Rheumatology Book

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Causes of Limp in ChildrenAka: Pediatric Limp Causes

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  1. Causes: Organic
    1. Characteristics
      1. Pain on passive internal rotation
      2. Pain during both night and day
      3. Pain occurs on weekends and vacations
      4. Pain interrupts play and other pleasant activities
      5. Pain localized to joint
      6. Unilateral pain (red flag)
      7. Child limps or refuses to walk
      8. Pain fits with local anatomic explanation
      9. Concurrent signs and symptoms of systemic disease
      10. Acute onset in last 3 months
    2. Differential diagnosis
      1. All ages (always consider)
        1. Septic Arthritis
        2. Osteomyelitis
        3. Malignancies (Uncommon)
      2. Age under 2 years
        1. Congenital Hip dysplasia (most common)
        2. Toddler's Fracture
        3. Tibial Stress Fracture
        4. Cerebral Palsy
      3. Ages 3-5 years
        1. Toxic or Transient Synovitis (most common)
        2. Leukemia
      4. Ages 5-9 years
        1. Legg-Calve-Perthes Disease (most common)
        2. Muscular Dystrophy
      5. Ages 11-16 years
        1. Slipped Capital Femoral Epiphysis (most common)
        2. Legg-Calve-Perthes Disease
        3. Tarsal Coalition
        4. Juvenile Rheumatoid Arthritis
        5. Osteochondritis Dissecans of the Knee
        6. Discoid meniscus
  2. Causes: Non-Organic
    1. Characteristics
      1. No pain on passive internal rotation
      2. Pain occurs only at night and on school days
      3. Pain does not interfere with normal activities
      4. Pain located between joints
      5. Bilateral symptoms
      6. Child is able to walk normally without a limp
      7. Pain pattern does not fit any recognizable anatomy
      8. Systemic signs and symptoms absent
    2. Differential diagnosis
      1. Growing Pains
      2. School Phobias
  3. Causes: Hematology and Oncology
    1. Sickle Cell Anemia (causes osteonecrosis)
    2. Benign Neoplasm
      1. Osteoblastoma
      2. Osteoid Osteoma
    3. Malignant Neoplasm
      1. Ewing Sarcoma
      2. Leukemia
      3. Osteosarcoma
      4. Spinal cord tumor
  4. Causes: Congenital and Developmental disorders
    1. Congenital deformity
      1. Clubfoot
      2. Short femur or other Limb Length Discrepancy
      3. Congenital Hip dysplasia
      4. Discoid lateral meniscus
    2. Developmental bone disorder
      1. Legg Disease
      2. Slipped Capital Femoral Epiphysis
    3. Neuromuscular disorders
      1. Cerebral Palsy
        1. Developmental delay
        2. Spasticity or hypertonia
        3. Asymmetric motor activity or Deep Tendon Reflexes
      2. Muscular Dystrophy
      3. Spinal Dysraphism (e.g. Myelomeningocele)
  5. Causes: Infection
    1. Osteomyelitis
    2. Septic Arthritis
    3. Lyme Disease
    4. Meningitis
    5. Soft tissue abscess or Cellulitis
    6. Pyomyositis
    7. Diskitis or Vertebral Osteomyelitis
  6. Causes: Musculoskeletal
    1. Fracture, Trauma or overuse
      1. Osteochondritis dissecans (overuse injury)
      2. Fracture or Stress Fracture (consider Child Abuse)
      3. Intra-articular injury or Hemarthrosis (may also be caused by Hemophilia)
      4. Patellofemoral Syndrome (Chondromalacia Patellae)
      5. Osgood-Schlatter Disease
      6. Sever Disease
      7. Soft tissue foreign body (e.g. foot)
    2. Rheumatologic conditions
      1. Acute Rheumatic Fever
      2. Juvenile Rheumatoid Arthritis
      3. Reactive Arthritis
      4. Systemic Lupus Erythematosus
      5. Transient Synovitis
  7. Causes: Referred intra-Abdominal Pain
    1. Appendicitis or other psoas abscess
    2. Neuroblastoma

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