limp approach is an imp topic, esp related to DDH, early diagnosis and early management is life changing in children.

1. APPROACH TO A LIMPING
CHILD
PRESENTED BY : CAPT BISHWO KUNWAR
MODERATED BY : COL S C SHAW

2. CONTENTS
• Introduction
• Normal gait cycle
• Incidence
• Etiologies
• Approach
• Take home message

3. NORMAL GAIT
• 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.
• At age 1 year, many children can walk without support. By age 18
months, most children walk, and many can run. Coordination with
reciprocal arm swing develops by age 2 years.
• Finer adjustments to the gait pattern may not occur until the child is
aged 8-10 years, when normal adult gait pattern is attained

4. NORMAL GAIT CYCLE
• With increasing age, the duration of single limb stance ,walking velocity, and step length
increase, whereas the number of steps taken/min decreases.

5. NORMAL GAIT IN CHILDREN
TODDLERS 3-5 YEARS > 7 YEARS
Wide base of support
Short, sometimes asymmetric steps
Occasional foot slapping as they pick
up speed
Arm motion is nonreciprocal with
their legs
They fall frequently
Symmetric strides
Reciprocal arm motion
Stable velocity pattern (age 5)
Adult pattern

6. LIMP
• Limp is defined as a deviation from a normal age-appropriate gait
pattern resulting in an uneven, jerky, or laborious gait.
• Can be caused by pain, weakness, or deformity

7. INCIDENCE
•1.8 per 1,000 children
•male : female : 1.7: 1
•Median age 4.4 years
•Right and left limbs equally involved
•80 % reported with pain
•Most common cause was: transient synovitis

8. WAYS TO APPROACH GAIT DISTURBANCE

9. WAYS TO APPROACH GAIT DISTURBANCES
• LONGEVITY ( ACUTE OR CHRONIC)
• GAIT PATTERN
• AGE
• LOCATION
• ETIOLOGY

10. Longevity of gait disturbance
• ACUTE
Previous normal gait
Often unclear onset or
associated activity
Historical observation may be
flawed
Includes etiologies that may
require urgent diagnosis and
treatment
• LONG STANDING
Possibly since initial walking
Possible delayed milestones
Unilateral vs B/L
Perinatal history
Motor milestones: smooth
progression or plateau or regression
General vs specific site.
Unlikely to need urgent t/m , but
may be imp. to diagnose in a timely
manner

11. ABNORMAL GAIT PATTERN
• Antalgic gait (painful) • Non –Antalgic gait (painless)
Trendelenburg gait
Steppage Gait
Circumduction Gait
Vaulting Gait
Stooping Gait

12. 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
• Fracture , unilateral slipped capital femoral epiphysis , soft tissue
injury, septic or other arthritis.

13. TRENDELENBURG GAIT
• A downward pelvic tilt away from the affected hip during the swing
phase as a result of weakness of the contralateral Hip Abductors
• LCP, U/L SCFE,DDH

15. STEPPAGE GAIT
• Result of the inability to actively dorsiflex the foot, with exaggerated hip and knee
flexion during the swing phase
• Seen with a foot drop
• Neurological diseases (CP , hereditary motor sensory neuropathy) which cause
loss of dorsiflexion of the ankle

17. VAULTING GAIT
• Occurs when the knee is hyperextended and locked at the end of the
stance phase and the child vaults over the extremity
• Limb length discrepancy or abnormal knee mobility or a stiff leg.
• Differs from toe-walking as the heel does strike the floor
normally

18. CIRCUMDUCTION GAIT
• To avoid the foot from scrapping
the ground, the hip and the lower
limb rotates outward
• In hemiplegic patients
• Other causes:
Prosthesis too long
Locked knee
Foot set in planter flexion
Lack of knee flexion

19. TOE WALKING GAIT
• Child walks on his/her toe caused by heel pain or by increased flexor
muscle tone in the lower leg
• Mild cerebral palsy, heel foreign body , tethered spinal cord

20. STOOPING GAIT
• Child shuffles with hip flexed due to irritation of the psoas muscle by
intra-abdominal inflammation
• In appendicitis, pelvic inflammatory disease, psoas muscle abscess

21. ETIOLOGIES
ANTALGIC GAIT NON – NATALGIC GAIT

22. ASSESSMENT – HISTORY
• Age
• Sex : DDH > Girls , LCPD, SCFE > Boys
• Pain ?
• Location
• Duration and course
• H/O Trauma ? H/O child abuse ?
• Dose limp improves or aggravates with walking
• No of involved joints
• Associated symptoms (fever , weight loss, anorexia, back pain , arthralgia)
• Limping vs not walking
• Pain at rest ? At night ?

