Pediatric Limp Differential Diagnoses

  • Author: Brian Wai Lin, MD; Chief Editor: Richard G Bachur, MD   more...
 
Updated: Apr 11, 2011
 
 

Differential Diagnoses

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Contributor Information and Disclosures
Author

Brian Wai Lin, MD  Staff Physician, Stanford/Kaiser Emergency Medicine Residency, Stanford University School of Medicine

Brian Wai Lin, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Coauthor(s)

Erik D Schraga, MD  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Kathryn J Stevens, MD, FRCR  Assistant Professor, Department of Radiology, Musculoskeletal Imaging and Assistant Professor of Orthopaedic Surgery (by courtesy), Stanford Medical Center

Kathryn J Stevens, MD, FRCR is a member of the following medical societies: British Society of Skeletal Radiology, International Skeletal Society, International Society for Magnetic Resonance in Medicine, and Radiological Society of North America

Disclosure: Nothing to disclose.

Specialty Editor Board

Garry Wilkes  MBBS, FACEM, Director of Emergency Medicine, Calvary Hospital, Canberra, ACT; Adjunct Associate Professor, Edith Cowan University; Clinical Associate Professor, Rural Clinical School, University of Western Australia

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Grace M Young, MD  Associate Professor, Department of Pediatrics, University of Maryland Medical Center

Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD  Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston

Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Martin I Herman, MD, to the development and writing of this article.

References

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  5. Kocher MS, Mandiga R, Zurakowski D, Barnewolt C, Kasser JR. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am. Aug 2004;86-A(8):1629-35. [Medline].

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  10. Shavit I, Eidelman M, Galbraith R. Sonography of the hip-joint by the emergency physician: its role in the evaluation of children presenting with acute limp. Pediatr Emerg Care. Aug 2006;22(8):570-3. [Medline].

  11. Tsung JW, Blaivas M. Emergency department diagnosis of pediatric hip effusion and guided arthrocentesis using point-of-care ultrasound. J Emerg Med. Nov 2008;35(4):393-9. [Medline].

  12. Carraccio CL, Lomonico MP, Fisher MC. Limp as a presenting sign of meningitis. Pediatr Infect Dis J. Sep 1990;9(9):673-4. [Medline].

  13. Causey AL, Smith ER, Donaldson JJ, Kendig RJ, Fisher LC 3rd. Missed slipped capital femoral epiphysis: illustrative cases and a review. J Emerg Med. Mar-Apr 1995;13(2):175-89. [Medline].

  14. Dabney KW, Lipton G. Evaluation of limp in children. Curr Opin Pediatr. Feb 1995;7(1):88-94. [Medline].

  15. Gavalas M, Potts H, Galasko CS. Bone infection and the limping child in the accident & emergency department: a diagnosis to be considered. Arch Emerg Med. Sep 1992;9(3):323-5. [Medline].

  16. Herman MI. A limping 6 year old. In: Yamamoto L, et al, eds. Radiology Cases in Pediatric Emergency Medicine. Vol 4 Case 16. 1997.

  17. Lee RW, Demos TC. Limp and altered gait. In: Rosen P, Doris PE, Berkin RM, et al. Diagnostic Radiology in Emergency Medicine. 1992:509-40.

  18. Leet AI, Skaggs DL. Evaluation of the acutely limping child. Am Fam Physician. Feb 15 2000;61(4):1011-8. [Medline].

  19. Leung AK, Lemay JF. The limping child. J Pediatr Health Care. Sep-Oct 2004;18(5):219-23. [Medline].

  20. Luhmann SJ, Jones A, Schootman M, Gordon JE, Schoenecker PL, Luhmann JD. Differentiation between septic arthritis and transient synovitis of the hip in children with clinical prediction algorithms. J Bone Joint Surg Am. May 2004;86-A(5):956-62. [Medline].

  21. Mankin KP, Zimbler S. Gait and leg alignment: What's normal and what's not. Contemp Pediatr. Nov 1997;41-70.

  22. Markowitz C, Wynkoop W, Dvonch V. Limping toddlers. Orthopedics. Jul 1986;9(7):1021-3. [Medline].

  23. Myers MT, Thompson GH. Imaging the child with a limp. Pediatr Clin North Am. Jun 1997;44(3):637-58. [Medline].

  24. Phillips WA. The child with a limp. Orthop Clin North Am. Oct 1987;18(4):489-501. [Medline].

  25. Renshaw TS. The child who has a limp. Pediatr Rev. Dec 1995;16(12):458-65. [Medline].

  26. Scrutton DS, Robson P. The gait of 50 normal children. Physiotherapy. Oct 1968;54(10):363-8. [Medline].

  27. Singer J. Evaluation of acute and insidious gait disturbance in children less than five years of age. Adv Pediatr. 1979;26:209-73. [Medline].

  28. Snook ME, LiPuma JJ. Pelvic muscle abscess. An unusual cause of gait disturbance in young children. Clin Pediatr (Phila). May 1993;32(5):298-9. [Medline].

