Sections

Pediatric Limp

Treatment

Prehospital Care

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

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.

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.

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.

Long-Term Monitoring

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.

Medication

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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 Treatment & Management

Prehospital Care

Emergency Department Care

Consultations

Long-Term Monitoring

References

Tables

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