The document discusses the evaluation and causes of a limping child. It defines a limp and describes different types of gaits that can help narrow the differential diagnosis. Common causes of limp are then outlined based on age and acuity. The evaluation involves a thorough history, physical exam focusing on general appearance, vital signs, gait, musculoskeletal exam, and examining the abdomen, genitalia, spine and lower extremities. Based on history and exam findings, appropriate diagnostic tests or imaging may be pursued. For most children, treatment is conservative but specialty referral is needed for emergency conditions like septic hip or slipped capital femoral epiphysis.

1. Limping child
Dr Hidayah Almasoud
2020

2. Defintion
• Limp is defined as an abnormality in gait that is caused by pain,
weakness, or deformity [1,2,5,6]. In toddlers and young children,
conditions that cause limp may present as a refusal to walk or stand.
At times, ataxia may masquerade as a limp, but a careful examination
usually distinguishes this condition based on the absence of
tenderness, weakness, or deformity, and the presence of movements,
often involving the trunk or upper extremities as well as the lower
extremities, characteristic of cerebellar dysfunction fthyyy
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3. Limp can be further described by gait pathology,
which can help narrow the differential diagnosis
• ●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. Examples of conditions that may present with toe-walking include cerebral palsy, peripheral neuropathy, hereditary
spastic paraparesis, or spinal cord disorder [7]. Influenza A may cause acute calf myositis with self-limited toe-walking.
• ●Stooping gait – A stooping gait with hips flexed throughout the gait cycle suggests psoas muscle or obturator nerve irritation
associated with 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 (picture 1). This gait frequently
accompanies slipped capital femoral epiphysis, Legg-Calvé-Perthes disease, and developmental dysplasia of the hip.
• ●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.

5. Antalgic gait Most common; short-stance phase caused by pain in the weight-bearing extremity
Fracture (including toddler or Salter I fracture), unilateral slipped capital femoral
epiphysis, apophysitis, soft tissue injury, transient synovitis, osteomyelitis, septic or
other arthritis, foot foreign body, osteochondritis dissecans, hemarthrosis,
vasoocclusive crisis, benign or malignant tumor, painful foot lesions (eg, plantar
wart, hand-foot-mouth disease, or immunoglobulin A vasculitis [Henoch-Schönlein
purpura])
Trendelenburg gait
Downward pelvic tilt during the swing phase caused by weakness or spasm in the
contralateral gluteus medius muscle
Legg-Calvé-Perthes, unilateral slipped capital femoral epiphysis (moderate to severe
chronic slip), or developmental dysplasia of the hip
Steppage gait
Seen with a foot drop; presents with exaggerated hip and knee flexion during the
swing phase to clear the dropped foot from the floor
Neurologic diseases which cause loss of dorsiflexion of the ankle
Toe-walking gait
Child walks on his/her toes caused by heel pain or by increased flexor muscle tone in
the lower leg
Mild cerebral palsy, Sever disease, heel foreign body, idiopathic, tethered spinal cord
Vaulting gait
The knee is hyperextended and locked at the end of the stance phase of the gait and
the child vaults over the extremity
Limb length discrepancy or abnormal knee mobility
Stooping gait
Patient shuffles with hip flexed due to irritation of the psoas muscle by
intraabdominal inflammation
Appendicitis, pelvic inflammatory disease, psoas muscle abscess

6. Causes of limp in
children by age
and acuity
Any age Toddler and young child (1 to 5 years of age) School age (5 to 12 years of age) Older child and adolescent (13 to 19 years of age)
Acute
•Abdominal/pelvic abscess, including pelvic
inflammatory disease in adolescent females and
periappendiceal abscess (referred pain)
•Blister or skin wound caused by poor-fitting
footwear Contusion (soft tissue, muscle, or bone)
•Foot foreign body (eg, splinter)
•Fracture
•Osteomyelitis
•Malignancy*
•Meningitis
•Peripheral neuropathy (eg, Guillain-Barré
syndrome)
•Postinfectious (reactive) arthritis
•Septic arthritis¶
•Spinal epidural abscess
•Viral myositis
•Child abuse (eg, traumatic periosteitis or
metaphyseal-epiphyseal fracture)
•DiscitisΔ
•Hand-foot-mouth disease (enterovirus infection)
•Hemarthrosis (hemophilia)
•IgA vasculitis (Henoch-Schönlein purpura)
•Immunization (IM shot)
•Salter-Harris I fracture
•Septic hip
•Toddler's fracture
•Transient synovitis
•Ligament sprain or tear
•Salter-Harris

