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Pediatric LimpAka: Limping in Children

Epidemiology
1. Limb pain is common (7% of pediatric visits)
Organic Causes
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
Non-Organic Causes
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
Other Causes
1. Osgood-Schlatter Disease
2. Osteochondritis Dissecans
3. Patellofemoral Syndrome (Chondromalacia Patellae)
4. Cerebral Palsy
  1. Developmental delay
  2. Spasticity or hypertonia
  3. Asymmetric motor activity or Deep Tendon Reflexes

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This page was written by Scott Moses, MD. This page was last revised before 5/10/08, prior to consistent tracking of revision date. This page was last published on 6/1/2008. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 6.0.