This document discusses the approach to evaluating a limping child. It begins by outlining the main causes of a limp as being pain, weakness, or structural abnormalities. Different abnormal gaits are then described that may provide clues to the underlying etiology, such as an antalgic gait indicating pain in one limb. A differential diagnosis is presented divided by painless versus painful limps and by age. The approach is then outlined as obtaining a thorough history, performing a full examination, ordering appropriate investigations, and determining the proper management.
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Approach to Limping Child Differential Diagnosis
1. Approach to a limping
child
BY
Magdy Shafik Ramadan
Senior Pediatric and Neonatology consultant
M.S, Diploma, Ph.D of P ediatrics
2. Pathophysiology
Three major factors cause a child to limp: pain,
weakness, and structural or mechanical
abnormalities of the spine, pelvis, and lower
extremities (Clark, 1997; deBoeck & Vorlat, 2003; Lawrence, 1998).
A normal gait is composed of symmetrical, alternating,
rhythmical motions involving two phases: stance and
swing. The stance phase normally encompasses 60%
of the gait cycle. The type of gait may be helpful in
identifying the etiology of the limp .
3. Some Abnormal Gaits
An antalgic gait results from pain in one extremity
that causes the patient to shorten the stance phase
on that side with a resultant increase in the swing
phase. The most common causes of an antalgic
gait are trauma or infection .
A Trendelenburg gait is a downward pelvic tilt
away from the affected hip during the swing phase
as a result of weakness of the contralateral gluteus
medius muscle .
The gait disturbance is commonly observed in
children with developmental dysplasia of the hip,
Legg-Calves-Perthes disease, or slipped capital
femoral epiphysis. If the involvement is bilateral, a
waddling gait results
4. A steppage (equinus) gait is a result of the
inability to actively dorsiflex the foot, with
exaggerated hip and knee flexion during the
swing phase. A steppage gait is seen in
children with neuromuscular diseases (eg,
cerebral palsy) that cause impairment of
dorsiflexion of the ankle.
A vaulting gait (مشيةالقفز)
occurs when the knee is hyperextended and
locked at the end of the stance phase and the
child vaults over the extremity .A vaulting gait
is seen in children with limb length
discrepancy or abnormal knee mobility.
5. A stooped gait is characterized by walking
with bilaterally increased hip flexion A
stooped gait is common in children with pelvic
or lower abdominal pain.
8. Differential Diagnosis
Painless limpPainful limpAge
1- Developmental dyplasia of
the hip
2- Neuromuscular disease
Cerebral palsy
Muscular dystrophy
3- lower limb length inequality
4- chronic slipped upper
femoral epiphysis
1-Infection
2- inflammatory :JRA, SLE
3- Trauma
4-1ry or metastatic tumor
5-hematological disease
Hemophilia, SCA, leukemia
6-Legg-Calve-Perthes Disease
(AVN of femoral head)
7-acute slipped upper femoral
epiphysis*
11- 18yr
*very tall and/or obese. Limp and pain in the hip. Leg is held in an extemal rotation position.
Often painful on internal rotation of the hip. Association with hypothyroidism
9. Differential Diagonsis
Others: don’t forget to consider:
Appendicitis with psoas muscle irritation
Neoplasms- either cause pain or pathological
fractures
Retroperitoneal neoplasms or infection
Neuromusculature disorders
11. History
Age
Sex
Onset
Painful or painless? ( analysis…)
Acute or chronic
History of trauma
Association : Night pain, arthralgia, swelling,
morning stiffness, backache
12. History
Systemic review
Recent illness : URTI
Weight loss, anorexia
Fever, chills
Unexplained rash or bruising
Voiding problem
13. History
Past history
Medical : chronic illness
Drugs : steroids, antibiotic
Allergies
Developmental
Nutritional
Vaccination ( site, MMR vaccine)
Family history
Hemoglobinopathy, CTD, IBD, NMD
Social history