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THE LIMPING CHILD
PRESENTED BYDANIEL L. MORRISON, D.O.
CLINICAL PROFESSOR, MICHIGAN STATE UNIVERSITY
COLLEGE OF OSTEOPATHIC MEDICINE
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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.
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Common conditions that can cause a child
to limp:
• Conditions divided into two categories:
•Antalgic
•Trendelenburg
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Antalgic definition
• Painful limp• The child spends the greater
portion of the gait cycle on the asymptomatic leg than the symptomatic.
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•Antalgic
• Infectious–Septic arthritis–Osteomyelitis•Acute•Subacute
–Diskitis• Rheumatologic– Juvenile arthritis
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Antalgic cont.
• Trauma–Sprains,strains, contusions–Fractures•Toddler’s fx•Stress fx
* Be aware of child abuse
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Antalgic cont.
• Neoplasia–Benign•Osteoid osteoma
–Malignant•Osteogenic sarcoma•Ewing sarcoma•Leukemia•Spinal cord tumors
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Antalgic cont.
• Congenital–Tarsal coalition
• Acquired– Legg-Calve-Perthes disease–Slipped capital femoral
epiphysis
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Trendelenburg
• Dr. Friedrich Trendelenberg born in Berlin in 1844.
• Classic article reproduced the gait of patients with congenital dislocations of the hip.
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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
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Trendelenburg Limp
• Developmental dysplasia of the hip– Leg length discrepancy
• Neuromuscular Disease–Cerebral palsy–Muscular dystrophy
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Clinical History
• Begin with thorough history, family history, and physical examination
• Onset (acute-insidious)• Age (chronological-
developmental)• Symptom complex
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Differential Diagnosis based upon age
• Toddler (1-3 years of age)• Childhood (4-10 years)• Adolescence (11+ years)
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Differential for Toddlers
• Infection–Septic arthritis-hip,knee–Osteomyelitis–Diskitis
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Differential for Toddlers cont.
• Occult trauma–Sprains, strains, contusions–Toddler’s fx–Stress fx
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Differential for Childhood
• Infection–Septic arthritis of hip or knee–Osteomyelitis–Diskitis
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Differential for Childhood cont.
• Transient synovitis of the hip• Legg-Calve-Perthes disease• Juvenile arthritis• Trauma• Neoplasia• Leg length discrepancy
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Differential for Adolescence
• Slipped capital femoral epiphysis
• Juvenile arthritis• Trauma• Leg length discrepancy
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Differential for Adolescence cont.
• Neoplasia• HNP• Congenital Spine–Spina Bifida Occulta–Spondylolisthesis•L5 radiculopathy
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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.
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Gait Analysis
• Stance Phase–Heel strike, foot
flat, midstance, heel off, toe off
• Swing Phase–Acceleration,
mid swing, deceleration
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Distinguishing characteristics:
• redness, swelling, tenderness• abrasion suggesting trauma• café au lait spots• rash
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Characteristics cont.
• joint effusions• soft tissue masses• alteration of strength,
sensation, or DTRs
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Laboratory Assessment
• Blood cultures• WBC count with differential• Erythrocyte sedimentation rate• C-reactive protein level• Antinuclear antibody
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Imaging Modalities
• Plain Radiographs• Bone Scan• Ultrasound• Computed Topography• MRI
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Conclusion