Limp
Limp
Limp
1. Pain (Antalgic gait): the child will attempt to minimize support time on the painful
limb resulting in a decreased stance phase of the affected limb with a
compensatory increased stance phase on the opposite side. Pain can originate
from bone, joint, or soft tissue and be traumatic, infectious, inflammatory, or
neoplastic in origin.
2. Structural Abnormalities: limb length discrepancies, angular limb deformities,
tortional abnormalities, articular surface abnormalities, muscle contractures or
shortened tendons may all result in a limp. These may be congenital or
acquired.
3. Neuromuscular problems, including weakness or ataxia (cerebellar or
sensory). Unsteady gait can be a result of muscle injury, inflammation or
dystrophy, or a focal lesion in the central or peripheral nervous system affecting
either proprioception or motor control.
DIFFERENTIAL DIAGNOSIS OF LIMP BY AGE:
All Ages:
Trauma
Septic Arthritis
Osteomyelitis
Stress Fracture or overuse syndromes
Neuromuscular
Neoplasm, leukemia
and metatarsals. They will often not be demonstrated on plain radiographs, but may be
observed on bone scan or MRI.
Patellofemoral Pain Syndrome:
An extremely common form of repetitive microtrauma seen in active adolescents is
chondromalacia patella also known as patellofemoral pain syndrome. Pain results from
improper tracking of the patella often as a result of weakness of the medial thigh
muscles (the Vastus Medialis Obliqus or VMO). The child will often describe pain worse
with activity, particularly knee bends and stair climbing that is improved with rest.
Physical exam demonstrates a positive patellar grind test and painful patellar
compression, with a laterally tracking patella also known as a J-sign. Treatment is rest
and quadriceps muscle strength balancing.
Bone Tumors:
Both primary benign and malignant bone tumors should be included in the differential
diagnosis for all children presenting with a painful limp. If pain is persistent and
associated with swelling or constitutional symptoms of weight loss, fatigue, night sweats,
and especially if waking the child from sleep, one must act swiftly to rule out malignant
processes. Common benign bone tumors include unicameral bone cysts (well
circumscribed lytic lesions), aneurismal bone cysts, fibrous dysplasias (ground glass
appearance), and eosinophilic granulomas. Malignant bone tumors in children are most
often osteogenic sarcoma and Ewings sarcoma. Plain radiographs often show cortical
destruction that may be associated with a periosteal reaction. Skeletal neoplasms often
occur in the metaphyseal areas of the long bones, especially the knee and proximal
femur. Dont forget that leukemias can also cause a painful limp, therefore it is important
to check the blood for atypical lymphocytes.
Toddlers Fracture:
Because the bones of young children are less brittle, relatively minor traumas such as
jumping or twisting can result in incomplete fractures. Typically Toddlers fractures
involve the tibia or calcaneous, and are manifested by tenderness to palpation along the
bone with subtle spiral fractures seen on radiographs.
Leg Length Discrepancy:
Evaluated by measuring true and apparent leg lengths. It is important to establish the
cause of the leg length discrepancy because some can be progressive. Generally less
than 2 cm of inequality is acceptable for adult leg lengths. If the predicted length
discrepancy exceeds this, orthopedic management is necessary.
Legg-Calve Perthes Disease:
Idiopathic avascular necrosis of the femoral epiphyses occurring in young children most
commonly between the ages of 4 and 8 years and more common in males. Usually
presents with insidious onset limp with mild activity related pain in the groin, hip, thigh, or
knee. Physical exam demonstrates decreased abduction and internal rotation of the hip.
Plain radiographs of the hips are often sufficient to make the diagnosis.
