II. Epidemiology

  1. Limb pain is common (7% of pediatric visits)
  2. Atraumatic Limp
    1. Incidence: 1.8 per 1000 children
    2. More common in males (RR 1.7)
    3. Median age: 4.4 years old
    4. Fischer (1999) J Bone Joint Surg Br 81(6): 1029-34 [PubMed]

III. Causes

IV. Physiology

V. History

  1. Pain timing
    1. Acute onset
      1. Fracture, Musculoskeletal Injury
    2. Gradual onset
      1. Rheumatologic disorders, Stress Fracture, Osteomyelitis, tumors
    3. Constant pain
      1. Tumor, Infection
    4. Intermittent rest pain or night pain
      1. Tumor
    5. Morning stiffness
      1. Rheumatologic disorders, Stress Fracture
  2. Pain distribution
    1. Focal pain
      1. Infection, Fracture or tumor
    2. Radiating pain (especially burning pain)
      1. Neuropathic pain
    3. Migratory Joint Pain
      1. Acute Rheumatic Fever, Gonococcal Arthritis
    4. Hip Pain
      1. No systemic symptoms
        1. Legg-Calve-Perthes Disease (ages 4-9 years old)
        2. Slipped Capital Femoral Epiphysis (ages 11-16 years old)
      2. Systemic symptoms (e.g. fever) with increased inflammatory markers
        1. Septic Arthritis, Transient Synovitis, pelvic Osteomyelitis
        2. Sacroiliitis
        3. Psoas abscess
    5. Bone pain or tenderness
      1. Osteomyelitis (increased inflammatory markers)
      2. Acute Leukemia (CBC abnormalities)
      3. Osteosarcoma or Ewing Sarcoma (night pain, mass)
  3. Modifying factors
    1. Better with activity
      1. Rheumatologic conditions
    2. Worse with activity
      1. Overuse injury, Stress Fracture
    3. Associated with overuse
      1. Osteochondritis Dissecans, Osgood-Schlatter Disease, Jumper's Knee, Chondromalacia Patellae
      2. Sever Disease, Stress Fracture
  4. Associated findings
    1. Fever, weight loss, Night Sweats
      1. Cancer, Osteomyelitis, Rheumatologic condition, Septic Arthritis
    2. Hemarthrosis
      1. Bleeding Disorder (e.g. Hemophilia)
    3. Pharyngitis (preceding limp)
      1. Rheumatic Fever
    4. Neck Pain with fever, photophobia
      1. Meningitis
    5. Back pain or spinal tenderness
      1. Diskitis, Vertebral Osteomyelitis, spinal cord tumors
    6. Abdominal Pain
      1. Acute Abdomen (e.g. Appendicitis, psoas abscess), Neuroblastoma
    7. Diarrhea (preceding limp) as well as Conjunctivitis, Urethritis, oligoarthritis
      1. Reactive Arthritis
    8. Urinary symptoms (may be associated with Vomiting)
      1. Pelvic disorder (e.g. pelvic abscess)
  5. Associated exposures, events and conditions
    1. Tick Bite
      1. Lyme Disease
    2. Trauma
      1. Fracture (e.g. Toddler's Fracture), Musculoskeletal Injury, skin foreign body
    3. Sexual abuse or sexually active
      1. Gonococcal Arthritis, Reactive Arthritis

VI. Exam: Systemic Signs

  1. Eye
    1. See Ocular Manifestations of Rheumatologic Disease
  2. Abdomen
    1. Abdominal mass
      1. Neuroblastoma, psoas abscess
    2. Abdominal tenderness
      1. Appendicitis or psoas abscess (Psoas Sign positive)
      2. Ovarian pathology (includes young girls)
      3. Other Acute Abdominal Pain
    3. Hepatomegaly or Splenomegaly with Lymphadenopathy
      1. Cancer
      2. Rheumatologic disorder
  3. Neurologic
    1. See Developmental Delay
    2. See Muscle Weakness in Children
  4. Skin
    1. See Cutaneous Signs of Rheumatic Disease
    2. Skin warm, tender, red overlying joint
      1. Septic Arthritis
    3. Ecchymosis
      1. Nonaccidental Trauma
    4. Midline spinal skin changes (e.g. dermal sinus, midline Lipoma, sacral dimple)
      1. See Cutaneous Signs of Dysraphism
    5. Neurocutaneous Syndrome (e.g. Cafe-Au-Lait Macule)
      1. See Neurofibromatosis

