Limping

By admin On Dec 11, 2022

Ovid: Pediatrics

Editors: Tornetta, Paul; Einhorn, Thomas A.; Cramer, Kathryn E.; Scherl, Susan A.

Title: Pediatrics, 1st Edition

> Table of Contents > Section II: – Emergency Department > 10 – Limping

Limping

Richard M. Schwend

Jon Shereck

Limping is a common complaint in children of all ages.
The child often presents to the primary care physician or to the
emergency room with either a limp or has completely stopped walking. It
is important to understand normal walking development and mechanics
when evaluating the child with a limp.

Although young children fall frequently, they have
normal protective reflexes, and being already close to the ground,
injuries are rare. The very young child learning to walk relies on a
variety of compensations, typically involving proximal body segments,
to keep from falling. These include:

Hands held high
A wide-based gait
Hip, knee, and ankle flexion
Increased time in double stance

Walking maturity follows very predictable developmental milestones (Table 10-1).

PATHOGENESIS

Etiology

Limping is a compensation for a disorder of normal
walking mechanics. Limping can be caused by a large variety of
conditions from high in the central nervous system such as a brain or
spinal cord tumor, or by very distal problems, such as a foreign body
in the foot.

TABLE 10-1 DEVELOPMENTAL MILESTONES OF WALKING MATURITY

Age	Milestone
13 mo	Independent walking
18 mo	Reciprocal arm swing, heel-strike
24 mo	Normal knee flexion in stance
36 mo	Mature angular rotations
7 yr	Adult pattern, single-limb stance, velocity, cadence, step length

Pathomechanics

The following disturbances of normal walking mechanics
may cause a child to limp. By determining the mechanism for the limp,
the physician can more specifically use the physical examination to
determine cause.

Pain

Antalgic Gait

Less time is spent in single-leg-stance.
Stride length is shortened. The child walks slowly and cautiously. When
severe, the child will refuse to walk.
Most common reason a child will acutely limp.
Common conditions include acute
fractures, such as a toddler fracture of the tibia or calcaneus, stress
fracture, infection (especially in the hip), and foreign body in the
foot.

Weakness

Trendelenburg or Waddling Gait

The hip muscles are stabilizers for single limb stance. The child uses the proximal segments to compensate for distal weakness.
A trunk shift toward the affected side (Trendelenburg gait) is used to compensate for weak hip abductors.
Increased lumbar lordosis compensates for anterior pelvic tilt from weak hip extensors.
The child hikes the hip and flexes the
knee excessively during swing phase to clear a dropped foot due to a
weak tibialis anterior muscle.
The Gower sign, in which the child uses
the hands to climb up the thighs, is a classic example of using
proximal compensation for distal weakness, as seen in Duchenne muscular
dystrophy.

Short Limb

In contrast to adults, children with a very short limb typically compensate by walking on the toes on the involved side.
Hemiplegia and developmental dysplasia of
the hip are frequent causes of a short limb, although other mechanisms
also affect the gait in these conditions.

P.84

Joint Stiffness

This is commonly seen in the early stages of Perthes disease with synovitis and restricted hip motion.
There is typically an adduction contracture and loss of internal rotation and extension.

Spasticity

Common in children with spastic cerebral palsy.
Children with spastic diplegia typically have a history of prematurity.
The child with mild spastic hemiplegia
may have a delay in walking (after age 18 months) and a very subtle
limp. Asking the child to run accentuates the limp and the upper
extremity posturing. The orthopaedic surgeon will frequently be the
first physician to recognize this condition.

Poor Balance

Seen in children with cerebral palsy,
Friedrich ataxia, and Charcot-Marie-Tooth disease. Patients with
Charcot-Marie-Tooth disease have been described as having a stiff
“marionette gait.”

BOX 10-1 CLASSIFICATION OF LIMPING BY AGE

All Ages

Septic hip arthritis
Trauma and abuse
Leukemia
Discitis
Developmental dysplasia of the hip
Neoplasia
Neuromuscular conditions
Juvenile rheumatoid arthritis
Epidural abscess
Discoid lateral meniscus
Sacroiliac joint infection
Cellulitis
Stress fracture
Foreign body

Toddlers (1-3 Yr)

Septic hip arthritis
Tibia fracture
Calcaneal fracture
Spastic hemiplegia
Developmental dysplasia of the hip

Children (4-10 Yr)

Transient hip synovitis
Perthes disease
Juvenile rheumatoid arthritis

Adolesents (>10 Yr)

Slipped capital femoral epiphysis
Spondylolisthesis
Overuse injuries
Tarsal coalition
Gonococcal septic arthritis
Osteonecrosis of the femoral head
Chondrolysis of the hip

Classifications

Classification can be made based on several factors:

Age (Box 10-1).
Limping disasters, both acute and chronic. This is the most important classification (Box 10-2).
Location (Box 10-3).
System (Table 10-2).