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Toddler's fracture. Reproduced with permission from Radiology Cases in Pediatric Emergency Medicine, Volume 4, Case 18, Melinda D. Santhany, MD. Kapiolani Medical Center for Women and Children, University of Hawaii, John A. Burns School of Medicine.
Demonstration of Galeazzi test to evaluate for leg length discrepancy.
Demonstration of FABER test to evaluate for sacro-iliac joint pathology.
Demonstration of prone internal rotation. The maneuver increases intracapsular pressure in the hip and will not be tolerated by a patient with an inflammatory process.
Legg-Calve-Perthes disease. Patient with a painful hip and limp for several months. Reproduced with permission from Loren Yamamoto, Radiology Cases in Pediatric Emergency Medicine.
Transient synovitis. Ultrasound image of the left hip shows a large joint effusion. The fluid was aspirated leading to complete resolution of symptoms. No organisms were grown, and the diagnosis was transient synovitis.
Ewing sarcoma. Anteroposterior radiograph of the femur in a 14-year-old male shows an ill-defined permeative lytic lesion of the proximal femur, with lamellated periosteal reaction (arrows). Coronal inversion recovery MRI image demonstrated a tumor within the proximal femur, with reactive bone marrow edema. Lamellated periosteal reaction is present (arrows), and edema is seen in the adjacent soft tissues. The tumor was biopsy-proven as Ewing sarcoma.
Juvenile idiopathic arthritis. Anteroposterior radiograph of the hip shows ballooning of the femoral metaphysis and flattening of the femoral epiphysis, with erosion of the femoral head. On the sagittal T2-weighted image, a joint effusion with prominent nodular synovitis is observed (arrows). Erosions are seen in the acetabulum and femoral head (open arrows).
Knee radiographs in leukemia. Oblique radiographs of the knee show lucent metaphyseal bands, which are seen in 90% of patients with leukemia.
Osteochondroma. Anteroposterior and lateral radiographs of the left leg in a 10-year-old boy with hereditary multiple exostoses showing multiple osteochondromas (arrows).
Osgood-Schlatter disease. Lateral radiograph of the left knee showing fragmentation of the tibial tubercle with overlying soft tissue swelling, consistent with Osgood-Schlatter disease.
Osteoid osteoma. Anteroposterior film of the femur in a 10-year-old boy shows cortical thickening of the medial aspect of the distal femur (arrows). Coronal inversion recovery demonstrates a high signal intensity lesion in the medial cortex, with associated bone marrow edema, biopsy proven to be an osteoid osteoma.
Osteomyelitis. Anteroposterior radiograph of the pelvis in a 16-month-old boy shows erosion and lucency of the metaphysis in the right proximal femur (arrows). Coronal inversion recovery image show a joint effusion in the right hip. Extensive bone marrow edema is present in the femoral metaphysis, with edema in the surrounding soft tissues.
Osteosarcoma. Anteroposterior and lateral radiographs in a 9-year-old girl shows a destructive lesion of the distal femoral metaphysis medially, with aggressive sunburst periosteal reaction and a Codman's triangle on the lateral view (arrow). Coronal T1-weighted and axial T2-weighted images showing an expansile tumor of the distal femur with cortical destruction and extension into the soft tissues (arrows).
Slipped capital femoral epiphysis. Anteroposterior pelvis in an overweight13-year-old adolescent girl shows widening of the epiphyseal plate with irregular margins. Frog leg lateral views shows posteromedial displacement of the femoral head.
Legg-Calve-Perthes disease. Anteroposterior and frog leg lateral radiographs of the pelvis in a 8-year-old girl shows fragmentation and collapse of the left femoral capital epiphysis.
Developmental dysplasia of the hip. Anteroposterior radiograph of the pelvis in a 2-year-old child demonstrates a shallow acetabulum on the right, with lateral uncovering of the femoral head. The left hip appears unremarkable.
Table. Diagnostic Considerations for Limping, Organized by System and Patient Age
System/AgeToddler (1-3 y)Child (4-10 y)Adolescent (11-16 y)
Infectious/InflammatorySeptic arthritisSeptic arthritisSeptic arthritis (consider Neisseria gonorrhoeae)
OsteomyelitisOsteomyelitis
Transient synovitisTransient synovitis
MeningitisDiskitis
Orthopedic/MechanicalFractures (consider toddler's, nonaccidental trauma)FracturesFractures (consider stress fractures, overuse syndromes)
OsteochondrosesOsteochondroses (consider Legg-Calve-Perthes)Osteochondroses (consider Osgood-Schlatter)
Strains/sprainsStrains/sprainsStrains/sprains
Foot/shoe foreign bodiesFoot/shoe foreign bodies
Leg length discrepancySlipped capital femoral epiphysis
Developmental dysplasia of the hipChondromalacia patellae
Osteochondritis dissecans
NeoplasticNeuroblastomaOsteosarcomaOsteosarcoma
Leukemia (ALL)Ewing's sarcomaEwing's sarcoma
OsteochondromaOsteochondromaOsteochondroma
Osteoid osteomaOsteoid osteoma
NeuromuscularHereditary motor sensory neuropathies (includes Charcot-Marie-Tooth)
Myositis
Peripheral neuropathy
Muscular dystrophy
Reflex sympathetic dystrophy
RheumatologicJuvenile idiopathic arthritisJuvenile idiopathic arthritis
Henoch-Schonlein purpuraHenoch-Schonlein purpura
Gout/pseudogoutGout/pseudogoutGout/pseudogout
SLESLE
Serum sickness & serum sickness-like reactionsRheumatic feverRheumatic fever
HematologicSickle cell disease (vaso-occlusive crisis)
Hemophilia (hemarthrosis)
Intra-abdominalAppendicitisAppendicitisAppendicitis
Psoas abscessPsoas abscessPsoas abscess
Testicular torsion
PID
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