24. ASSESSMENT : EXAMINATION
• Examination of a Toddler /child can be difficult
• Calm environment
• During examination : entire lower limbs , hips and back should
be visible.
• In ambulating, multiple passes, systematically evaluate each
level.
Don’t forget!!!
• Both intra-abdominal pathology and testicular torsion
may present as limp
• So always examine abdomen and testes in boys!

25. ASSESSMENT : EXAMINATION
• INSPECTION:
General appearance : sick/non sick
Walking? Limp vs general gait abnormality
Begin by noting the resting limb position
Comparing both sides for symmetry
Evaluate areas of erythema, swelling and deformity

26. ASSESSMENT : EXAMINATION
• PALPATION :
To localize point of maximal tenderness
To detect any masses
Assess range of motion in each joint
Check adjacent joints too to rule out referred pain.
Measurement of leg length(hip to knee joint, knee joint to ankle)(both
legs)
NOTE : Examination should be done in standing, supine and prone position

29. Galeazzi’s test
- Performed by putting the child in a supine position and then flexing the hips and knees by
bringing the ankles to the buttocks .
- Positive when the knees are of different heights.
-Abnormal shortening of the leg can be caused by DDH, Perth's disease.

30. VIDEOS

31. Klisic test

32. Sacroiliac pathology

33. FABER TEST

34. PELVIC COMPRESSION TEST/ PSOAS SIGN
PELVIC COMPRESSION TEST: PSOAS SIGN:

35. LAB TESTS USED TO EVALUATE A CHILD WITH A LIMP
TESTS DISEASE
CBC INFECTION, INFLAMMATION AND MALIGNANCY
CRP INFECTION, INFLAMMATION AND MALIGNANCY
ESR INFECTION, INFLAMMATION AND MALIGNANCY
ANA SLE
ANTI SREPTOLYSIN O TITRE ARF
BLOOD CULTURE INFECTION
BONE CULTURE OSTEOMYLITIS
COAGULATION PROFILE HEMOPHILIA
SYNOVIAL FLUID ANALYSIS
SYNOIVIAL FLUID CULTURE
SEPTIC ARTHRITIS, TRANSIENT SYNOVITIS
POSITIVE POSITIVE
URETHRAL AND STOOL CULTURES REACTIVE ARTHRITIS
THROAT CULTURE ARF
URETHRAL , CERVICAL, PHARYNGEAL AND RECTAL
CULTURES
GONOCOCCAL ARTHRITIS

38. X-RAY
• Always 2 views
• Children too young to localize pain or
give a reliable history, the entire
lower legs should be imaged
• Initial radiographs may be normal in
children with stress fractures, toddler’s
fracture, Legg disease, osteomyelitis, or
septic arthritis.
• Ossification variants
• Neoplasm may take even longer
• Subtle fracture (i.e. toddler) may not be
seen.
• Frog-leg lateral radiograph of a patient
with slipped capital femoral epiphysis.
• Note the slip in the patient’s right hip
(arrow) compared with the normal left hip.

39. USG
• Sensitive for detecting effusion in the
hip joint
• Ultrasound-guided aspiration
• Hip dislocation in neonatal period
• No radiation
• Can not separate infection from
effusion

40. CT SCAN
CT shows small well defined, regular, subperiosteal, septated mixed density
lesion with a hyperdense speck as the nidus with no soft tissue abnormality or
joint abnormality with no significant periosteal response suggesting osteoid
osteoma.
• High radiation
• Mostly for anatomic delineation/confirmation of
already identified /suspected pathology
Tarsal coalition
Osteiod osteoma
spondylosis

41. MRI
• Expensive
• Excellent visualization of joints, soft tissues,
cartilage, and medullary bone
• Early changes prior to x-ray (and possibility of
earlier treatment)
• Sensitivity and specificity
• Osteomyelitis, malignancies, identifying stress
fractures , slipped capital femoral

42. BONE SCAN
• Good for bone, not so much for joints.
• Sensitive but not specific
• Tech.99 bone scan
 Osteomyelitis
 Septic arthritis.
 Neoplasms
 Unclear location

46. TODDLERS FRACTURE
• This is oblique fracture of the distal tibia
without a fibula fracture , there is often no
significant trauma .
• Patients are usually 1 to 3 years old , but
can be as old as 6 and present with limping
and pain
DX :
• History
• Examination
• Imaging studies
Treatment
• Splint/cast

47. SLIPPED CAPITAL FEMORAL EPIPHYSIS
• Is an adolescent hip disorder where the femoral
neck and shaft displace relative to theepiphysis
• Present with pain in the groin , the part of thethigh
, knee , limping , and the leg be short andexternally
rotated.
Risk factors : obesity , age 10-16 ,endocrine
disorders
Dx : history , examination , X-ray
Treatment : screw
Complications : chondrolysis , avascular necrosis

48. DEVELOPMENTAL DYSPLASIA OF THE HIP
• Abnormal formation or developmental
malalignment of the hip.
• Compromise a spectrum of disorders
including acetabular dysplasia without
displacement , subluxation ,and
dislocation .
• More common in the left side , more
common in females .
Etiology :Genetic , Hormonal ,Intrauterine
,Postnatal.

