Pediatric Limp 

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

Background

Limp is defined by a deviation from the normal gait pattern expected for a child's age.[1] It can be a challenging problem for the emergency or pediatric practitioner, as causes span multiple organ systems and anatomic locations. The differential diagnosis may be categorized based on acuity of presentation, age of the patient, etiology, type of gait disturbance, or anatomic location of suspected pathology.

Diagnostic entities range from trivial causes such as a rock in the shoe to potentially life- and limb-threatening causes such as septic arthritis and malignancy. The possibility of serious pathology underlying an acute presentation of limp makes accurate assessment, diagnostic evaluation, treatment, and appropriate follow-up essential.

Also see Limping Child for additional information.

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Pathophysiology

Walking is the culmination of the successful integration of numerous biomechanical systems. Almost every major system of the body can be involved. Ultimately, any process affecting the upper or lower motor neurons, motor end plates, musculature, bony structures, or joints may manifest as a limp.

Upper motor neuron lesions, such as brain anoxia and cerebral palsy, may be detected in the spastic gait (toe walking and/or scissoring) of an afflicted child. Destruction of the dorsal columns may result from neurosyphilis or spinal column space-occupying lesions, leading to loss of proprioception and subsequent slapping gait.

Peripheral nerve palsies, such as hereditary motor sensory neuropathy (including Charcot-Marie-Tooth disease) or posttraumatic peroneal nerve palsy, can result in a steppage gait.

Musculoskeletal pathology of the lower extremity and back most often lead to an antalgic gait. These may be traumatic, infectious, inflammatory, or rheumatologic in nature. Toddler's fractures, abuse injuries, sprains, and avascular necrosis (eg, vertebrae, femur, tarsals, metatarsals) are all possible contributors to the antalgic gait. Joint pathology, such as idiopathic avascular necrosis of the hip (Legg-Calve-Perthes disease), may cause a Trendelenburg gait as described below.

Posttraumatic, infectious, or degenerative back and spine disease can also produce alterations in gait.

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Epidemiology

Frequency

United States

The incidence of limping is not known.

International

While little published data exist, one European study found the incidence of atraumatic limp in children aged 1-14 years to be 180 cases per 100,000, or every 58th visit to a pediatric emergency department.[2]

Mortality/Morbidity

Although relatively uncommon, a few "can't miss" causes of pediatric limp may cause significant morbidity and mortality. Among 243 patients visiting one pediatric emergency department, 1.6% were diagnosed with osteomyelitis, 2.1% were diagnosed with Legg-Calve-Perthes disease, and 0.8% were diagnosed with a neoplasia.[3] No patients in this cohort had a septic arthritis or fracture related to child abuse. Thus, the incidence of these conditions and other life- and limb-threatening conditions presenting as a limp are poorly characterized.

Sex

  • Limping due to trauma and trauma-related conditions (eg, Legg-Calve-Perthes disease, toxic synovitis, tibial osteitis, groin strains) is observed more commonly in males than in females.
  • Incidence of congenital conditions (eg, limp associated with congenital hip dysplasia and meningomyelocele) corresponds to the sex predilection of the underlying condition.
  • Some systemic illnesses associated with limping (eg, rheumatoid arthritis [RA], systemic lupus erythematosus [SLE]) have a predilection for females.

Age

Age group of the patient may be one of the most helpful factors in narrowing the initial differential diagnosis of limping:

Toddlers (aged 1-3 y)

These children are ambulatory and active but have immature gaits and are thus prone to falls, typically with a torsional component.

Infections play a major role, as the bony cortex is developing and its ability to resist bacterial invasion is limited.

Causes of limp in the toddler are infectious/inflammatory (eg, transient synovitis, septic arthritis, osteomyelitis), trauma (eg, toddler's fracture [see the image below], stress fractures, puncture wounds, lacerations), neoplasm, developmental dysplasia of the hips, neuromuscular disease, cerebral palsy, and congenital hypotonia.

Toddler's fracture. Reproduced with permission froToddler'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.

Children (aged 4-10 y)

Being more rambunctious carries with it more risk of high-energy injuries, such as fractures, dislocations, and ligamentous injuries.

Microtrauma to the vascular supply of the femoral head is thought to be a cause of Legg-Calve-Perthes disease (LCP), a common source of limping in this age group. See the image below.

Legg-Calve-Perthes disease. Patient with a painfulLegg-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.

Infections continue to plague this age group. Terminal vessels occur in the metaphysis of growing bones, which is a common site for infection.

Rheumatoid conditions begin to emerge.

Neoplastic lesions such as leukemia (see the first image below) and Ewing sarcoma (see the second image below) can occur.

Knee radiographs in leukemia. Oblique radiographs Knee radiographs in leukemia. Oblique radiographs of the knee show lucent metaphyseal bands, which are seen in 90% of patients with leukemia. Ewing sarcoma. Anteroposterior radiograph of the fEwing 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.

Adolescents (older than 11 y)

The bony architecture is more mature and resilient, and muscle strength also has increased dramatically.

A slipped capital femoral epiphysis is an example of how bone maturation, strength, and weight mismatches can result in problems (see the image below).

Slipped capital femoral epiphysis. AnteroposteriorSlipped 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.

At this age, arthritis, sexually transmitted diseases (with arthralgias and arthritis), and neoplasms may present as a limp.

Other common causes of limping in the adolescent are juvenile arthritis (see the first image below), trauma, leg length discrepancy, and neoplasms such as osteosarcoma (see the second image below).

Juvenile idiopathic arthritis. Anteroposterior radJuvenile 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). Osteosarcoma. Anteroposterior and lateral radiograOsteosarcoma. 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).
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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

  1. Nelson WE, Behrman RE, Kliegman R, Arvin AM. Textbook of Pediatrics. 15th ed. Philadelphia, Pa: Saunders; 1996.

  2. Singer JI. The cause of gait disturbance in 425 pediatric patients. Pediatr Emerg Care. Mar 1985;1(1):7-10. [Medline].

  3. Fischer SU, Beattie TF. The limping child: epidemiology, assessment and outcome. J Bone Joint Surg Br. Nov 1999;81(6):1029-34. [Medline].

  4. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am. Dec 1999;81(12):1662-70. [Medline].

  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].

  6. Berezin S, Newman LJ, Wasserman E. Limp in a child associated with Yersinia enterocolitica infection. N Y State J Med. May 1984;84(5):230-1. [Medline].

  7. Reed L, Baskett A, Watkins N. Managing children with acute non-traumatic limp: the utility of clinical findings, laboratory inflammatory markers and X-rays. Emerg Med Australas. Apr 2009;21(2):136-42. [Medline].

  8. Nadel HR. Bone scan update. Semin Nucl Med. Sep 2007;37:332-9. [Medline].

  9. Vieira RL, Levy JA. Bedside ultrasonography to identify hip effusions in pediatric patients. Ann Emerg Med. Mar 2010;55(3):284-9. [Medline].

  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].

  29. Swischuk LE. Limp in young child. Pediatr Emerg Care. Mar 1990;6(1):65-6. [Medline].

  30. Tolo V, Wood B. The limping child. In: Pediatric Orthopedics Primary Care. Baltimore, Md: Williams & Wilkins; 1993:278-83.

  31. Tuten HR, Gabos PG, Kumar SJ, Harter GD. The limping child: a manifestation of acute leukemia. J Pediatr Orthop. Sep-Oct 1998;18(5):625-9. [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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