Limping Child
Developmental stages of gait
- 10-12mths à Cruises while holding on to objects
- 12-14mths à walk short distances and stands unaided
- 17-21mths à walks on one foot long enough to walk up steps
- 30-36mths à balances on 1 foot
- >36mths à like adult
Clinical Features
Symptoms
- Constitutional sx
o Most impt: is he eating well?
- Pain? Characteristics?
- Dysfunction? Weakness (trouble getting off floor – myopathic/ neuropathic)? Bear weight?
- Duration?
- Recent trauma? Mechanism?
- Time of day worse (inflammatory – morning stiffness + end of day)
Signs
- Look
o Deformity, erythema, swelling, effusion, limited ROM, asymmetry, wasting.
o Gait
o Scoliosis
- Feel
o Leg length, mm circumference, warmth, fluctuance, palpable masses
- Move
o Deal with good leg/ arm first, injured last
o Stiffness, ROM, laxity
Differential Diagnosis
- Trauma
o Fracture, Stress #, toddler’s # (minimally displaced spiral # of tibia), soft tissue contusion, ankle sprain
- Infections
o Cellulitis, osteomyelitis (localised pain, refuse to walk), septic arthritis (pain, refuse to walk, not eating), Lyme disease, TB of bone, Gonorrhoea, Postinfectious reactive arthritis
- Tumour
o Spinal cord, bone tumours, bengin (osteoid osteoma, Osteoblastoma), malignant
- Inflammatory
o JRA, transient synovitis, SLE
- Congenital
o DDH, sickle cell anaemia, congenitally short femur, clubfoot
- Developmental
o – LCP disease, Slipped capital femoral epiphysis
- Neurologic
- Common causes 1-5y
o Trauma (buckle #, greenstick # - bone soft, complete #), Transient synovitis, osteomyelitis/ septic arthritis, DDH, JCA (hot swollen joint), non-accidental injury (multiple rib #, # of different ages)
- Common causes 5-10y
o Trauma, transient synovitis, OM, SA, Legg-Calve-Perthes disease (limp, avascular necrosis)
- Common cuases 10-15y
o Trauma, OM, SA, slipped upper femoral epiphysis (can occur as chronic/ simple trip, chondromalacia of patella (softness of cartilage), neoplasia (commonly metaphyseal end – proximal – of femur, Ewing’s sarcoma – spine, pelvic, diaphysis of long bones)
Investigations
- Bloods
o FBC, CRP – rises 2-3h, drops soon after inflammation ends, ESR – takes 4-5d to rise, stays up longer(OM, septic, transient synovitis), BC (OM, septic)
- Imaging:
o XR (trauma, LCP disease, slipped upper fem epiphysis can’t pick up OM – need to remove bone)
o US (effusion)
o CT/ MRI (not useful early in presentation)
o Bone scan is useless in acute limping
- Others:
o Joint aspirate (septic, effusion)
Management
- Physio (transient synovitis)
- Pinning (slipped upper femoral epiphysis)
Source
Dr John Batten 2014
- 10-12mths à Cruises while holding on to objects
- 12-14mths à walk short distances and stands unaided
- 17-21mths à walks on one foot long enough to walk up steps
- 30-36mths à balances on 1 foot
- >36mths à like adult
Clinical Features
Symptoms
- Constitutional sx
o Most impt: is he eating well?
- Pain? Characteristics?
- Dysfunction? Weakness (trouble getting off floor – myopathic/ neuropathic)? Bear weight?
- Duration?
- Recent trauma? Mechanism?
- Time of day worse (inflammatory – morning stiffness + end of day)
Signs
- Look
o Deformity, erythema, swelling, effusion, limited ROM, asymmetry, wasting.
o Gait
o Scoliosis
- Feel
o Leg length, mm circumference, warmth, fluctuance, palpable masses
- Move
o Deal with good leg/ arm first, injured last
o Stiffness, ROM, laxity
Differential Diagnosis
- Trauma
o Fracture, Stress #, toddler’s # (minimally displaced spiral # of tibia), soft tissue contusion, ankle sprain
- Infections
o Cellulitis, osteomyelitis (localised pain, refuse to walk), septic arthritis (pain, refuse to walk, not eating), Lyme disease, TB of bone, Gonorrhoea, Postinfectious reactive arthritis
- Tumour
o Spinal cord, bone tumours, bengin (osteoid osteoma, Osteoblastoma), malignant
- Inflammatory
o JRA, transient synovitis, SLE
- Congenital
o DDH, sickle cell anaemia, congenitally short femur, clubfoot
- Developmental
o – LCP disease, Slipped capital femoral epiphysis
- Neurologic
- Common causes 1-5y
o Trauma (buckle #, greenstick # - bone soft, complete #), Transient synovitis, osteomyelitis/ septic arthritis, DDH, JCA (hot swollen joint), non-accidental injury (multiple rib #, # of different ages)
- Common causes 5-10y
o Trauma, transient synovitis, OM, SA, Legg-Calve-Perthes disease (limp, avascular necrosis)
- Common cuases 10-15y
o Trauma, OM, SA, slipped upper femoral epiphysis (can occur as chronic/ simple trip, chondromalacia of patella (softness of cartilage), neoplasia (commonly metaphyseal end – proximal – of femur, Ewing’s sarcoma – spine, pelvic, diaphysis of long bones)
Investigations
- Bloods
o FBC, CRP – rises 2-3h, drops soon after inflammation ends, ESR – takes 4-5d to rise, stays up longer(OM, septic, transient synovitis), BC (OM, septic)
- Imaging:
o XR (trauma, LCP disease, slipped upper fem epiphysis can’t pick up OM – need to remove bone)
o US (effusion)
o CT/ MRI (not useful early in presentation)
o Bone scan is useless in acute limping
- Others:
o Joint aspirate (septic, effusion)
Management
- Physio (transient synovitis)
- Pinning (slipped upper femoral epiphysis)
Source
Dr John Batten 2014