7. Chronic
•Abdominal/pelvic
abscess, including pelvic
inflammatory disease in
adolescent females and
periappendiceal abscess
(referred pain)
•Benign bone tumor (eg,
osteoid osteoma or
osteoblastoma)
•JIA and other
inflammatory disease◊
•Malignancy*
•Meningitis (meningeal
irritation)
•Peripheral neuropathy
•Psoas abscess (referred
pain)
•Spinal cord tumor
•Spinal epidural abscess
•Vertebral osteomyelitis
•Cerebral palsy
•Developmental dysplasia
of the hip
•Infantile Blount disease or
other causes of pathologic
bowing (eg, rickets,
skeletal dysplasia, or
asymmetric growth)
•Posterior fossa tumor
(ataxia that may be
misinterpreted as limp)
•Apophysitis of the heel
(Sever disease)
•Avascular necrosis of the
hip (Legg-Calvé-Perthes
disease)
•Closed spinal dysraphism
with tethered cord
•Growing pains
•Leg length discrepancy
•Navicular osteochondrosis
(Köhler disease)
•Osteochondritis dissecans
•Patellar apophysitis
(Sinding-Larsen-Johansson
disease)
•Tarsal coalition
•Transient synovitis
•Apophysitis of the tibial
tuberosity
(Osgood Schlatter disease)
•Complex regional pain
syndrome (lower leg)
•Fifth metatarsal traction
apophysitis (Iselin disease)
•Herniated disc
•Metatarsal avascular
necrosis (Freiberg disease)
•Osteochondritis dissecans
•Scoliosis
•Slipped capital femoral
epiphysis
•Spondylolisthesis
•Spondylolysis
•Stress fracture
•Tendonitis

8. • The location of pain does not always reflect the location of pathology
[2,3]:
• ●Hip conditions can cause pain in the knee or thigh
• ●Abdominal conditions may cause hip or thigh pain
• ●Back conditions may have referred pain down the back of the leg or
to the lateral thigh

9. EVALUATION
• A careful history and physical examination provide important
information regarding the likely cause for the limp and guide the
approach to radiographic studies and laboratory testing. Life-
threatening or emergency conditions must be diagnosed promptly

10. Historical features Causes of limp
Fever
Osteomyelitis, septic arthritis, systemic JIA, malignancy (eg, leukemia, metastatic neuroblastoma), or
acute rheumatic fever
History of trauma Fracture, superficial or deep (muscle) contusion, muscle strain, or ligament sprain
Activity increases pain
SCFE, apophysitis, osteochondrosis, joint hypermobility syndrome, osteochondritis dissecans, or stress
fracture
Activity decreases pain Oligoarticular JIA, complex regional pain syndrome
Cyclic pain pattern, nocturnal
Malignancy (eg, leukemia, Ewing sarcoma, or osteogenic sarcoma) or benign bone tumor (eg, osteoid
osteoma)
Abdominal pain
Immunoglobulin A vasculitis (Henoch-Schönlein purpura), appendicitis with periappendiceal abscess,
ovarian torsion, pelvic inflammatory disease, or psoas abscess
Back pain
Discitis, vertebral osteomyelitis, spondylolysis, spondylolisthesis, spinal epidural abscess, or herniated
disc
Migratory arthralgia Acute rheumatic fever, gonococcal arthritis
Morning stiffness Oligoarticular JIA
Rash
Immunoglobulin A vasculitis (Henoch-Schönlein purpura), serum sickness and serum sickness-like
reactions, SLE, or gonococcal arthritis
Current viral illness (especially influenza) Benign acute myositis
Recent upper respiratory viral illness Transient synovitis
Recent antibiotic use Serum sickness and serum sickness-like reactions
Recent urogenital or gastrointestinal bacterial infection Reactive arthritis
Recent intramuscular injection vaccinations Sterile abscess, muscle inflammation
New or poorly fitting shoes Pressure necrosis or blisters
Family history of connective tissue disorders SLE, JIA
Endocrinopathies (hypothyroidism, panhypopituitarism, and/or hypogonadism) SCFE
Important historical findings associated with specific causes of limp in children

11. Physical examination
• — A careful physical examination helps to narrow the differential
diagnosis of the limping child, especially when physical findings
suggest a likely site of abnormality either in the lower extremity or
elsewhere (eg, the abdomen, spinal column, or neuromuscular
system

12. How to approach to examination
• . For patients in significant pain, analgesia appropriate to the degree
of pain should be provided before examination.
• Children who refuse to bear weight on the leg should not be forced to
walk until further assessment has excluded fracture or other serious
pathology
• After evaluation of the gait or if gait evaluation is deferred, further
examination is best performed with the young child sitting in the
caregiver's lap. The physician should start by observing the child's
appearance and positioning from a distance and observing how they
hold or move the lower extremities. If the child is upset, the physician
should permit time for the parent to calm the child.

