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Morning Report:

Limping
Spencer Barfuss
12.10.2018
Case
A 15 month old infant presents to the
Emergency Department with a “limp”. His
father reports that his son was walking
well, but started to walk funny yesterday
and today refuses to bear weight on his
left leg. He notes that over this time he
has been very fussy with diaper changes,
but seems fine if you leave his leg alone.
There is no known history of trauma.
Why do I care?
 5% of ER visits over a 3 month period were
due to inability to bear weight and/or
limp
 Differential is broad and ranges from
minor injury to orthopedic emergency
and malignancy
Differential Diagnosis
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Approach to the child with a limp


Visit UpToDate
Evaluation of a limp
 Antalgic gait
 shortened stance phase
 Hip circumduction
 Toe walking
 Trendelenburg
 Weak abductors
 Hip/knee flexion
 Leg length compensation
History
 Details of the limp – OLD CARTS/Sacred 7
(able to bear weight, pattern, duration,
pain, associated symptoms)
 Fever/chills?
 Recent viral illness or bacterial infection?
 Weight loss?
 Tick bites, rashes, travel?
Physical Examination
1. Start with non-painful limb
2. Evaluate for rash/skin lesions
3. Evaluate spine
4. Pelvic girdle (avulsion injury)
5. Look for erythema, swelling, echymosis,
laceration, abrasion
6. Evaluate for symmetry
7. Don’t forget the neurovascular evaluation
Diagnostic Testing
 X-raysfor most
 For possible infection: CBC, ESR, CRP, BCx
 Lyme titers if in north east
 Rheumatoid factor and ANA may be
considered

 Other imaging options:


 Ultrasound (effusion, deep abscess, foreign
body?)
 MRI/CT for specialized situations
1. Traumatic injury
2. Infection Focus on
3. Neoplasm 3 most important
causes

Differential Diagnosis
Traumatic Injuries
 Vascular compromise
 No pulse, skin blue (vascular congestion) or pale
(arterial insufficiency)
 If delay in treatment expected attempt gross
reduction
 Open Fractures
 Fracture + skin disruption
 Requires washout
 Compartment Syndrome
 Three “A”s: Anxiety, Agitation, and increasing
Analgesia needs
 Key Fractures – tibial shaft, suracondylar humerus,
forearm.
Other traumatic injuries
 NAT
 Lower extremity fractures in non-ambulating child
 Metaphyseal corners fractures, epiphyseal separations
 Toddler Fracture
 Limp after minor twist or fall.
 Initial X-rays often negative.
 Retained foreign body
 Plantar cellulitis, draining laceration, or induration with
fluid collection
 Evaluate with X-ray and/or ultrasound
 Consider pseudomonas for puncture through shoe
Infections - presentations
 Generally present with painful limp/inability to
bear weight and fever
 Septic arthritis of the hip
 Must not miss as damage to cartilage and blood
supply begins within 6-12 hours and may be
irreversible after 1-2 days.
 Hip held in flexion, slight abduction and external
rotation. Resists passive movement due to pain.
 Cellulitis, fasciitis, myositis, septic arthritis,
osteomyelitis.
 Swelling, tenderness, erythema, effusion, and
limited joint motion.
Septic Arthritis
 Toxic (transient) synovitis vs. Septic arthritis
 Less acute symptoms, milder elevations in
inflammatory markers
 Kocher criteria for septic arthritis
 Temperature > 38.5
 WBC > 12,000
 ESR > 40 or CRP >2.5
 Inability to weight bear
 Score of 1 = 3% chance of septic arthritis, 2 =
40%, 3 = 93%, 4 = 99%.
Septic Arthritis workup
 Radiographs, ultrasound
 CBC with diff, ESR, CRP, and blood
cultures
 Joint aspiration to confirm
 WBC > 50,000
 >75% PMNs
 + gram stain
 Treatment: washout + antibiotics
Hip ultrasound with effusion

Image from Radiology Assistant


Osteomyelitis & Deep soft
tissue infections
 Fever and limping that slowly worsens
over 1-3 days
 Induration, swelling, local tenderness, and
painful range of motion are commonly
seen
 WBC, ESR, CRP usually elevated
 Contrasted MRI is the best test for
diagnosis
Toxic (Transient) Synovitis
 Diagnosed in up to 85% of children presenting
with limping and atraumatic hip pain
 Age 3-8, commonly preceded by a viral
infection (2 weeks to 1 month before)
 Normal to mildly abnormal labs
 Treatment: activity modification and anti-
inflammatory medications. 7-10 days until
resolution of symptoms.
JIA
 Joint pain, swelling without large effusion,
and stiffness (often worse in AM)
 Lasts longer than 6 weeks
 No detectable cause

 May have systemic symptoms (lethargy,


loss of appetite)
Lyme Disease
 Begins with Erythma migrans +/-
headache, malaise, and fatigue
 May present with acute onset arthritis
(knee most common) and generalized
muscle aches
 Low threshold for consideration in
endemic areas
Neoplasms
 Hallmark: pain, worse at night preventing
restful sleep
 May see systemic signs and symptoms
 Lethargy, fever, weight loss
 Rare,but often of high concern to the
family
Benign tumors
 Osteochondroma
 Distal femur, proximal tibia
 Treatment: excision if symptomatic
 Osteoid Osteoma
 Vascular nidus surrounded by sclerotic
bone
 M>>F, presents with limping and pain
(shocker!)
 Usual treatment: excision
Malignancies
 Primary bone tumors,
leukemia/lymphoma, bone metastases,
and soft tissue sarcomas can all present
with limping
 Night pain is most pronounced in these
patients, but is not universally present
 May have an identifiable mass
Other Causes
 Developmental
 Overuse
 Neurologic
 Inflammatory
Developmental Causes
 Developmental dysplasia of the hip
 Early childhood presentation: Painless “limp” or
“abnormal gait”
 Older: activity related hip pain
 Diagnose with XR
 Legg-Calve-Perthes
 Idiopathic avascular necrosis of the femoral head
 Age 2-12 (peak 6-8), M>F
 Painful limp with limited hip motion
 May appear similar to toxic synovitis
Legg-Calve-Perthes
(SCFE)
Slipped Capital Femoral Epiphysis
 Slipping along the growth plate, due to
endocrine/metabolic conditions or due to
excessive abnormal mechanical stresses
 Most common in age 10-14, obese children,
Pacific islanders, M>F
 If stable prognosis is good to excellent
 Unstable (cannot bear weight) has risk of
severe AVN (up to 50%)
 Key finding: Limited internal rotation
 1/3 with bilateral disease
SCFE
Overuse
 Osgood-Schlatter
 Apophysitis of tibial tubercle
 Age 9-14, running/jumping, M>F
 Treatment: ice, anti-inflammatories, activity
restriction
 Sever disease
 Apophysitis of the calcaneus
 Age 7-9, hardwood floor or cleats
 Treatment: as above
 Note: Rule out more serious conditions first
Osgood - Schlatter
*Orthopedic emergencies*
 SepticArthritis
 Compartment syndrome
 Neurovascular compromise
 Open fractures
 Unstable slipped capital femoral epiphysis
References
 Pediatrics
in Review: The Limping Child
 UpToDate: Approach to the child with a
Limp