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The Limping Child
The author wishes to acknowledge the contribution of John A. Herring and John G. Birch for their work in the previous edition version of this chapter.
Limping is common in children and can represent a diagnostic challenge for the orthopaedist. , , , , A painful or painless limp may be caused by multiple conditions: from the benign (e.g., an unrecognized splinter in the foot) to serious (e.g., a septic hip or a malignant neoplasm). a
a References , , , , , , , , , .
The clinician must approach each patient in a systematic and orderly manner to avoid missing or delaying the correct diagnosis.
A thorough history and physical examination are the first steps toward diagnosis. b
b References , , , , , , , , , , , , .
History is reviewed for evidence of injury, recent illness, duration of symptoms, location of pain, chronicity of limp, and mitigating or inciting factors. The joints are inspected for irritability, swelling, effusion, erythema, and warmth; the presence of muscle atrophy is noted and measured; and both active and passive ranges of motion are assessed. Obviously, attention is paid to the child’s gait, as various pathologic conditions produce a characteristic limp that may be helpful in diagnosis.
The need for ancillary diagnostic tests is based on the history and clinical examination. c
c References , , , , , , , , .
These tests may include laboratory studies, radiography, and, in some cases, ultrasonography, computed tomography (CT), or magnetic resonance imaging (MRI). In a healthy child with a normal history and physical examination, observation may be appropriate and resolution may be expected in a short period of time. If an expected improvement does not occur, further evaluation may be initiated.
This chapter provides information to help in the assessment of a limp in a child. We will defer specific discussion of individual diagnoses to their respective chapters within this text. Normal gait is described in Chapter 5 . We will not discuss limp secondary to an obvious injury.
Common disorders responsible for an abnormal gait vary by the age of the patient. Special considerations of three different age groups—toddlers (1 to 3 years), children (4 to 10 years), and adolescents (11 to 15 years)—are presented ( Box 6.1 ). ,
Box 6.1
Differential Diagnosis of Limping in Various Age Groups
| Toddler (1–3 yr) | Child (4–10 yr) | Adolescent (11–15 yr) |
|---|---|---|
| Transient synovitis | Transient synovitis | Slipped capital femoral epiphysis |
| Septic arthritis | Septic arthritis | Hip dysplasia |
| Diskitis | Legg-Calvé-Perthes disease | Chondrolysis |
| Toddler’s fracture | Discoid meniscus | Overuse syndromes |
| Cerebral palsy | Limb length discrepancy | Osteochondritis dissecans |
| Muscular dystrophy | ||
| Developmental dysplasia of the hip | ||
| Coxa vara | ||
| Pauciarticular juvenile arthritis | ||
| Rarities | ||
| Leukemia | ||
| Osteoid osteoma |
Abnormal Gait Patterns in Children
A child’s gait pattern can be affected by numerous factors, including pain or inflammation, weakened muscles, abnormal muscle activity, joint abnormalities, and limb length discrepancy. , , Each of these conditions produces a characteristic limp, which can be recognized by the movements of the pelvis and trunk and the position of the joints of the lower extremities as the child walks and runs. Familiarity with these gait patterns helps significantly in identifying the underlying cause of a limp.
Antalgic Gait
An antalgic gait, which is usually caused by pain in the lower extremity or occasionally in the back, is generally the most common type of gait disturbance in the limping child. An antalgic gait can be caused by any condition that causes pain during weight bearing in a lower extremity, and the pain can originate from any part of the extremity, from the foot to the hip. This gait is characterized by a shortened stance phase of gait as the child takes quick, soft steps on the affected leg (“short stepping”) to minimize pain. If the source of pain is in the hip, the patient also leans toward the affected side during stance phase to decrease the abductor force across the joint. The unaffected limb is brought forward more quickly than normal in swing phase and therefore has a prolonged stance phase.
An antalgic gait may be observed in children whose pain results from spinal disorders such as diskitis or vertebral osteomyelitis. In such cases, the child walks very slowly or refrains from walking altogether to avoid jarring the back and aggravating the pain.
Trendelenburg Gait
A Trendelenburg gait is observed in patients with functionally weakened hip abductor muscles. This weakness makes it difficult for the child to support the body weight on the affected side. This gait disturbance is commonly observed in children with a dislocated hip from developmental dysplasia of the hip (DDH), congenital coxa vara, or coxa vara secondary to another disorder (i.e., Legg-Calvé-Perthes disease or slipped capital femoral epiphysis [SCFE]). In these conditions, the abductor muscles themselves are normal but are at a mechanical disadvantage due to functional shortening. As a result, during the stance phase of gait, the hip abductors function ineffectively, and the pelvis tilts away from the affected side. In an attempt to lessen this effect, the child compensates by leaning over the affected hip. This brings the center of gravity over the hip and reduces the pelvic drop ( Fig. 6.1 ). The characteristic pattern of the Trendelenburg gait usually is obvious after the child has repeated the gait cycle a couple of times. Because the child has no pain, the amount of time spent in stance phase on the affected side may be normal (this is distinctly different from an antalgic gait).
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