BOX 10-3 CLASSIFICATION OF LIMPING BY LOCATION

General

Fractures
Overuse
Child abuse
Leukemia
Arthritis
Osteomyelitis
Soft tissue infection
Neuromuscular conditions
Benign bone lesions
Malignant bone lesions

Abdominal and Pelvic

Appendicitis
Kidney infection
Psoas abscess
Pelvic abscess
Pelvic mass

Central Nervous System and Spine

Cerebral palsy
Spina bifida
Spinal cord tumor
Epidural abscess Discitis
Spondylolysis
Herniated disc
Vertebral end-plate fracture
Hereditary sensory motor neuropathy

Hip

Septic arthritis
Transient synovitis
Perthes disease
Slipped capital femoral epiphysis
Pelvic infection

Lower Extremity

Limb length discrepancy
Tibia fractures
Calcaneal fractures
Foreign body

P.85

TABLE 10-2 CLASSIFICATION OF LIMPING BY SYSTEM AND SIGNS AND SYMPTOMS^a

Condition	Signs, Symptoms, Pearls
Congenital and Developmental
Developmental hip dysplasia	Unstable hip newborn, limited abduction in older infant
Limb length discrepancy	May walk on toes; measure limb lengths
Torsional deformities	Best detected on prone examination
Idiopathic toe walking	Exclude cerebral palsy or muscle dystrophy
Mild clubfoot	Equinus, heel varus, forefoot adductus
Coxa vara	Trendelenburg limp, radiographic changes
Short femur	Galeazzi sign, confirm on radiograph
Discoid lateral meniscus	Clicking in knee, lack of full knee extension
Intraarticular ganglion	Pain, restricted knee extension
Tarsal coalition	Pain, subtalar stiffness, valgus foot, or varus
Infection-Related
Septic hip arthritis	III, fever, hip pain at rest
Septic arthritis	Fever, pain, stiff swollen joint
Osteomyelitis	Pain, swelling if superficial, fever
Epidural abscess	Pain, fever, won’t walk, loss of function
SI joint infection	Pain, fever, pain with FABER
Discitis	Back pain, abdominal pain, won’t walk
Lyme disease	Erythema migrans, arthritis
Appendicitis	Pain, loss of apetitite, abdominal tenderness
Pylonephritis	Back pain, fever
Poliomyelitis	Muscle pain, weakness
Tuberculosis of bone	Swelling, radiograph changes, positive PPD
Guillain-Barré syndrome	Ascending generalized weakness
Traumatic and Stress-Related
Child abuse	Multiple lesions or fractures
Acute fractures	Pain, swelling, deformity
Stress fractures	Pain with activity
Slipped capital femoral epiphysis	Hip pain with activity, loss of internal rotation in flexion
Tibia, calcaneus, and cuboid toddler fractures	Swelling, tender to palpation, often not diagnosed for several weeks
Vertebral end-plate fracture	Trauma, back pain, radiculopathy
Sprains and contusions	Very common
Foreign body	Often missed
Osteochondroses	Pain, swelling, or mechanical symptoms
Neuromuscular
Cerebral palsy, hemiplegia	Mild delay walking, subtle limp
Spina bifida	Worsening gait may be from tethered cord or shunt malfunction
Duchenne muscular dystrophy	Boys; toe walking or loss of walking ability
Spinal cord tumor	Pain and night pain, loss of function
Hereditary sensory motor neuropathies	Cavus feet, “marionette gait,” subtle hip weakness
Friedrich ataxia	Balance problems, may present as scoliosis
Tethered spinal cord	Pain, spasticity, loss of function
Inflammation
Transient hip synovitis	After viral illness, less ill than septic hip
Juvenile rheumatoid arthritis	Chronic joint pain and effusion
Ankylosing spondylitis	Back and sacroiliac joint pain, stiffness
Henoch-Schönlein purpura	Periarticular findings may precede purpuric rash, abdominal pain and hemorrage, renal
Benign Neoplasia
Osteoid osteoma	Night pain relieved by aspirin
Osteoblastoma	Pain, lesion larger than 2 cm
Unicameral bone cyst proximal femur	No findings, or pain, or pathologic fracture
Langerhan histiocytosis	Pain, skeletal lesions, diabetes insipidus
Intramuscular hemangioma	Pain, swelling of superficial lesions
Chondroblastoma	Pain and swelling, epiphyseal location
Malignant Neoplasia
Spinal cord tumors	Pain, night pain, loss of function
Osteogenic sarcoma	Pain, swelling, or mass
Ewing sarcoma	Pain, swelling, or mass
Leukemia	Malaise, fever, joint swelling, pain
Rhabdomyosarcoma	Soft tissue mass, pain
General and Metabolic, Genetic
Sickle cell disease	Pain crisis, osteonecrosis
Hemophilia	Joint pain, swelling, muscle bleeds
Rickets	Pain, swelling, irritable, deformity
Hyperparathyroidism	Skeletal and abdominal pain, irritability, mental status changes
Scurvy	Pain and swelling, bleeding gums, skin rash
Other Causes
Legg-Calvé-Perthes disease	Hip pain, stiffness, and limp
Conversion reaction	Symptoms do not fit the physical findings
^a Although by no means complete, this classification is an extensive list of common and uncommon conditions. Use it as a checklist and supplement to the other classifications if the diagnosis is still uncertain.
FABER, flexion, abduction, external rotation; PPD, positive protein derivative; SI, sacral iliac.

