Diagnostic Considerations

Table. Diagnostic Considerations for Limping, Organized by System and Patient Age (Open Table in a new window)

System/Age	Toddler (1-3 y)	Child (4-10 y)	Adolescent (11-16 y)
Infectious/Inflammatory	Septic arthritis	Septic arthritis	Septic arthritis (consider Neisseria gonorrhoeae)
	Osteomyelitis	Osteomyelitis
	Transient synovitis	Transient synovitis
	Meningitis	Diskitis
Orthopedic/Mechanical	Fractures (consider toddler's, nonaccidental trauma)	Fractures	Fractures (consider stress fractures, overuse syndromes)
	Osteochondroses	Osteochondroses (consider Legg-Calve-Perthes)	Osteochondroses (consider Osgood-Schlatter)
	Strains/sprains	Strains/sprains	Strains/sprains
	Foot/shoe foreign bodies	Foot/shoe foreign bodies
	Leg length discrepancy		Slipped capital femoral epiphysis
	Developmental dysplasia of the hip		Chondromalacia patellae
			Osteochondritis dissecans
Neoplastic	Neuroblastoma	Osteosarcoma	Osteosarcoma
	Leukemia (ALL)	Ewing's sarcoma	Ewing's sarcoma
	Osteochondroma	Osteochondroma	Osteochondroma
		Osteoid osteoma	Osteoid osteoma
Neuromuscular	Hereditary motor sensory neuropathies (includes Charcot-Marie-Tooth)
	Myositis
	Peripheral neuropathy
	Muscular dystrophy
	Reflex sympathetic dystrophy
Rheumatologic	Juvenile idiopathic arthritis	Juvenile idiopathic arthritis
	Henoch-Schonlein purpura	Henoch-Schonlein purpura
	Gout/pseudogout	Gout/pseudogout	Gout/pseudogout
		SLE	SLE
	Serum sickness & serum sickness-like reactions	Rheumatic fever	Rheumatic fever
Hematologic	Sickle cell disease (vaso-occlusive crisis)
Hematologic	Hemophilia (hemarthrosis)
Intra-abdominal	Appendicitis	Appendicitis	Appendicitis
	Psoas abscess	Psoas abscess	Psoas abscess
			Testicular torsion
			PID

Differential Diagnoses

Ankle Fracture Management in the ED
Ankle Injury, Soft Tissue
Appendicitis
Brain Abscess
Cat Scratch Disease (Cat Scratch Fever)
Erythema Multiforme
Femoral Shaft Fractures in Emergency Medicine
Foot Fracture
Gout and Pseudogout
Heavy Metal Toxicity
Hemophilia, Type A
Hemophilia, Type B
Hip Fracture in the ED
Inflammatory Bowel Disease
Insect Bites
Knee Fracture Management in the Emergency Department
Legg-Calve-Perthes Disease in the ED
Mechanical Back Pain
Nongenital Warts
Pediatrics, Meningitis and Encephalitis
Pelvic Fracture Management in the ED
Rheumatic Fever in Emergency Medicine
Rheumatoid Arthritis (RA)
Sickle Cell Disease (SCD)
Spinal Cord Neoplasms
Tibia and Fibula Fracture Management in the ED

