the limping child

THE LIMPING CHILD

PRESENTED BYDANIEL L. MORRISON, D.O.

CLINICAL PROFESSOR, MICHIGAN STATE UNIVERSITY

COLLEGE OF OSTEOPATHIC MEDICINE

Introduction

• Limping is a common problem in children and adolescents. The different diagnoses of limping is extensive and includes numerous abnormalities of the lower extremity and spine.

Common conditions that can cause a child

to limp:

• Conditions divided into two categories:

•Antalgic

•Trendelenburg

Antalgic definition

• Painful limp• The child spends the greater

portion of the gait cycle on the asymptomatic leg than the symptomatic.

•Antalgic

• Infectious–Septic arthritis–Osteomyelitis•Acute•Subacute

–Diskitis• Rheumatologic– Juvenile arthritis

Antalgic cont.

• Trauma–Sprains,strains, contusions–Fractures•Toddler’s fx•Stress fx

* Be aware of child abuse

Antalgic cont.

• Neoplasia–Benign•Osteoid osteoma

–Malignant•Osteogenic sarcoma•Ewing sarcoma•Leukemia•Spinal cord tumors

Antalgic cont.

• Congenital–Tarsal coalition

• Acquired– Legg-Calve-Perthes disease–Slipped capital femoral

epiphysis

Trendelenburg

• Dr. Friedrich Trendelenberg born in Berlin in 1844.

• Classic article reproduced the gait of patients with congenital dislocations of the hip.

Trendelenburg’s Sign

• Positive sign shows the pelvis hanging down on the swinging side

• Negative sign show the pelvis angled up on the swinging side

Trendelenburg Limp

• Developmental dysplasia of the hip– Leg length discrepancy

• Neuromuscular Disease–Cerebral palsy–Muscular dystrophy

Clinical History

• Begin with thorough history, family history, and physical examination

• Onset (acute-insidious)• Age (chronological-

developmental)• Symptom complex

Differential Diagnosis based upon age

• Toddler (1-3 years of age)• Childhood (4-10 years)• Adolescence (11+ years)

Differential for Toddlers

• Infection–Septic arthritis-hip,knee–Osteomyelitis–Diskitis

Differential for Toddlers cont.

• Occult trauma–Sprains, strains, contusions–Toddler’s fx–Stress fx

Differential for Childhood

• Infection–Septic arthritis of hip or knee–Osteomyelitis–Diskitis

Differential for Childhood cont.

• Transient synovitis of the hip• Legg-Calve-Perthes disease• Juvenile arthritis• Trauma• Neoplasia• Leg length discrepancy

Differential for Adolescence

• Slipped capital femoral epiphysis

• Juvenile arthritis• Trauma• Leg length discrepancy

Differential for Adolescence cont.

• Neoplasia• HNP• Congenital Spine–Spina Bifida Occulta–Spondylolisthesis•L5 radiculopathy

Physical Examination

• Observing the child’s walk after removing all clothing except diaper or underwear and having the child walk a sufficient distance to observe the gait pattern.

Gait Analysis

• Stance Phase–Heel strike, foot

flat, midstance, heel off, toe off

• Swing Phase–Acceleration,

mid swing, deceleration

Distinguishing characteristics:

• redness, swelling, tenderness• abrasion suggesting trauma• café au lait spots• rash

Characteristics cont.

• joint effusions• soft tissue masses• alteration of strength,

sensation, or DTRs

Laboratory Assessment

• Blood cultures• WBC count with differential• Erythrocyte sedimentation rate• C-reactive protein level• Antinuclear antibody

Imaging Modalities

• Plain Radiographs• Bone Scan• Ultrasound• Computed Topography• MRI

Conclusion