13. • f the source of the limp cannot be localized clearly by the history and
simple observation (which is often the case in the young or nonverbal
child), the examiner must proceed systematically through
examination of the spine, central and peripheral nervous system,
hips, knees, ankles, and feet [6]. In addition, the abdomen and
external genitalia should be examined to identify unusual causes of
limp (eg, psoas abscess, pelvic inflammatory disease, or testicular
torsion).
• Obvious traumatic injury on examination in the absence of a credible
history suggests child abuse.

14. • General appearance
• Vital signs
• Gait
• MSK
• Abdomen and genitalia
• Spine
• Lower extremeties
• Cns
• Skin

16. DIAGNOSTIC APPROACH
• The history and physical examination should guide further evaluation.

17. • Laboratory studies and/or imaging are usually not indicated in the
child with an obvious cause for a limp such as:
• ●Superficial soft tissue injury
• ●Insect bite or sting
• ●Plantar wart
• ●Painful plantar vesicles of hand, foot, and mouth disease
• ●Friction blister

18. • further evaluation is warranted in the limping child, especially in
patients with the following features [1,2,10,18]:
• ●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

19. Acute limp
• Signs of infection
• Localized findings, no signs of infection
• No localized findings, no signs of infection

20. Subacute, chronic, or intermittent limp
• Nighttime pain or pain at rest
• Pain increased with activity
• Joint pain and/or swelling
• Trendelenburg gait
• Ataxia or weakness
• Back or abdominal pain
• Pain or functional disability out of proportion to clinical findings

22. MANAGEMENT
• Management is dictated by the specific diagnosis. Most children have
a benign or non-urgent cause for their limp and can be managed as
outpatients with appropriate medical follow-up:

23. • Afebrile children with normal radiographs and pain managed by a nonsteroidal
antiinflammatory medication (eg, ibuprofen) may be discharged to home with
follow-up by the primary care provider to ensure that symptoms resolve.
• ●Patients in whom a toddler's fracture is suspected but not apparent on plain
radiograph should undergo immobilization of the affected leg (eg, short leg splint,
controlled ankle movement [CAM] walker boot, or short leg cast) and, if pain and
limp persist, outpatient follow-up in 7 to 10 days with reimaging (typically a
repeat plain radiograph) and evaluation by an orthopedic surgeon for casting
(image 1). Patients who are asymptomatic out of immobilization can discontinue
immobilization without further imaging or follow-up.
• ●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 [21].

24. • Children in whom a provisional diagnosis that does not require
emergency management is apparent or being considered (eg, juvenile
idiopathic arthritis [JIA], Legg-Calvé-Perthes disease, or tarsal
coalition) should have follow-up arranged with an appropriate
specialist.

25. • Specialty consultation and/or hospital admission should occur for children whose findings indicate life-
threatening or emergency conditions (table 2).
• Examples include:
• ●Surgical drainage of a septic hip should occur as soon as possible once the diagnosis is made. Treatment of
bacterial arthritis in other joints varies according to the site and should also take into account the likelihood
of Lyme arthritis, which does not usually require drainage. (See "Bacterial arthritis: Treatment and outcome
in infants and children" and "Musculoskeletal manifestations of Lyme disease", section on 'Lyme arthritis'.)
• ●Osteomyelitis warrants timely evaluation for the likely pathogen and administration of antibiotics. The
evaluation and treatment of osteomyelitis is discussed separately. (See "Hematogenous osteomyelitis in
children: Management".)
• ●Children with a slipped capital femoral epiphysis (SCFE) require immediate non-weightbearing and urgent
referral to an orthopedic surgeon for operative stabilization. (See "Evaluation and management of slipped
capital femoral epiphysis (SCFE)", section on 'Management'.)
• ●A child with a likely oncologic process (eg, leukemia or bone tumor) needs admission for staging work-up
and initiation of treatment. (See "Bone tumors: Diagnosis and biopsy techniques" and "Overview of the
clinical presentation and diagnosis of acute lymphoblastic leukemia/lymphoma in children".)
• ●Children with fractures concerning for child abuse should undergo further evaluation as described
separately. (See "Physical child abuse: Diagnostic evaluation and management".)