Abstract
A child who presents with an acute onset of limping can have a serious, sometimes life-threatening diagnosis and must have a comprehensive evaluation. Delays in diagnosis and treatment can result in significant morbidity and mortality. Often the child is too young to communicate symptoms. Historical clues, a comprehensive physical examination combined with laboratory studies, and imaging are often needed to arrive at a final working diagnosis. It is important to develop a stepwise approach to treating the acutely limping child as the differential diagnosis of limp in a child is extensive
Keywords
Blount’s disease, developmental dysplasia of the hip, Legg-Calvé-Perthes, limp, septic arthritis, slipped capital femoral epiphyyses, Toddler’s fracture
1
Why is an acutely limping child a serious concern?
A child who presents with an acute onset of limping can have a serious, sometimes life-threatening diagnosis and must have a comprehensive evaluation. Delays in diagnosis and treatment can result in significant morbidity and mortality. Often the child is too young to communicate symptoms. Historical clues and a comprehensive physical examination combined with laboratory studies and imaging are often needed to arrive at a final working diagnosis ( Fig. 40.1 ). It is important to develop a stepwise approach to treating the acutely limping child. The differential diagnosis of limp in a child is extensive as described in Table 40.1 .
| Traumatic/Mechanical | Fractures, developmental dysplasia, slipped capital femoral epiphysis, tarsal coalition, child abuse, overuse injury, leg length discrepancy, clubfoot, osteochondritis desiccans, Sever disease, Blount disease |
| Infectious | Septic arthritis, osteomyelitis, Lyme disease, psoas abscess, diskitis, appendicitis |
| Inflammatory | Transient synovitis, Reiter syndrome, lupus, juvenal rheumatoid arthritis, ankylosing spondylitis |
| Vascular | Legg-Calvé-Perthes disease, osteonecrosis, sickle cell disease |
| Neoplastic | Leukemia, lymphoma, Ewing sarcoma, osteogenic sarcoma |
| Metabolic | Rickets, hyperparathyroidism |
| Neuromuscular | Muscular dystrophy, cerebral palsy, peripheral neuropathy |
2
What exactly is a limp?
A limp typically will come from an antalgic gait. During an antalgic gait, the stance phase on the affected side will be shortened to prevent pain on that side. Assessing a limp is difficult because most children do not have a rhythmic, steady gait until after 7 years of age, so an acute change in the gait cycle that is typically observed by the parents becomes essential to help evaluate gait.
4
What is the key factor in forming the differential diagnosis for an acutely limping child?
The differential can be narrowed based on age upon presentation. For example, slipped capital femoral epiphyses (SCFE) are more common in overweight boys over the age of 11, while Legg-Calvé-Perthes (LCP) is more common in those between 4 and 10 years of age ( Table 40.2 ). An atraumatic limp in a child up to 3 years of age is most commonly septic arthritis, developmental dysplasia of the hip (DDH), or toddler’s fracture.
| Age Group | Diagnostic Considerations |
|---|---|
| Early walker: 1 to 3 years of age | Painful Limp Septic arthritis and osteomyelitis Transient monarticular synovitis Occult trauma (“toddler’s fracture”) Intervertebral diskitis Malignancy Painless Limp Developmental dysplasia of the hip Neuromuscular disorder Cerebral palsy Lower extremity length inequality |
| Child: 3 to 10 years of age | Painful Limp Septic arthritis, osteomyelitis, myositis Transient monarticular synovitis Trauma Rheumatologic disorders Juvenile idiopathic arthritis Intervertebral diskitis Malignancy Painless Limp Developmental dysplasia of the hip Legg-Calve-Perthes disease Lower extremity length inequality Neuromuscular disorder Cerebral palsy Muscular dystrophy (Duchenne) |
| Adolescent: 11 years of age to maturity | Painful Limp Septic arthritis, osteomyelitis, myositis Trauma Rheumatologic disorder Slipped capital femoral epiphysis: acute; unstable Malignancy Painless Limp Slipped capital femoral epiphysis: chronic; stable Developmental dysplasia of the hip: acetabular dysplasia Lower extremity length inequality Neuromuscular disorder |
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