This document discusses the approach to evaluating a limping child. It outlines that the main causes of a limp are pain, weakness, or structural abnormalities. The type of gait can provide clues to the underlying etiology. Common abnormal gaits seen in children include antalgic, Trendelenburg, steppage, vaulting, and stooped gaits. The differential diagnosis depends on the child's age and whether the limp is painful or painless. A thorough history, physical exam, investigations like imaging and labs, and gait analysis can help identify the cause.

1. Approach to limping child
BY
DR. HARDIK PAWAR
CARE HOSPITAL

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
• 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 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.
• 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.
• A scissors gait caused due to cerebral palsy , legs cross while walking
• A waddling gait seen in bilateral hip involvement

4. Differential Diagnosis
Age Painful limp Painless limp
1-3yr 1- Infection 1- Developmental
Septic arthritis / dyplasia of the hip
osteomyelitis/ 2- Neuromuscular
cellulitis / synovitis disease
2- Trauma -Cerebral palsy
3- 1ry or metastatic -Muscular dystrophy
neoplasm 3- lower limb length
inequality

5. Differential Diagnosis
Age Painful limp Painless limp
4 - 10yr 1-Infection 1-Developmental dyplasia
2- inflammatory JRA, SLE of the hip
3- Trauma 2- NMD
4- 1ry or metastatic tumor 3- Lower limb length
5- hematological disease inequality
4 –hereditary motor
Hemophilia, SCA,
leokemia sensory neuropathy
charcot’s marrie tooth
6-Legg-Calve-Perthes disease
Disease , Kohler’s (AVN)

6. Differential Diagnosis
Age Painful limp Painless limp
11- 18yr 1-Infection 1- Developmental dyplasia of
2- inflammatory :JRA, SLE the hip
3- Trauma 2- Neuromuscular disease
4-1ry or metastatic tumor Cerebral palsy
5-hematological disease Muscular dystrophy
Hemophilia, SCA, leukemia 3- lower limb length inequality
6-Legg-Calve-Perthes Disease 4- chronic slipped upper
(AVN of femoral head) femoral epiphysis
7-acute slipped upper femoral
epiphysis*
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

7. 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

8. Approach
• History
• Examination
• Investigation
• Management

9. History
• Age
• Sex
• Onset
• Painful or painless? ( analysis…)
• Acute or chronic
• History of trauma
• Association : Night pain, arthralgia, swelling,
morning stiffness, backache

10. History
• Systemic review
– Recent illness : URTI
– Weight loss, anorexia
– Fever, chills
– Unexplained rash or bruising
– Voiding problem

11. History
• Past history
– Medical : chronic illness
– Drugs : steroids, antibiotic
– Allergies
– Developmental
– Nutritional
– Vaccination ( site, MMR vaccine)
• Family history
– Hemoglobinopathy, CTD, IBD, NMD
• Social history

12. Examination
• General inspection + Gait
• Vital signs & anthropometric measurements
• Musculoskeletal examination +Back exam
• Neurological examination
• Evaluate leg lengths- anterior iliac spine to
medial mallelous

13. Investigations
• CBC
• ESR, CRP
• Blood culture
• Sickle test
• Coagulation test
• Peripheral smear
• Immunological : RF, ANA, etc

14. Investigations
• Imaging studies
– Plain x ray
– U/S
– CT
– MRI
– Radionuclide studies
– Bone scan

15. Investigations
normal traumatic JRA Septic
• Synovial Arthritis
fluid appearance Clear to
yellow
Bloody to
straw colored
Cloudy yellow Purulent
aspiration
WBC <200 <5,000 5,000- 80,000 50,000-
200,000
Polymorphs <25% <25% 50-75% 75-100%
other High RBC Bacterial
count culture
positive
Low glucose
High protien

17. Thank you!