The document discusses the evaluation of limping in children. It defines different types of limps and their causes. A normal gait in children is described. Common pathologic gaits seen in children include antalgic, toe-walking, stooping, Trendelenburg, steppage, and vaulting gaits. Evaluation of a limp includes history of present illness, pain characteristics, associated symptoms, and physical examination. Management depends on findings, with most children having a benign cause managed as outpatients. Further evaluation is warranted for children younger than 3, signs of infection, limited joint movement, inability to walk, or history of chronic limp.

1. EVALUATION OF
THE LIMPING CHILD
Adib Mursyidi
ETD IIUM Medical Centre

2. Definition
■ Limp  abnormality in gait that is caused by pain, weakness, or deformity.
■ In toddlers and young children  refers to refusal to walk or stand.
■ Hip and the knee  common locations for pathology

3. Normal Gait
■ Children : walk at age 12-15months, run by 18months
■ The normal gait: smooth, rhythmic, symmetric, and effortless
■ Gait of children younger than 3 to 3.5 years of age is notable for:
– Increased flexion of the hips, knees, and ankles, which provides a lower center of gravity
and facilitates balance
– Rotation of the feet externally and more spread in relation to the shoulder width,
providing a wider base of support
– A smaller percentage of the gait cycle spent in single limb stance
– A faster cadence but slower velocity because of shorter stride length
■ Achieved the adult pattern of gait by 7 years of age

4. Pathologic gait
■ Antalgic gait – Antalgic gait is the most common type of limp encountered in children;
it is characterized by a short stance phase on the affected extremity due to pain.
– An antalgic gait is associated with bone and soft tissue trauma, infection, inflammation,
and bony lesions.
■ Toe-walking gait – A child will toe-walk due to heel pain, calf pain, or neurologic
abnormality with increased flexor muscle tone in the lower leg.
– Eg: cerebral palsy, peripheral neuropathy, hereditary spastic paraparesis, or spinal cord
disorder, acute calf myositis

5. ■ Stooping gait – A stooping gait with hips flexed throughout the gait cycle suggests
psoas muscle or obturator nerve irritation
– Eg: appendicitis, psoas muscle abscess, pelvic inflammatory disease, ovarian torsion, or
testicular torsion.
■ Trendelenburg gait –Trendelenburg gait describes a downward pelvic tilt or shift
toward the unaffected limb as it swings through caused by gluteus medius muscle
weakness or spasm in the affected leg when it is in stance phase
– This gait frequently accompanies slipped capital femoral epiphysis, Legg-Calvé-Perthes
disease, and developmental dysplasia of the hip.

6. ■ Steppage gait – Patients with a foot drop due to neurologic disease display
exaggerated hip and knee flexion as the affected leg swings through to keep the foot
from dragging on the floor. It is often accompanied by a slap of the foot during heel
strike.
■ Vaulting gait – Patients with limb length discrepancy or abnormal knee mobility
maintain the knee hyperextended and locked at the end of stance phase and "vault"
over the affected leg.

7. Common causes of limping

10. Evaluation
■ History — help identify possible causes for limp
– Age
– Duration – Limps of acute onset are typically due to trauma or acute infection
– Trauma – Soft tissue injury (eg, superficial or deep muscle contusion, ligamentous sprain,
or muscle strain)
– Fever – Fever suggests possible osteomyelitis and septic arthritis

11. ■ Pain characteristics – difficulty describing and localizing pain.
– Constant severe pain, localized and consistently: seen in fractures, septic arthritis,
osteomyelitis, and sickle cell disease.
– Preference to crawl or walk on the knees in toddlers may indicate foot pain.
– Intermittent, less severe pain:JIA, Legg-Calvé-Perthes disease,SCFE, Osgood-Schlatter
disease, and transient synovitis.
– Cyclic pain that occurs at night or wakens the child suggests malignancy (eg, leukemia,
osteogenic sarcoma, Ewing sarcoma) or benign bone tumors (eg, osteoid osteoma).
– Bilateral calf or thigh pain may indicate myositis

12. ■ Associated symptoms
– Morning stiffness ("gel phenomenon") is often found in patients with oligoarticularJIA.
– Incontinence, sciatica, or leg weakness suggests a spinal cord problem
■ Past medical history
– Upper respiratory viral illness may precede transient synovitis.

13. Physical Examination
■ Difficult!
■ In a patient with significant pain, appropriate analgesia should be given
■ Examination must include:
– Abdomen and genitalia
– Spine
– Lower extremity
– Nervous system
– Skin

14. Management
■ Most children have a benign / non-urgent cause for their limp and can be managed as
outpatients with appropriate medical follow-up:
– Afebrile children with normal radiographs and pain  NSAIDs may be discharged with
follow-up by the primary care
– Patients where fracture is suspected but not apparent on plain radiograph should
undergo immobilization of the affected leg, outpatient follow-up in 7 to 10 days with
reimaging

15. – Febrile children without joint effusion and with normal radiographic and blood studies
may also be followed as an outpatient if clinical findings are most suggestive of myositis
or transient synovitis
– Children in whom a provisional diagnosis that does not require emergency management
should have follow-up arranged with an appropriate specialist.

16. Summary
■ Further evaluation is warrant in the limping child, especially in patients with the
following features:
– Three years of age and younger
– Signs of infection (eg, fever; exquisite joint tenderness with marked limitation of motion;
or localized redness, warmth, or swelling)
– Limitation of joint movement on examination, especially at the hip
– Inability to walk
– History of chronic or intermittent limp
■ Disposition of the child with a limp depends upon the results of the initial evaluation.

17. Thank you
■ Reference:
■ Uptodate: Evaluation of limping child