P.86

DIAGNOSIS

History and Examination

A thorough history and physical examination with
thoughtful consideration of pathophysiology and classification should
usually determine the most likely location and cause of the limp.
During the evaluation, the physician should be particularly suspicious
of the limping disasters listed in Box 10-2.

History

Child’s age.
Acute or chronic onset.
History of trauma or infection.
Is pain present? Be very specific about onset, location, quality, intensity, and radiation.
Constant pain or night pain is always worrisome and suggests infection or tumor.
Morning pain suggests childhood arthritis.
Bilateral or unilateral symptoms? Bilateral suggests generalized conditions.
Is child systemically ill? Limp with
lower extremity pain, fever, and malaise lasting for several weeks
suggests a serious general condition such as leukemia

Physical Examination

Undress the child sufficiently to visually observe. Goal is to precisely localize the area of pathology.
Does the child appear ill or well?
Is the child protecting or splinting a particular body part, such as the hip? If the child has significant hip pain at rest,
suspect septic arthritis. Due to the frequency of important pathology
found at the hip, a careful examination of this area is essential.
Gait: If the child seems well, first
examine while walking. Observe the feet, knees, hips, and spine during
stance and swing phase. Observe with both of normal and abnormal
walking mechanics in mind.
Standing examination: Observe spine for symmetry, lesions, and range of motion.
Trendelenburg sign.
Have patient get up off the floor (Gower maneuver).
Tabletop examination: Observe the
patient’s most comfortable position. Patients with transient synovitis
are typically comfortable at rest, whereas those with septic hip
arthritis are not.
Look for swelling and rash. Lightly touch skin to check for warmth. Have child do active range of motion before passive motion is checked. Gently roll the child’s foot internally and externally to check hip rotation.

Radiologic Findings

Children who appear well, but have a limp, have a 96% chance of having a normal radiograph.
Radiographs should be used to confirm the suspected diagnosis, not to make the diagnosis.
Fractures and Legg-Calvé-Perthes disease are the two most common conditions diagnosed on plain radiographs.
Some fractures such as spiral tibia or
calcaneal fractures in the toddler are not apparent on radiographs
until 2 or 3 weeks later when new bone is formed.
Image the entire pelvis—anteroposterior and lateral—when obtaining a hip radiograph. Do not
use a pelvic shield as it will obscure important findings and often
requires the film to be repeated, thus increasing the radiation dose.

