Published on 21/03/2015 by admin
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Last modified 21/03/2015
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Chapter 29 LIMP
Timothy J. Horita
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.
• Aminoglycosides
• Chemotherapy (many)
• Loop diuretics
• Nonsteroidal anti inflammatory agents (NSAIDs)
• Phenytoin and other anti siezure medications
• Quinine
• Sedatives and hypnotics
• Thalidomide
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
Infection
• Cellulitis
• Diskitis
• Epidural abscess
• Gonorrhea
• Lyme disease
• Myositis
• Osteomyelitis
• Postinfectious reactive arthritis
• Rheumatic fever
• Septic arthritis
• Toxic synovitis
• Tuberculosis of bone
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
• Agyroposis
• Ataxia-telangiectasia
• Cerebral palsy
• Flaccid paralysis
• Hereditary sensory motor neuropathies
• Herniated disc
• Hypotonia
• Spasticity
• Spinal muscular atrophy
• Tethered cord
Tumor
Instant Work-ups A Clinical Guide to Pediatrics