49. TREATMENT OF DDH
• Upto 6 months: Pavlik harness ~ 6 wks
• Anterior strap > Hip in Flexion : 90- 100 ֯
• Posterior Strap Hip in Abduction
• If no improvement @ 4wks on USG – discontinue
• Late Diagnosed DDH ( 6mo – 2yrs): Closed Reduction
under GA
• Maintain reduction in SPICA cast for 12 weeks > abduction
orthosis
• Failure : Open Reduction
• >2yrs : Open Reduction

50. LEGG CALVE PERTHES DISEASE
• Hip Disorder of Unknown Etioogy
• Temporary interruption of Blood Supply to Proximal femoral epiphysis –
Osteonecrosis & Deformity
• Etiology : Poorly Understood : > Procoagulant state
• 4 stages of pathogenesis : Initial , Fragmentation , Healing , Residual
• Initial – 6 mo, Synovtis , Jont irritablity, Early necrosis Revascularisation –
osteoclastic mediated resorption of necrotic tissue – necrotic tissue replaced by
fibrovasular tissue.
• Fragmantation- 8 mo, Femoral epiphysis collapse

51. TREATMENT
• < 6 Yrs – Few residual problems > 9 yrs – poor
prognosis
• Petrie Cast for 6 weeks : Abduction & Internal
rotation
• Followed by Abduction arthrosis
• Surgical correction:
• Varus Osteotomy of proximal femur
• Pelvic osteotomy
• After Healing : Mx of residual deformity

52. OSTEOMYELITIS
• Acute osteomyelitis is an infection
in the bone
• More common in the long bones
of the arms and legs, can happen in
children of any age.
• Osteomyelitis happens when a
bacterial infection from another
part of the body spreads to the
bone.
• In children, an infection in the
blood is a common cause of
osteomyelitis
• Mainly clinical
• Blood Culture
• ESR & CRP ( Mainly during follow-
up)
• Xray – No role in acute phase.
Osteopenia ( radiolucency) ,
Periosteal reaction
Periosteal new bone formation
Infants- loss of normal fat planes
C/c- Sequestrum/Involucrum

53. CLINICAL MANIFESTATIONS
• Neonates – Pseudoparalysis
• Pain on movement ( Diaper change)
• Older Infants:-
• Fever
• Swelling (Spread to periosteal space)
• Erythema
• Limp/refusal to walk
• Hip - hip, thigh, or abdominal pain.
• Pulmonary embolism (in deep DVT)
• Sequestrum
• Sclerotic , Necrotic piece of bone surrounded by inflammatory exudate and granulation tissue.
Involucrum
- Sheath of new reactive immature , subperiosteal bone that forms around Sequestrum

54. TREATMENT
MEDICAL T/M
• Emperical
- Based on common organism, age group and
sensitivity pattern in population.
In Neonates – Anti staphyloccocal penicillin
- Naficllin or Oxacillin : 150-200mg/kg divided q6h
+
Cefotaxime 150-225mg/kg divided q8h
• In population with > 10 % MRSA
- Vancomycin 60mg/kg divided q6h (gold
standard)
SURGICAL T/M
• In c/o frank pus on aspiration /MRI
• C/c Osteomyelitis : surgical removal of
sinus tract and sequestrum
• PHIYSOTHERAPY – Limb kept in extension
Passive exercise as soon as pain
subsdes

55. TRANSIENT SYNOVITIS
• Reactive Arthritis
• Non-specific inflammatory condition/ post viral
immunological synovitis
• Age group 3-8 yrs
• 70 % have h/o non specific URTI 1-2 wk before onset
• Painful limp
• Markers of inflammation normal or slightly raised
• USG Hip – effusion
• Immediate DD – Septic arthritis
• Rx – Symptomatic Recovery by 3-6 wks

56. SEPTIC ARTHRITIS
• Infection of joint space
• Without treatment - damage to
the synovium, adjacent cartilage,
and bone, and cause permanent
disability.
• Half of all cases occur by 2 yr of
age and ¾th of all cases occur
by 5 yr of age.
• Adolescents and neonates are at
risk of gonococcal septic
arthritis.
• MC - Stap. Aureus
- Strep. Pneumonia
- H.Influenza
- Kingella Kingae
- Gonococci
- N. meningitids
- Candida- in neonates with
indwelling catheters

57. • Characteristic position of flexion and external rotation
(This position decreases intra-capsular pressure – highly s/o
septic arthritis.)

