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Pediatric Limp Workup

  • Author: Brian Wai Lin, MD; Chief Editor: Kirsten A Bechtel, MD  more...
 
Updated: Nov 07, 2014
 

Laboratory Studies

Laboratory testing may be indicated if a serious or systemic cause of limp is suspected. Comprehensive testing is typically not necessary; investigations should be used to exclude or confirm suspected diagnoses based on history and physical examination. CBC count and erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) level are usually the most helpful and often are requested by consultants.

  • Complete blood cell count
    • Any abnormal value in the WBC count, hemoglobin or hematocrit, or platelet count warrants further investigation, especially for signs of neoplastic disease. Bone pain, which may cause a limp, is a subtle but early and important sign of neoplastic disease in children, namely, leukemia or osteosarcoma.
    • A markedly elevated ESR may be suggestive of an underlying rheumatoid condition if no clear infectious source or supportive clinical findings are found.
  • A WBC count greater than 12,000 cells/mm and ESR greater than 40 mm/h in combination with an inability to bear weight and history of fever have been suggested as diagnostic criteria to distinguish septic arthritis from transient synovitis in patients with acute hip pain.[5]
    • These criteria are widely used by orthopedic surgeons in determining which patients require hip arthrocentesis.
    • Note that external validation in another retrospective cohort showed diminished performance of these criteria,[6] and they have not been prospectively validated to date.
    • A recent retrospective study suggests that even in cases in which transient synovitis is believed to be the diagnosis, hip joint aspiration may provide faster pain relief, earlier return to normal gait pattern, and earlier hospital discharge, as compared with traditional treatment with rest and NSAIDs.[7] Thus, hip aspiration may be a reasonable treatment for any patient with severe disability from limp and a significant joint effusion seen on ultrasound.
  • A blood culture should be considered for patients with limp and fever.
  • Serum chemistries: Serum electrolytes and liver function tests are of little diagnostic value but may be obtained if a systemic/metabolic cause of limp is a concern.
  • Urinalysis may be obtained.
    • Hematuria may be associated with endocarditis, HSP, acute glomerulonephritis, and SLE.
    • Pyuria often is associated with appendicitis or salpingitis, both of which may result in a shuffling or vaulting gait.
    • The presence of uric acid crystals may support the diagnosis of gout. Obtain serum uric acid level if gout is suspected. Although an uncommon pediatric diagnosis, it may be seen in renal transplant patients who often have asymptomatic hyperuricemia.
  • Stool cultures: Salmonella enteritis and Yersinia infection may cause joint symptoms.[8]
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Imaging Studies

Plain radiographs are the minimal imaging workup necessary on the initial ED visit to evaluate for obvious bony pathology. Other imaging studies may be scheduled or obtained on an inpatient basis depending on the severity of diseases being considered.

