaluate range of motion and identify asymmetric turning of the spine

Evaluation of spinal extension

Full range of motion at the hips, knees, and ankles

Measurement of thigh and calf circumference to evaluate for atrophy

FABER test (hip flexion, abduction, and external rotation) to evaluate for pain in the sacroiliac joint

Inspection of forefoot angle and foot shape (Figures 29-1 and 29-2)

Examination of the feet for clawing of the toes or cavus foot deformity

Examination of foot angle with respect to the thigh (Figure 29-3)

Focused neurologic examination

• Walking on the toes

• Walking on the heels

• Hopping on one foot

• Deep tendon reflexes

• Sensory exam

Evaluation of symmetry internal rotation of the hips by placing the child in the prone position with the knees flexed and the ankles falling away from the body (Figure 29-4)

Galeazzi test to evaluate for developmental dysplasia of the hip or a leg-length discrepancy (Figure 29-5)

Figure 29-1 Observation of long axis of foot for medial deformity of metatarsals in relation to long axis of feet.

(From Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:23–66.)

Figure 29-2 Foot shape. Using the same position for measurement of the thigh-foot angle, in Figure 29-3 the shape of the foot can also be evaluated. In this illustration, the left foot has normal alignment, whereas the right foot demonstrates metatarus adductus.

(From Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:23–66.)

Figure 29-3 With patient in the prone position and knees flexed at 90 degrees, foot angle is observed in relation to thighs.

(From Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:23–66.)

Figure 29-4 Examination of hip rotation with the child in the prone position and knees bent at 90 degrees.

(From Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics, 17th ed. Philadelphia: WB Saunders; 2004:23–66.)

Figure 29-5 Galeazzi test.

(From Leet AI, Skaggs DL. Evaluation of the acutely limping child. Am Fam Physician 2000;61:1011–1018, with permission.)

Initial Work-up

Complete blood count (CBC), erythrocyte sedimentation rate (ESR), and/or C-reactive protein (CRP)	If infection or leukemia is being considered
Aspiration of the joint with fluid analysis for cell counts, Gram stain, aerobic and anaerobic cultures, protein, and glucose. Include a culture for gonorrhea if the patient is sexually active	If a septic process is suspected
Plain films of the areas in question. Films of the entire extremity should be considered for referred pain. Films of the entire extremity should be strongly considered in the nonverbal patient (a fracture is identified in 20% of these patients with a limp)	To evaluate the bones and joints

Additional Work-up

Ultrasonography of the hip to identify fluid in the hip joint	Useful when infection of the hip is suspected
Alkaline phosphatase, calcium, electrolytes	If a neoplastic process is suspected
Serum rheumatoid factor	If inflammatory disease is suspected, though inflammatory diseases in children often are seronegative
Creatine kinase	If Duchenne muscular dystrophy is suspected
Bone scan	May be considered when the cause of a child’s limp cannot be localized by history or physical examination
Computed tomography (CT) scan (best to evaluate bone structure) or magnetic resonance imaging (MRI; best to evaluate tissue)	To further evaluate bright areas on bone scan, to further evaluate a particular part of a limb in question, or to evaluate the lumbosacral spine