58. INVESTIGATIONS
• TLC – elevated
• ESR – Raised
• CRP- Reactive
• Blood culture
• Synovial fluid Culture ( gold
standard)
• Cervical/anal/throat swab –
suspected Gonoccocal infection
• X-ray – Widening of joint capsule
-Soft tissue edema
-Obliteration of
normal fat lines
• USG
• CT /MRI- presence of joint fluid
• Radionuclide – Technetium scan
-Positive within 2 days

60. Medical and Surgical Management
• Same as Osteomyelitis
• Duration of treatment:-
-In Strept /Kingella- 2weeks
-In Stap.Aureus & Gram
Negatives – Longer duration.
Normalisation of ESR &CRP.
• Infection of the hip - surgical
emergency
• Other Joint - Daily aspirations of
synovial fluid
• If fluid continues to accumulate
after 4-5 days, arthrotomy or
video assisted arthroscopy is
needed.
• At the time of surgery, the joint is
flushed with sterile saline
solution.

62. TAKE HOME MESSAGE
• Acute limp in a child should be taken seriously as it can indicate serious
underlying pathology
• Age of child is important when considering the most likely aetiology
• If trauma has occurred there is lower threshold for performing x-rays in
children as fractures and dislocations are more common
• For atraumatic limp, red flags are age < 3 yr , inability to bear wt, systemic
illness, pain or restricted movement of hip

63. TAKE HOME MESSAGE…
• In children 3-9 who are well , have no fever , are able to bear wt,
and < 48 hr history of atraumatic limp transient synovitis is usually
the cause
• Suspect SCFE in children > 10 yr if there is reduced internal rotation
of hip and pain on extreme of movement
• Kocher’s criteria may be useful in distinguising transient synovitis
from septic arthritis

64. REFRENCES
• Am Fam Physician. 2015;92(10):908-916. Copyright © 2015
American Academy of Family Physicians.)
• Nelson textbook of pediatrics'.
• Tachdjian pediatric
• 2020 Up To date

65. QUIZ

66. The gait of a child become similar to that of an adult at
• A. 3 yr
• B. 5 yr
• C. 7 yr
• D. 9 yr
• E. 11 yr

67. Transient synovitis (toxic synovitis) is a reactive arthritis and is one of
the most common causes of hip pain in young children. All the
following clinical manifestations are true EXCEPT
• A. it is most prevalent between 3 and 8 yr of age
• B. 70% of affected children have had a preceding nonspecific upper
respiratory tract infection
• C. symptoms often develop acutely
• D. children are usually able to bear weight on the affected limb
• E. usually associated with a high grade fever

68. Legg-Calvé-Perthes disease is a hip disorder of unknown etiology that
results from temporary interruption of the blood supply to the
proximal femoral epiphysis, leading to osteonecrosis and femoral head
deformity. Of the following, the MOST common presenting symptom is
• A. limp of varying duration
• B. pain
• C. failure to ambulate
• D. atrophy of the muscles of the thigh
• E. an apparent leg-length inequality

69. Toddler fractures occur in young ambulatory children. The age range for this
fracture is typically around 1-4 yr. All the following statement are true
EXCEPT
• A. children in this age group are usually unable to describe the area of
injury well
• B. radiographs may show no fracture
• C. classic symptom is refusal to bear weight
• D. Inflammatory markers may be ordered to rule out infectious processes
• E. fracture is treated with bed rest and analgesia for approximately 2 wk

70. 5-year-old child with Down syndrome complaining of intermittent
symptoms of torticollis, weakness of the lower limbs and gait
disturbances. Of the following, the NEXT important step is to
• A. reassure the family
• B. send for radiological assessment of the neck
• C. send for thyroid antibodies
• D. send for radiological assessment of the airway
• E. send for thyroid function test

71. A 12-year-old male adolescent has pain of the right upper thigh that gradually
becomes more severe and most often at night; it usually relieved by taking salicylates
medication. Examination reveals limping, atrophy, and weakness of the right lower
extremity. Plain radiography shows a round lucent lesion at the diaphysis of the right
upper femur, about 0.5 cm in diameter, surrounded by sclerotic cortical bone
formation. Of the following, the MOST likely diagnosis is
• A. Ewing sarcoma
• B. osteosarcoma
• C. osteoid osteoma
• D. osteoblastoma
• E. nonossifying fibroma