  • Plain films should include views of the entire limb, bearing weight when possible.[9] Films of the bones/joints above and below the site of suspected pathology may be required in the toddler or nonverbal child who poorly localizes pain. Consider obtaining films of the contralateral, unaffected side if a pediatric radiologist is not available for immediate interpretation, as multiple growth plates and ossification centers in developing children can make interpretation difficult. Spine films may be indicated with back pain, midline tenderness, or any neurologic complaints.
  • Bone scan
    • Intravenous technetium 99m–labeled methylene diphosphonate tracer accumulates in areas of increased cellular activity, blood flow, and bone turnover. A 3-phase scan consisting of a blood flow, blood pool, and delayed imaging phases is the current recommended protocol.
    • Scintigraphy is useful in detecting early Legg-Calve-Perthes disease, osteomyelitis, diskitis, stress fractures, and osteoid osteomas. Scintigraphy is 84-100% sensitive and 70-96% specific for osteomyelitis. It also has an adjunctive role to the skeletal survey for nonaccidental trauma.
    • Bone scans deliver a relatively high radiation dose, an important consideration in children. Other diagnostic modalities including plain films and ultrasonography should be considered first, especially when anatomic site of pathology is easily located by physical examination.
    • Timing of scintigraphy in the evaluation of the limping child may pose a diagnostic dilemma. False-negative results may be produced by scanning too early, as results may not become positive until 48-72 hours into an inflammatory process.[10] Further complicating the matter is that procedures such as joint aspiration, which should be performed as soon as possible in suspected septic arthritis, may cause false-positive scintigraphy results. It is therefore up to the clinician’s judgment as to how to orchestrate these procedures in a limping patient with suspected serious pathology.
  • Ultrasonography is useful for diagnosing soft tissue and joint pathology.[11] A key advantage of ultrasonography is that anatomic structures can be evaluated both statically and dynamically.
    • It is particularly useful in younger children in whom the skeleton is incompletely ossified; for example, it can make the diagnosis of DDH in infants.
    • Ultrasonography can confirm the presence of a joint effusion and can guide diagnostic or therapeutic aspiration.
    • Although currently the domain of radiologists, ultrasonography of the hip by the emergency physician may have developing role for guiding bedside management of limping patients.[12, 13]
  • Computerized tomography scan
    • Judicious use of CT scanning may be indicated for the limping pediatric patient. In the absence of neurologic or musculoskeletal examination findings, intra-abdominal pathology becomes a greater concern. Atypical appendicitis, psoas abscesses, and GU tract abnormalities may be visualized.
    • CT scan gives better resolution of bone and soft tissues than plain films and has the advantage of multiplanar imaging capabilities. CT can also help identify periosteal abscesses or pyomyositis in association with osteomyelitis.
    • CT scan can aid in diagnosing joint effusions. However, given the adverse effects of radiation exposure and the availability of other diagnostic modalities, CT should not be used for this purpose.
    • Tarsal coalition, the abnormal union of two or more bones of the hindfoot and midfoot, is one disorder that has been better studied since the advent of CT scanning.
  • Magnetic resonance imaging
    • MRI is an excellent imaging modality to evaluate bony and soft tissue pathology and has the advantage of multiplanar imaging capabilities and no radiation exposure.
    • MRI is the imaging modality of choice for evaluating internal joint derangement, soft tissue or bony infection, tumors, and osteonecrosis. It is also helpful for imaging the brain and spinal cord.
    • Disadvantages of MRI include expense, relatively poor availability, and long duration. The prolonged scan time can result in significant motion artifact and may necessitate sedation in younger children. Contraindications to MRI include pacemakers, intracranial surgical clips, metallic foreign bodies, particularly in the eye, and indwelling pumps or stimulator devices.
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Other Tests

See the list below:

  • Synovial fluid analysis remains the criterion standard for diagnosis of suspected septic arthritis.
  • Cerebrospinal fluid
    • Meningitis has been associated with limping, probably due to meningismus.[14]
    • A cerebrospinal fluid (CSF) analysis should be obtained if meningitis is strongly suspected (ie, symptoms including fever, headache, meningismus).
  • Other tests (informational): These usually are obtained on subsequent visits (not on the first ED visit) to investigate chronic, progressive, or recurrent causes of limp.
    • Sickle cell preparation
    • Lupus erythematosus (LE) preparation
    • Lupus antibodies
    • Antinuclear antibody (ANA)
    • Anti-DNA (rheumatoid arthritis, scleroderma, SLE)
    • Antimuscle antibodies (myasthenia gravis)
    • Human leukocyte antigen (HLA) (Specific HLA types are associated with various rheumatoid disorders.)
    • Rheumatoid factors
    • Creatinine phosphokinase (myositis)
    • Aldolase (some forms of muscular dystrophy)
    • Serologies such as Lyme disease, parvovirus, or antistreptolysin-O (ASLO)
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Procedures

See the list below:

  • Arthrocentesis: Aspiration of synovial fluid from the hip, knee, ankle, metatarso-phalangeal, or interphalangeal joints should be performed as clinically indicated. See Arthrocentesis, Ankle and Arthrocentesis, Knee.
  • Bone aspirates: Fine needle aspiration or open biopsy may be indicated in the nonemergent setting to confirm suspected diagnoses of malignancy causing limp, such as osteosarcoma or Ewing sarcoma, and to identify other bony or soft tissue lesions.
  • Sputum aspirates: Tuberculous arthritis is rare but becoming more common in association with immune deficiency states. Pott disease may be an insidious cause of limp but would more likely be associated with systemic symptoms of tuberculosis.
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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, 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 Associate Professor of Musculoskeletal Imaging, Department of Radiology, Associate Professor of Orthopedic Surgery (by courtesy), Stanford Medical Center

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Additional Contributors

Garry Wilkes, MBBS, FACEM Director of Clinical Training (Simulation), Fiona Stanley Hospital; Clinical Associate Professor, University of Western Australia; Adjunct Associate Professor, Edith Cowan University, Western Australia

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference 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 discrepancy Slipped capital femoral epiphysis 
Developmental dysplasia of the hip Chondromalacia 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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