The Limping Child



Background

  • A limp is defined as an asymmetric gait and is a deviation from a normal age-appropriate gait pattern
  • Most presentations are benign and do not require investigations, however serious pathology must be considered

Key points

  • A thorough gait assessment, examination of the lower limbs, spine and other relevant body systems is essential to accurately localise the source
  • A patient who cannot put any weight on the affected limb cannot be discharged without a clear diagnosis
  • Severe localised joint pain is concerning for septic arthritis

Approach


Assessment

Assessment Limp : 0-4 years:

Duration

Systemic Features

Location

Range of Motion

Imaging

Developmental Dysplasia of the hip

Weeks None Bilateral in 20% Dislocatable hip (<3 months). Limited hip abduction (<1 year). Toe walking (>1 year) X-ray: AP/ frog leg lateral view

Transient Synovitis

Days Possible recent viral infection Unilateral Limited internal rotation Not usually required

Septic Arthritis (Hip)

Days Fever
Chills, rigors
Severe localised joint pain Held in external rotation, abduction and flexion US. Further imaging and joint aspiration in conjunction with Orthopaedics
Assessment Limp : ≥5 years:

Duration

Location

Range of Motion

Leg length Disparity

Imaging

Perthes

Weeks Bilateral in 10% Limited abduction and internal rotation Late finding X-ray: AP/ frog leg lateral view

SUFE

Acute or chronic Bilateral in 30%. Vague pain in groin, hip or knee Externally rotated leg Yes X-ray: AP/frog leg lateral view

Septic Arthritis (Hip)

Days Fever, chills, rigors Severe localised joint pain Held in external rotation, abduction and flexion US. Further imaging and joint aspiration in conjunction with Ortho.

Other pathologies considered

  • Malignancy – solid or haematological
  • Fracture/Sprain
  • Neuromuscular disease – cerebral palsy, muscular dystrophy
  • Neurological - ataxia, guillain-barre, transverse myelitis, stroke
  • Rheumatological/Immunological – HSP, vasculitis, juvenile RA, discitis, osteomyelitis
  • Non MSK – appendicitis, testicular or ovarian torsion, Psoas Abscess

* Appendix

Predicted Probability of Septic Arthritis (%)

No. of Factors

Modified Kocher Criteria

Kocher Criteria

0 17 0.2
1 37 3
2 62 40
3 83 93
4 93 99
5 98  

Factors: Temp >38.5°C, WBC >12 x109/L, ESR >40 mm/Hr, refusal to weight bear ± CRP >20 mg/mL (if using modified Kocher criteria)


Discharge Criteria

Cause of limp identified and managed/referred appropriately or

  • No red flags identified
  • Patient ambulating with mild/no discomfort with simple analgesia
  • Patient information sheet provided


Content by Dr Aisling Farrell, Dr Emma Fauteux. Last review Dr ÍOS 12/06/22.