Approach to a Child with a Limp



Fig. 15.1
MRI of the right hip shows an osteoid osteoma at the upper metaphyseal end of the right femur




This case illustrates several learning points:


  1. (a)


    Many cases of limp or limb pain are attributed to trauma which actually is insignificant or eventually irrelevant to the final diagnosis [1].

     

  2. (b)


    Nocturnal pains should alert one to the possibility of osteoid osteoma or malignancy and specifically pains that wake up a child at night argue against functional causes.

     

  3. (c)


    Subtle physical findings – in this case, the mild wasting of the mid thigh can give a clue to the diagnosis in cases of limp.

     

  4. (d)


    Pain originating in the region of the hip may be referred to the knee [2].

     

  5. (e)


    Targeted investigation after localizing the origin of the pain easily reveals the diagnosis in most cases (MRI of the hip revealed the pathology in this boy).

     

  6. (f)


    Last but not the least, investigation and approach to a limping child are best performed by a specialist with experience in musculoskeletal medicine with the help of an orthopedic surgeon being sought in select cases, most often after a diagnosis [3].

     


Introduction


A limp is defined as any deviation in the walking pattern away from the expected normal for the child’s age [4]. The causes range from simple and benign as ill-fitting new shoes or a plantar wart or strain/sprain to potentially devastating diagnoses such as septic arthritis or even malignancy. This chapter details the causes of a limp in a child and broadly categorizes them based on their underlying causation into a painless or painful limp. A careful history and physical examination are often all that are necessary to arrive at a final diagnosis in several cases [5]. In the rest, they provide a direction to investigate and identify the cause. The bedside approach is discussed in detail.


Epidemiological Data from India and Abroad


The exact incidence of limping in children in India is not known. A study of 243 children, from Scotland, less than 14 years of age presenting to the emergency department for acute atraumatic limp, reported an incidence of 1.8 per 1000 children, with a male-to-female ratio of 1.7:1 and a median age of 4.4 years [6]. Limb involvement was almost equal and it was painful in 80 % of the children. The predominant diagnosis was transient synovitis of the hip (TSH) in 39.5 % and Legg-Calve-Perthes disease (LCPD) accounted for 2%. Uniquely in our country, the referral pathways (either by self-referral or by family physician) lead many children to see the orthopedic surgeon as a point of first contact even though orthopedic causes account for only a fraction of the cases.


The Normal Gait


In order to understand and approach limp better, it is important to have a basic understanding of the physiology of gait. The normal child begins to walk at 12–14 months of age. Initially it is normal for the child to walk with a wide-based externally rotated gait, taking numerous short steps. The gait then undergoes orderly stages of development. Walking velocity, step length and the duration of the single-limb stance increase with age and the number of steps taken per minute decreases. A mature gait pattern is well established by about 3 years of age and the gait of a 7-year-old child resembles that of an adult [7] (Fig. 15.2). A normal mature gait cycle consists of the stance phase, during which the foot is in contact with the ground and the swing phase, during which the foot is in the air.

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Fig. 15.2
The normal gait cycle


Etiopathology of Limping



Limping Can Be Caused by Three Categorical Processes [8, 9]





  1. 1.


    Painful (antalgic gait): The child attempts to minimize support time on the painful limb resulting in a decreased stance phase of the affected limb and a compensatory increased stance phase on the opposite side. The pain could originate from any of the anatomical structures of the limb or even the abdomen and can be traumatic, infectious, inflammatory or neoplastic in origin.

     

  2. 2.


    Nonpainful (Trendelenburg gait): Here the stance phase is equal between involved and non-involved limbs, but the child leans or shifts toward the involved limb to balance. This gait is indicative of proximal muscle weakness or hip instability. The causes may be congenital or acquired such as limb length discrepancies, limb deformities, muscle contractures or shortened tendons.

     

  3. 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.

     


Causes of Limp by Anatomic Site of Origin


Limp can be best classified by the anatomic site of origin (Table 15.1) [4, 8, 9]. The division of the causes into common, less common and rare is based on the perception of a primary care pediatrician.


Table 15.1
Causes of limp by anatomical origin
































































Anatomical origin

Common

Less common

Rare

Skin/soft tissue

Impacted foreign bodies

Thorn/splinter
   

Muscle, ligament, entheses

IM injections, sprain, strain, and sports injuries

Viral myositis

Juvenile dermatomyositis

ERA

Bones

Trauma

Occult fracture, toddler abuse

Vitamin D3 deficiency

Leukemia

Osteoid osteoma

Osteomyelitis

Leg length discrepancy

Unicameral bone cyst

Caffey disease

Osteosarcoma

Ewing sarcoma

Neurological

Cerebral palsy

Guillain-Barre syndrome

Polio

Zoster

Polyarteritis nodosa

Spinal cord diskitis

Vaso-occlusive

Vasculitis-HSP

Deep vein thrombosis

Rarer vasculitides

Joints (hip alone)

Transient synovitis (TSH)

Reactive arthritis

LCPD

SCFE

Tuberculosis

DDH

AVN – femoral head

Septic arthritis

Protrusio acetabuli

Joints

(knee alone)

Reactive

Overuse

Osgood-Schlatter disease

Chondromalacia patellae

Juvenile psoriatic arthritis

OJIA

Coagulopathy

Joints

(ankle, subtalar alone)
 
Tuberculosis

Tumor

Tarsal coalition
 

Joints

(multiple)

Postinfective including RF

Reiter’s syndrome

PJIA

OJIA

ERA

SLE
 

Functional
 
Conversion reaction

RSD


ERA enthesitis-related arthritis, HSP Henoch-Schonlein purpura, TSH transient synovitis of the hip, LCPD Legg-Calve-Perthes disease, SCFE slipped capital femoral epiphysis, DDH developmental dysplasia of the hip, AVN avascular necrosis, JIA juvenile idiopathic arthritis, OJIA oligoarticular JIA, RF rheumatic fever, PJIA polyarticular JIA, SLE systemic lupus erythematosus, RSD reflex sympathetic dystrophy, RF + ve JIA rheumatoid factor-positive JIA


Approach to a Child with Limp


The approach to rheumatologic and musculoskeletal etiology of limp is as follows [4, 5, 811]:



  • Ask: A thorough history is to be obtained from parents and child (as appropriate). An incomplete history and an uncooperative patient pose a significant challenge. Table 15.2 lists the questions to be asked with possible etiologies.


    Table 15.2
    Approach to a child with limp – ASK






































    What

    Why

    Age

    1–4 years – DDH, OJIA, TSH, leg length discrepancy

    4–10 years – TSH, LCPD

    Adolescent – overuse (sports), SCFE

    Sex

    Male – coagulopathies (X-linked recessive), SCFE,

    Osgood-Schlatter disease, ERA, TSH

    Female – OJIA, PJIA, chondromalacia patellae

    Trauma (significant vs. insignificant)

    IM injections

    Accidental vs. recurrent

    Danger in attributing a limp to trauma and missing a potentially significant diagnosis

    Recurrent – consider non-accidental injury

    Onset

    Acute (hours to days) – trauma, coagulopathies, TSH, vaso-occlusive, septic arthritis

    Subacute (days to weeks) – viral myositis, reactive arthritis, osteomyelitis, malignancy

    Chronic (weeks to months) – JIA, SCFE, malignancy

    Type of pain (if child is capable of describing)

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    Oct 25, 2017 | Posted by in RHEUMATOLOGY | Comments Off on Approach to a Child with a Limp

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