Other Imaging Studies

Ultrasound
- □ Highly sensitive for detecting hip effusion, but less specific to distinguish transient synovitis from septic hip arthritis.
- □ The presence of fluid in hip joint must be explained, especially if the ESR and CRP are elevated.
- □ Ultrasound is useful for examining other joints and soft tissues.
Bone scan
- □ Sensitive but not very specific.
- □ Rarely is needed urgently to decide treatment.
- □ Useful for screening the entire skeleton in child abuse, suspected discitis, pelvic osteomyelitis, and osteoid osteoma.
- □ Useful for detecting overuse injuries and stress fractures.
- □ Test tends to be overused.
Magnetic resonance imaging
- □ Helpful to image suspected spinal cord tumors, epidural abscess, discitis, pelvic abscess and soft tissue lesions.
- □ Consult with radiologist before test is performed.
- □ Always look at the images yourself and preferably with the radiologist.

Other Studies

Complete blood count
- □ Use to screen for elevated leukocytes and anemia.
- □ With an elevated erythrocyte
  sedimentation rate (ESR), the combination of thrombocytopenia, anemia,
  neutropenia, lymphocytosis, and blasts cells present on the peripheral
  smear is very suggestive of childhood leukemia.
ESR
- □ Sensitive indicator of inflammation and should always be obtained if infection, arthritis, or malignancy is suspected.
- □ Slow to rise and fall: It is increased
  after 24 to 48 hours and may remain elevated for several weeks after
  appropriate treatment of infection.
- □ An ESR over 50 mm per hour is associated with an important diagnosis in three-fourths of limping children.
C-reactive protein
- □ Acute phase protein made in the liver, responds to inflammation.
- □ Rises within 6 hours and becomes normal within 6 to 10 days.
- □ More sensitive than ESR in following resolution of infection.
Joint aspiration
- □ Aspirate joint if septic arthritis is a possibility.
- □ A dry tap in the hip joint may still be an infection. Use arthrography or ultrasound to confirm that needle is truly in the joint.
- □ Normal fluid less than 200 leukocytes with 25% polymorphonuclear (PMN).
- □ 75% of patients with septic arthritis have more than 80,000 PMN.

Putting It All Together

An ill-appearing child who is not walking is always of concern and suggests a serious diagnosis (Box 10-2).
The physical examination should locate the area of involvement. Fever,
severe or night pain, non-weightbearing and tenderness on palpation,
combined with an elevated ESR, suggest a deep inflammatory process such
as septic hip arthritis.

TREATMENT

Nonoperative Options

Treatment depends on an accurate diagnosis.
Most causes of limping can be treated conservatively.
Transient synovitis is a frequent cause
of limping or refusal to walk. With bed rest and antiinflammatory
medication, the child may be markedly improved by the next morning. Hip
aspiration is not necessary if the diagnosis is clear and the patient
improves.

Surgical Indications/Contraindications

Septic hip arthritis, epidural abscess, and unstable slipped capital femoral epiphysis require urgent surgical management.
A patient who has lost the ability to
walk should never be sent home from the emergency department without
making a clear diagnosis.

Complications

Septic hip arthritis: Femoral head osteonecrosis, physeal arrest, and arthritis
Epidural abscess: Permanent loss of neurologic function
Unstable slipped capital femoral epiphysis: Femoral head osteonecrosis, chondrolysis, and late degenerative arthritis

PEARLS

Remember the limping disasters (Box 10-2). Missed septic hip arthritis, spinal cord tumor, child abuse, and leukemia are particular disasters to avoid.
The hip is a common site of limping. Disorders about the hip are commonly misdiagnosed.
Developmental hip dysplasia and mild hemiplegia in the toddler are common causes of a delay in walking or a persistent limp.
Always be concerned about the child who loses ability to walk.
Always consider child abuse in the infant, young child, or the patient with multiple bone and soft tissue injuries.
Constant pain and night pain are always worrisome.
If the diagnosis is unclear, reexamine the patient later or consult with a trusted colleague.
If a case is not following a predicted
course for the presumed diagnosis, there may be a different or
unexpected diagnosis. Leukemia is classic for prolonged limping with
many systemic complaints. Other rare conditions such as vitamin D
deficiency and scurvy can show up.
Be aware of the “cold” or “normal” bone scan of the hip. Instead, this may represent vascular compromise to the femoral head.
When aspirating a suspected septic hip
arthritis and no fluid is obtained, the needle might not be in the hip
joint; or, the purulent fluid may be too thick to flow through the
narrow gauge needle.
An adolescent with hip or thigh pain,
especially one who cannot walk, should always be suspected for slipped
capital femoral epiphysis.

P.88