Pediatric Limp Treatment & Management

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

Prehospital Care

Splinting and transportation make up the majority of services that prehospital personnel render to a limping patient.

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Emergency Department Care

  • Emergency care of the limping patient is broken into 4 components:
    • Relief of acute pain
    • Identification of the cause
    • Initiation of therapy for the source of the limping
    • Referral to the appropriate health care professional for follow-up care
  • Reduction of dislocations and displaced fractures reduces discomfort and may restore perfusion in cases of vascular compromise.
  • In cases of suspected osteomyelitis, diskitis, or septic joint, intravenous antibiotics should be initiated as soon as diagnosis is confirmed.
  • Acetaminophen or ibuprofen usually is adequate for pain relief, although opiates or local or regional anesthesia may be required for more painful or extensive conditions.
  • For fractures, sprains, and acute traumatic injuries, immobilization with home care instructions to rest, ice, and elevate the injured area may suffice to provide pain relief.
  • Whenever crutches are dispensed or prescribed, the provider has a duty to train the patient in the proper application, including walking forwards and backwards, plus ascending and descending a few steps. Document training in a chart note.
  • Various fractures and sprains may require splints; prefabricated knee immobilizers and short leg walker boots may be useful in weight-bearing injuries.
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Consultations

In most cases, the diagnosis is clear and no further consultation is necessary. Specific conditions may require consultation from the following specialists:

  • Orthopedic surgeon
  • Infectious diseases specialist
  • Neurologist or rheumatologist
  • Neurosurgeon
  • Child protective services: Any child with an unexplained fracture or injury should be referred for evaluation by Child Protective Services.
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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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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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