Limp in children

Question 1

Probability diagnosis

Answer 1

Post trauma/intense exercise causing strain syndromes Ill-fitting shoes

Hip disorders, esp. transient synovitis

Heel disorders (12–14 years)

Question 2

Serious disorders not to be missed

Answer 2

Toddlers

Developmental dysplasia hip (DDH)
Child abuse
Septic arthritis
Foreign body (e.g. needle in foot)

4–8 years
Perthes’ disorder
Transient synovitis

Adolescents
Slipped capital femoral epiphysis (SCFE)
Avulsion injuries (e.g. ischial tuberosity)
Osteochondritis dissecans of knee
Duchenne muscular dystrophy

All groups
Acute viral infections
Appendicitis
Septic infections:

• septic arthritis
• osteomyelitis
• tuberculosis

Cerebral palsy
Rheumatic fever
Tumour (e.g. osteosarcoma)
Juvenile idiopathic arthritis (oligo articular)
Juvenile rheumatoid arthritis
Spinal disorders:

• discitis
• fracture

Question 3

Pitfalls (often missed)

Answer 3

Foreign body (e.g. in foot)

Osteochondritis (aseptic necrosis):

• femoral head: Perthes’ disorder
• knee: Osgood–Schlatter disorder
• calcaneum: Sever disorder
• navicular: Köhler disorder

Myalgia = ‘growing pains’

Overuse syndrome (esp. adolescent):

• patellar tendonopathy (jumper’s knee)

Stress fractures (e.g. tibia, femoral neck, navicular)

Question 4

Key history

Answer 4

• Hx of trauma,
• Foci of infection including the skin
• Any unusual developmental problems.

The most common reasons and refuse to walk;

1. Trauma
2. sepsis
3. synovitis
4. DDH are perhaps

A painless waddling gait suggests DDH or Perthes’ disorder.

The limp must be considered to be due to a definite organic cause.

It is appropriate to focus initially on the hip.

Ask about the relationship of the limp to exercise and footwear.

Question 5

Key examination

Answer 5

The hip and the knee joints should be examined carefully if the source of the limp has no specific localisation

Get the child to walk and run on the toes and heels.

Note the gait and check whether it is;

• antalgic (painful)
• hemiplegic (arm held out in a balancing action)
• Trendelenburg (classic for DDH)

Look for evidence of muscle dystrophy

Never forget to examine the soles of the feet and between the toes

Question 6

Key investigations

Answer 6

FBE and ESR/CRP

blood culture

needle aspiration of joint

radiological:

• plain X-ray
• ultrasound
• bone scan
• CT or MRI scan.

Question 7

Diagnostic tips

Answer 7

Multiple fractures and epiphyseal separations in toddlers are highly suggestive of child battering—order a skeletal survey if suspected.

An acute limp may be due to;

• limb and spinal
• infection (osteomyelitis, septic arthritis)
• fracture
• an irritable hip (synovitis)

Chronic cases include;

• cerebral palsy
• DDH
• Perthes’ disorder
• chronic SCFE.

Infections of and around the hip joint are most common in infancy.

Classically, the hip is held immobile in about 30% of flexion with slight abduction and external rotation.

Hip pathology can cause pain in the knee.