Slipped Capital Femoral Epiphysis:
Typically seen in overweight adolescents just prior to the growth spurt. It is more
common in males. It is often idiopathic, but may be associated with endocrine diseases
including hypothyroidism. Usually presents with pain in hip, thigh, or knee. Physical
exam demonstrates a Trendelenburg gait with external rotation at the hip. Internal
rotation of the hip is limited. Plain radiographs of the hip are often sufficient to make the
diagnosis. Because a slipped epiphysis is at significant risk for further slipping and
destruction of the vascular supply to the head to the femur, once diagnosed the patient
should be non weight bearing and immediate referral to orthopedics obtained. 25-40%
will have bilateral involvement therefore it is necessary to monitor the contralateral side
with serial radiographs to screen for pathology.
QUESTIONS TO ASK ON HISTORY
PHYSICAL EXAMINATION
As with all orthopedics physical exams, the evaluation of the limping child should include
inspection, palpation, range of motion, and special tests.
See the PGALS (Pediatric Gait Arms Legs Spine) link elsewhere in this module to review
an approach to a screening examination, looking for affected joints that might be
involved in rheumatologic disease. Here we present a more focused approach to the
child with a limp.
Inspection:
Dont forget to ensure proper exposure of the child. There should be minimal
clothing and the child should be barefoot so that you may observe the feet and
toes
Gait: Have the child walk barefoot noting any abnormalities in gait. Try to focus
on movement at each of the hip, knee and ankle joints through all phases of gait.
If an abnormality is noted, try to classify among the following types of abnormal
gait:
1. Antalgic Gait: less time spent in stance phase of the affected limb
2. Trendelenburg Gait: the pelvis tilts away from the pathologic hip during
stance on the ipsilateral leg. During walking this can appear as shifting of the
torso towards the pathological side to compensate for abductor weakness.
This is seen in conditions causing hip inflammation or hip muscle weakness.
3. Steppage Gait: commonly is observed in patients with foot drop due to injury
to the peroneal nerve or disease causing weakness of the tibialis anterior
muscle.
4. Toe-walking gait: is manifested unilaterally when a true or apparent leg
length discrepancy is present. It may also be present bilaterally in the case of
short Achilles tendons or it may be a behavioral phenomenon.
Can the child run, stand on one foot, hop on one foot, walk on heels and toes,
squat?
Have the child stand on one foot (Trendelenburg test) to assess hip abductor
strength
Note muscle bulk, swelling, erythema, deformities, asymmetries of the trunk,
hips, and lower extremities
Evaluate the shoes for unusual wear patterns
Measure True and Apparent Leg Lengths
True leg length is the distance from the anterior superior iliac spine to the medial
malleolus. The apparent leg length is the distance from the umbilicus to the
medial malleolus. Contractures and muscle spasms can make the lengths seem
different, when in fact the skeleton is symmetric. Generally less than 2
centimeters of true inequality is acceptable in an adult
Assess the spine for deformities, scoliosis, range of motion, or pain
Palpation:
Assess any suspected joints for tenderness to palpation
Pay attention to palpation over the hip joints, sacro-iliac joints, greater
trochanters, knees and ankles. Test for joint effusions, especially in the knees.
Range of Motion:
Assess range of motion, laxity, stiffness and guarding at all suspected joints.
Full Neurological Evaluation
Test lower extremities for strength, sensation (especially proprioception), deep
tendon reflexes. Also cerebellar testing should be performed should ataxic gait
be a concern.
Special tests
Assessment of hips with the child prone. Prone internal rotation of the hip is the
most sensitive provocative marker of hip pathology
FABER Test (Hip Flexion, ABduction, External Rotation). With the child supine,
place the ipsilateral ankle on the contralateral knee and provide slight downward
pressure on the ipsilateral knee. This will bring out pain of sacroiliac origin.
Galeazzi Test: With the child supine place heels to buttocks with hips and knees
flexed. If the knees are different heights this is a positive Galeazzi test,
suggesting leg length discrepancy or developmental dysplasia of the hips
Measurement of circumference of calves and thighs to look for atrophy
INVESTIGATIONS:
Based upon your careful history and physical examination, the following tests may be
helpful in assessing a child with a limp.
References: