eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Limp: Follow-up

Author: Brian Wai Lin, MD, Staff Physician, Stanford/Kaiser Emergency Medicine Residency, Stanford University School of Medicine
Coauthor(s): Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center; Kathryn J Stevens, MD, FRCR, Assistant Professor, Department of Radiology, Musculoskeletal Imaging and Assistant Professor of Orthopaedic Surgery (by courtesy), Stanford Medical Center
Contributor Information and Disclosures

Updated: Oct 2, 2009

Follow-up

Further Inpatient Care

  • If suspicion of septic arthritis, osteomyelitis, or neoplastic disease is strong, the child should be admitted to a pediatric service with appropriate pediatric consultative services.

Further Outpatient Care

  • All children with a limp should have close follow-up visits with their pediatrician or primary care physician within 24 hours of their ED visit. Any persistence of a limp without cause should be investigated further.

Complications

  • Left untreated, a slipped capital femoral epiphysis can result in permanent gait abnormalities.
  • Early treatment of several disorders that may cause limping can result in resolution or at least limit the extent of the injury.
  • The degree to which intervention will play a role is entirely dependent on the etiology of the limp.

Prognosis

  • The prognosis varies depending upon the etiology.

Miscellaneous

Medicolegal Pitfalls

Be vigilant in the approach to the limping individual because some pitfalls do exist. It is the duty of the practitioner to identify potentially life and limb-threatening conditions such as septic arthritis or a fracture. Although not necessarily an acutely life-threatening condition, underlying malignancy should be identified to avoid potential delay in diagnosis and treatment. Of utmost importance, all patients require appropriate discharge instructions and follow-up arrangements.

  • Some of the conditions associated with limping in which immediate diagnosis and treatment is of great importance include the following:
    • Septic arthritis of the hip, knee, or ankle
    • Osteomyelitis
    • Fractures and injuries related to child abuse
    • Tumors of the CNS may cause a progressive loss of gait, and a history of deterioration demands investigation. Ewing sarcoma and osteogenic sarcoma can be devastating if early detection does not occur.
  • Other causes do not demand urgent treatment, but their potential for long-term morbidity if undetected underscores the importance of timely follow-up:
    • Slipped capital femoral epiphysis
    • Developmental dysplasia of the hip
    • Fractures of the tarsal bones and some involving the ankles can be very subtle.
    • Salter-Harris type I fractures are often missed and may lead to long-term growth disturbance. Patients with open physes and traumatic injuries should not be casually considered to have a sprain without adequate follow-up.
  • The pediatric and emergency practitioner should be weary of labeling acute limps as idiopathic "growing pains." The diagnosis of growing pains requires that (1) leg pain is bilateral; (2) pain only occurs at night; and (3) the patient has no daytime symptoms or limping.1 This should thus be treated as a diagnosis of exclusion, after all emergent and urgent causes of limp have been considered.

Special Concerns

  • A system to follow-up the radiologist's reading is essential when incidental tumors are identified.
 
Acknowledgments

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.



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References
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References

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Further Reading

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Keywords

limping, limping in children, steppage gait, shuffling gait, peripheral nerve palsies, Marie-Charcot-Tooth disease, posttraumatic peroneal nerve palsy, ataxia, labyrinthitis, alcohol-induced organic brain disease, inherited diseases, Friedreich ataxia, otitis media, antalgic gaits, truncal lurch gait, exaggerated trunk swing, osteomyelitis, slapping gait, leg injuries, leg fractures, toddler's fractures, abuse injuries, sprains, avascular necrosis, Legg-Calve-Perthes disease, cerebral palsy, spastic paralysis, scissoring gait, vaulting gait, abnormal gait, toe-walking gait, leg length discrepancy, abductor lurch, Trendelenburg gait, waddling gait, stooped gait

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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, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
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.

Medical Editor

Garry Wilkes, MBBS, FACEM, Director of Emergency Medicine, Bunbury Hospital, Western Australia; Medical Director, St John Ambulance, WA Ambulance Service; Adjunct Associate Professor, Edith Cowan University; Clinical Associate Professor, Rural Clinical School, University of Western Australia, Australia.
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

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.

CME Editor

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.

 
 
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