VII. Exam: Gait

  1. See Gait Evaluation in Children
  2. Distinguish between painful (antalgic) and non-painful (nonantalgic) Abnormal Gait
  3. Antalgic Gait
    1. Stance phase on unaffected limb is shortened due to pain
    2. Refusal to bear weight (esp. with limited range of motion, systemic symptoms, fever) may be Septic Arthritis
  4. Nonantalgic gait
    1. See Abnormal Gait
    2. See Lower Extremity Abnormality in Children
    3. Includes Steppage Gait, Trendelenburg Gait, Circumduction Gait, Equinus Gait

VIII. Exam: General Musculoskeletal

  1. Joint Inflammation (Joint Swelling, warmth, and painful range of motion)
    1. Inflammatory Arthritis
    2. Septic Arthritis (non-weight bearing)
    3. Reactive Arthritis
  2. Muscle
    1. Muscular atrophy: Disuse atrophy or neurologic disorder
    2. Calf hypertrophy: Muscular Dystrophy
  3. Bone Tenderness
    1. Fracture or bone Contusion
    2. Bone Tumor (may present with palpable bone mass)
    3. Osteomyelitis
  4. Spine
    1. Evaluate spinal flexion and extension
    2. Evaluate for Scoliosis, lumbar lordosis, thoracic kyphosis

IX. Exam: Hip and Pelvis

  1. See Hip Exam
  2. See Hip Rotation Evaluation in Children
  3. See Hip Range of Motion
  4. Gluteal or thigh skin fold asymmetry
    1. Congenital Hip Dysplasia
  5. Galeazzi Sign
    1. Limb Length Discrepancy
  6. FABER Test or Pelvic Compression Test positive
    1. Sacroiliac Joint Disorder
  7. Trandelenburg Test positive
    1. Congenital Hip Dysplasia, weak hip adductors
  8. W-Sitting Position
    1. Associated with Femoral Anteversion
    2. Patient sits on floor with each heel adjacent to the ipsilateral hip
      1. Hips flexed and externally rotated
      2. Knees maximally flexed
  9. Hip resting position flexed and externally rotated
    1. Slipped Capital Femoral Epiphysis
      1. Hip unable to be abducted or internally rotated
    2. Hip Joint effusion
      1. Hip abducted
  10. Hip internal rotation lost
    1. Aseptic Necrosis of the Femoral Head
    2. Slipped Capital Femoral Epiphysis
    3. Intraarticular hip disorder
  11. Pelvic compression resulting in pain
    1. Sacroiliac joint disorder
    2. Pelvis Trauma

X. Exam: Leg

XI. Labs

  1. Obtain in cases where infection (e.g. Septic Arthritis) is strongly considered
    1. Joint aspiration for Gram Stain, cell count and Synovial Fluid culture
      1. Hip aspiration is best done under Ultrasound guidance (preferred) or fluoroscopy
      2. Blind hip aspiration carries risk of neurovascular injury
      3. Culture positive in 50-80% of aspirates (most commonly positive for Staphylococcus aureus)
      4. Synovial WBC Count >50,000 with PMNs >75%
    2. Complete Blood Count with platelets and differential
    3. Erythrocyte Sedimentation Rate (ESR)
    4. C-Reactive Protein (C-RP)
    5. Blood Culture
  2. Other labs to consider
    1. ASO Titer and/or Throat Culture
    2. Stool Culture (for Reactive Arthritis, esp. SSCE culture for Shigella)
    3. Urethral or urine dna probe for Gonorrhea and Chlamydia (for Reactive Arthritis)
    4. Lyme Titer
    5. Antinuclear Antibody (ANA)
      1. High false positive in healthy children (10-40%)
      2. Consider positive if titer >1:160 or 1:320
      3. SLE diagnosis requires 3 additional criteria beyond positive ANA

