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The Limping Child

Introduction

'The Limping Child' is a relatively common presentation to clinicians in general practice and/or A&E, with referrals often being made to paediatric or orthopaedic departments. The presentation can be difficult to diagnose especially when initial assessments are difficult in children. 

It is important to establish the cause of limping - this may be due to pain, weakness or musculoskeletal deformity.

History and examination followed by any necessary investigations will allow a suitable management plan to be established.

History

It is important to find out as much about the limp as possible, particular factors to ask about are:

  • Onset e.g. sudden, gradual, recurring/ remitting
  • Precipitating cause e.g. trauma, post-infection or fever
  • Duration e.g. constant vs. intermittent limp or any specific pattern
  • Progression of the limp e.g. improving or getting worse
  • Aggravating factor(s) e.g. flexion/extension of hip, micturition, increased physical activity
  • Complaint(s) of pain, hip pathology often presents as pain referred to the knee or back
  • Characteristic(s) of pain e.g. cramping, pulling, sharp, dull etc
  • Site(s) of pain*
  • Sleep disturbance e.g. is the pain so severe the child is woken from sleep? 
  • Associated symptom(s) e.g. weakness, swelling, redness, stiffness
  • Systemic symptom(s) e.g. weight loss, fever, night sweats
  • Med history e.g. sickle cell anaemia, juvenile arthritis, ankylosing spondylitis, malignancy
  • Drug history e.g. blood thinning medication, immunosuppressants
  • Family history e.g. rheumatological, neuromuscular disease etc.
  • Impact on activities of daily living
  • Social history e.g. what is the situation at home, carers, schooling etc.
  • Developmental history
  • Travel history 

*N.B. Bilateral nocturnal pain unrelated to other symptoms during the day could represent growing pains. This is a diagnosis of exclusion.

        Examination

        Examination should be carried out to make sense of the cause(s) of limp. It is important to have the child adequately exposed and to ensure you have assessed their gait appropriately.

        Examination should include:

        • Measurements of temperature and other vital signs
        • Measurements of the true and apparent leg lengths
        • Assessment of gait (if child is able to walk)
        • Inspection of the position adopted and for asymmetries of the trunk, hips and the lower limbs
        • Inspection of the affected leg for erythema, rashes, muscle bulk, swelling, deformity, hypermobility
        • Inspection of the shoes for wear, indicating uneven weight distribution and/or unusual movements
        • Exclude simple problem e.g. foreign body embedded in foot
        • Palpate the limb for tenderness, joint effusions etc
        • Assess the spine for any deformity, scoliosis, pain or limited range of movement
        • Assess range of movement of the lower limb joints (in supine and prone positions)
        • Examine the neurological system if appropriate e.g. cerebellar examination if ataxic gait is evident
        • Comparison with non-affected leg

          Differential diagnosis

          This should be narrowed down by analysing the limp by means of the:

          • Pattern of gait;
          • Presence or absence of pain;
          • Age of the child; and
          • Region of anatomy that is involved e.g. back, hip, knee, ankle, foot 

              Investigations

              If the limp is the only complaint and the child is otherwise well, a prescription of analgesia e.g. paracetamol, ibuprofen and arrangement for follow up could be considered. Parents and their children should be encouraged to return earlier if the limp worsens or new symptoms develop.

              • X-ray the tender or swollen area (AP and lateral films), especially if the history includes trauma. If there is no obvious tenderness on examination, an x-ray of the pelvis and hips should be organised. Ideally the joint above and below the problematic area should be imaged as well
              • WCC, CRP, ESR to confirm elements of infection and inflammation. Increased WCC, CRP and positive findings on abdominal imaging may point towards a diagnosis of psoas abscess.
              • If problem appears to be coming from hip but x-ray is inconclusive, ultrasound scan should then be requested. The combined use of ultrasound +/- needle aspiration of joint contents may be useful in cases of septic joints, effusions and/or abscesses.
              • Bone scans could highlight increased metabolic activity seen in stress fractures, infection and some tumours.
              • Pelvic x-ray indicating sacroillitis and positive HLA-B27 are suggestive of ankylosing spondylitis.
              • MRI appears to be useful in some cases.

               

                Acute causes of limp and those requiring urgent consideration



                Differential diagnosis: classification by age

                There are particular diagnoses that are more common in particular age groups. This table displays possible diagnoses according to three age groups: toddler, child and adolescent.



                Summary of differential diagnosis (click to enlarge mindmap)

                Mindmap summarising possible sources of a limp

                Management, Discharge Planning and Final Points

                After admission to hospital and management of the condition, it is important to ensure the child is ready to go home and will be supported by parents or carers. Children should be integrated back into schooling steadily if a significant period of time at school has been missed.

                As in all paediatric cases, it is vital to have non-accidental injury (NAI) at the back of your mind at all times. Children presenting with a history of trauma, an unclear or changing history and/or other signs as mentioned in the table above are vulnerable and should be monitored closely. 

                References and suggested readings

                1. Oxford Handbook of Emergency Medicine. 4th Edition. By Jonathan P. Wyatt, Robin N. Illingworth, Colin A. Graham, Kerstin Hogg - Oxford University Press (2012)

                2. Pediatric Orthopaedics and Sports Injuries - A Quick Reference Guide. By John F. Sarwark, Cynthia R. LaBella - American Academy of Pediatrics (2010)

                3. BMJ Best Practice Assessment of gait disorders in children. Last updated: March 2013.

                4. Approach to a child with a limp. The University of British Columbia. Last updated: Nov 2011. Date accessed: April 2013. Available from: http://learnpediatrics.com/body-systems/musculoskeletal-system/approach-to-the-child-with-a-limp/

                5. Causes of Limp in Children. Family Practice Notebook. Date accessed: April 2013. Available from: http://www.fpnotebook.com/rheum/Sx/CsOfLmpInChldrn.htm

                6. Wheeless' Textbook of Orthopaedics 

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