Workup

Nelson WE, Behrman RE, Kliegman R, Arvin AM. Textbook of Pediatrics. 15th ed. Philadelphia, Pa: Saunders; 1996.
Singer JI. The cause of gait disturbance in 425 pediatric patients. Pediatr Emerg Care. 1985 Mar. 1(1):7-10. [QxMD MEDLINE Link].
Fischer SU, Beattie TF. The limping child: epidemiology, assessment and outcome. J Bone Joint Surg Br. 1999 Nov. 81(6):1029-34. [QxMD MEDLINE Link].
Mathison DJ, Troy A, Levy M. Fever and limp: thinking outside the box. Pediatr Emerg Care. 2012 Dec. 28(12):1369-73. [QxMD MEDLINE Link].
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. 1999 Dec. 81(12):1662-70. [QxMD MEDLINE Link].
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. 2004 Aug. 86-A(8):1629-35. [QxMD MEDLINE Link].
Liberman B, Herman A, Schindler A, Sherr-Lurie N, Ganel A, Givon U. The Value of Hip Aspiration in Pediatric Transient Synovitis. J Pediatr Orthop. March/2013. 33:124-7. [QxMD MEDLINE Link].
Berezin S, Newman LJ, Wasserman E. Limp in a child associated with Yersinia enterocolitica infection. N Y State J Med. 1984 May. 84(5):230-1. [QxMD MEDLINE Link].
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. 2009 Apr. 21(2):136-42. [QxMD MEDLINE Link].
Nadel HR. Bone scan update. Semin Nucl Med. Sep 2007. 37:332-9. [QxMD MEDLINE Link].
Vieira RL, Levy JA. Bedside ultrasonography to identify hip effusions in pediatric patients. Ann Emerg Med. 2010 Mar. 55(3):284-9. [QxMD MEDLINE Link].
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. 2006 Aug. 22(8):570-3. [QxMD MEDLINE Link].
Tsung JW, Blaivas M. Emergency department diagnosis of pediatric hip effusion and guided arthrocentesis using point-of-care ultrasound. J Emerg Med. 2008 Nov. 35(4):393-9. [QxMD MEDLINE Link].
Carraccio CL, Lomonico MP, Fisher MC. Limp as a presenting sign of meningitis. Pediatr Infect Dis J. 1990 Sep. 9(9):673-4. [QxMD MEDLINE Link].
Kotlarsky P, Shavit I, Kassis I, Eidelman M. Treatment of septic hip in a pediatric ED: a retrospective case series analysis. Am J Emerg Med. 2016 Mar. 34 (3):602-5. [QxMD MEDLINE Link].
Causey AL, Smith ER, Donaldson JJ, Kendig RJ, Fisher LC 3rd. Missed slipped capital femoral epiphysis: illustrative cases and a review. J Emerg Med. 1995 Mar-Apr. 13(2):175-89. [QxMD MEDLINE Link].
Dabney KW, Lipton G. Evaluation of limp in children. Curr Opin Pediatr. 1995 Feb. 7(1):88-94. [QxMD MEDLINE Link].
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. 1992 Sep. 9(3):323-5. [QxMD MEDLINE Link].
Herman MI. A limping 6 year old. Yamamoto L, et al, eds. Radiology Cases in Pediatric Emergency Medicine. 1997. Vol 4 Case 16:
Lee RW, Demos TC. Limp and altered gait. Rosen P, Doris PE, Berkin RM, et al. Diagnostic Radiology in Emergency Medicine. 1992. 509-40.
Leet AI, Skaggs DL. Evaluation of the acutely limping child. Am Fam Physician. 2000 Feb 15. 61(4):1011-8. [QxMD MEDLINE Link].
Leung AK, Lemay JF. The limping child. J Pediatr Health Care. 2004 Sep-Oct. 18(5):219-23. [QxMD MEDLINE Link].
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. 2004 May. 86-A(5):956-62. [QxMD MEDLINE Link].
Mankin KP, Zimbler S. Gait and leg alignment: What's normal and what's not. Contemp Pediatr. 1997 Nov. 41-70.
Markowitz C, Wynkoop W, Dvonch V. Limping toddlers. Orthopedics. 1986 Jul. 9(7):1021-3. [QxMD MEDLINE Link].
Myers MT, Thompson GH. Imaging the child with a limp. Pediatr Clin North Am. 1997 Jun. 44(3):637-58. [QxMD MEDLINE Link].
Phillips WA. The child with a limp. Orthop Clin North Am. 1987 Oct. 18(4):489-501. [QxMD MEDLINE Link].
Renshaw TS. The child who has a limp. Pediatr Rev. 1995 Dec. 16(12):458-65. [QxMD MEDLINE Link].
Scrutton DS, Robson P. The gait of 50 normal children. Physiotherapy. 1968 Oct. 54(10):363-8. [QxMD MEDLINE Link].
Singer J. Evaluation of acute and insidious gait disturbance in children less than five years of age. Adv Pediatr. 1979. 26:209-73. [QxMD MEDLINE Link].
Snook ME, LiPuma JJ. Pelvic muscle abscess. An unusual cause of gait disturbance in young children. Clin Pediatr (Phila). 1993 May. 32(5):298-9. [QxMD MEDLINE Link].
Swischuk LE. Limp in young child. Pediatr Emerg Care. 1990 Mar. 6(1):65-6. [QxMD MEDLINE Link].
Tolo V, Wood B. The limping child. Pediatric Orthopedics Primary Care. Baltimore, Md: Williams & Wilkins; 1993. 278-83.
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Media Gallery

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.

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Table. Diagnostic Considerations for Limping, Organized by System and Patient Age

Table. Diagnostic Considerations for Limping, Organized by System and Patient Age

System/Age	Toddler (1-3 y)	Child (4-10 y)	Adolescent (11-16 y)
Infectious/Inflammatory	Septic arthritis	Septic arthritis	Septic arthritis (consider Neisseria gonorrhoeae)
	Osteomyelitis	Osteomyelitis
	Transient synovitis	Transient synovitis
	Meningitis	Diskitis
Orthopedic/Mechanical	Fractures (consider toddler's, nonaccidental trauma)	Fractures	Fractures (consider stress fractures, overuse syndromes)
	Osteochondroses	Osteochondroses (consider Legg-Calve-Perthes)	Osteochondroses (consider Osgood-Schlatter)
	Strains/sprains	Strains/sprains	Strains/sprains
	Foot/shoe foreign bodies	Foot/shoe foreign bodies
	Leg length discrepancy		Slipped capital femoral epiphysis
	Developmental dysplasia of the hip		Chondromalacia patellae
			Osteochondritis dissecans
Neoplastic	Neuroblastoma	Osteosarcoma	Osteosarcoma
	Leukemia (ALL)	Ewing's sarcoma	Ewing's sarcoma
	Osteochondroma	Osteochondroma	Osteochondroma
		Osteoid osteoma	Osteoid osteoma
Neuromuscular	Hereditary motor sensory neuropathies (includes Charcot-Marie-Tooth)
	Myositis
	Peripheral neuropathy
	Muscular dystrophy
	Reflex sympathetic dystrophy
Rheumatologic	Juvenile idiopathic arthritis	Juvenile idiopathic arthritis
	Henoch-Schonlein purpura	Henoch-Schonlein purpura
	Gout/pseudogout	Gout/pseudogout	Gout/pseudogout
		SLE	SLE
	Serum sickness & serum sickness-like reactions	Rheumatic fever	Rheumatic fever
Hematologic	Sickle cell disease (vaso-occlusive crisis)
Hematologic	Hemophilia (hemarthrosis)
Intra-abdominal	Appendicitis	Appendicitis	Appendicitis
	Psoas abscess	Psoas abscess	Psoas abscess
			Testicular torsion
			PID

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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 Emergency Physician, Echuca Regional Health, Victoria; Clinical Associate Professor, University of Western Australia, 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.

Pediatric Limp Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

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