XII. Imaging

  1. XRay of region suspected of causing limp
    1. Consider bilateral lower extremity where source is not obvious from history or exam
    2. Consider imaging opposite side for comparison (esp. SCFE)
    3. Hip XRays in children with limp should include frog-leg lateral view
      1. Exception: Do not perform this view if acute Slipped Capital Femoral Epiphysis is suspected
    4. Repeat XRay or other diagnostics in conditions which may have normal initial xrays (false negative)
      1. Stress Fractures
      2. Toddler's Fracture
      3. Leg-Calve-Perthes Disease
      4. Osteomyelitis
      5. Septic Arthritis
  2. Ultrasound hip
    1. High Test Sensitivity for hip effusion but does not differentiate fluid causes
    2. Hip effusions with suspicion of Septic Arthritis require immediate Ultrasound guided aspiration
      1. Send aspirate for Gram Stain, cell count and culture
  3. Bone scan
    1. High Test Sensitivity for identifying occult causes of Pediatric Limp
    2. Demonstrates occult Fracture, Stress Fracture, Osteomyelitis, tumor, metastases
    3. Findings are not specific for cause and requires further evaluation if positive
  4. Computed Tomography (CT)
    1. Evaluates Cortical Bone
  5. Magnetic Resonance Imaging (MRI) Pelvis
    1. Broadest applicable imaging modality in the evaluation of the Limping Child
    2. May identify Stress Fracture, malignancy or pelvic organ pathology
    3. Identifies Osteomyelitis, septic hip Arthritis (with contrast)

XIII. Evaluation: Red Flags distinguising organic from non-organic causes

  1. Red Flags suggestive of organic cause
    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. Reassuring Findings suggestive of non-organic cause (e.g. Growing Pains, School Phobias)
    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

XIV. Evaluation: Injury

  1. Acute Injury
    1. Fracture, Toddler's Fracture or Soft Tissue Injury
    2. Skin foreign body
  2. Overuse Examples
    1. Sever Disease (Achilles tendon)
    2. Osgood Schlatter Disease (Knee)
    3. Osteochondritis Dissecans
    4. Stress Fracture

XV. Evaluation: No systemic symptoms and no known injury

XVI. Evaluation: Systemic symptoms and no known Injury

  1. Obtain diagnostics
    1. Complete Blood Count (CBC)
    2. Erythrocyte Sedimentation Rate (ESR)
    3. C-Reactive Protein (C-RP)
    4. Specific imaging based on evaluation
  2. Back pain
    1. Obtain MRI to evaluate for Vertebral Osteomyelitis or diskitis
  3. Hip Pain with increased acute phase reactants (C-RP, ESR or White Blood Cell Count)
    1. See Transient Tenosynovitis of the Hip for protocol to distinguish from Septic Arthritis of the hip
    2. Joint aspiration to differentiate Septic Arthritis from Transient Synovitis or Reactive Arthritis
    3. Examination
      1. Psoas Sign: Consider Appendicitis or psoas abscess (CT Abdomen or MRI)
      2. Pelvic Bone tenderness: Consider pelvic Osteomyelitis
      3. Positive FABER Test or tenderness over SI joint
        1. Consider Sacroiliac infection or Spondyloarthropathy
  4. Bone pain
    1. Increased acute phase reactants (C-RP, ESR or White Blood Cell Count)
      1. Consider Osteomyelitis
    2. Night pain and palpable bony mass
      1. Consider bone tumor (e.g. Osteosarcoma or Ewing Sarcoma)
    3. Suppressed cell counts (Neutropenia, Anemia, Thrombocytopenia)
      1. Consider Leukemia

XVII. Precautions: Pitfalls

  1. Hip Septic Arthritis findings (contrast with Toxic Synovitis) in cases of fever, Hip Pain and reduced range of motion
    1. See Toxic Synovitis for decision rules
  2. Vertebral Osteomyelitis findings (contrast with diskitis) in children with fever, back pain and limp
    1. Persistent high fever
    2. Toxic appearance
    3. Back pain not limited to lumbar region
    4. Start with XRay spine, but MRI is most definitive modality
  3. Malignancy findings (contrast with rheumatologic conditions) in cases of fever, weight loss, Hepatomegaly, Arthritis
    1. Nonarticular bone pain or back pain
    2. Night Sweats
    3. Bruising
    4. Elevated Erythrocyte Sedimentation Rate, but normal to Low Platelet Count
    5. Low WBC Count, low-normal Platelet Count and night pain (ALL)
  4. Psoas abscess findings (contrast with Septic Arthritis) in cases of Abdominal Pain and Psoas Sign
    1. Flexing hip relieves pain and allows for painless internal and external range of motion
    2. Start with pelvic XRay (SI joint may be obscured) and pelvic Ultrasound
      1. MRI or CT Abdomen and Pelvis may be required

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Ontology: Limp occurring during childhood (C3662763)

Concepts Finding (T033)
SnomedCT 88121000119101
English Limp occurring during childhood (finding), Limp occurring during childhood, Limp in childhood
Spanish renguera producida durante la infancia, cojera producida durante la infancia (hallazgo), cojera producida durante la infancia