Treatment Approach to the Limping Child
The differential diagnoses of a limp in a child are broad. Normal age-related gait must first be differentiated from gait impairment. Once gait impairment is identified, differential diagnoses are narrowed as the history and physical examination findings begin to suggest a source for the limp. In many instances, a diagnosis is reached with the assistance of both laboratory testing and radiographic findings. Well-defined treatments exist for most causes and vary with the severity of the disease process or injury. Thankfully, most children respond well to therapy and resume walking normally without sequelae.
DIFFERENTIAL DIAGNOSIS:
1. BONES
- Fractures
- Legg-Calve-Perth's
- Slipped capital femoral epiphysis
- Tumors
- Vasoocclusive crisis of sickle cell disease
2. JOINTS
- Transient synovitis
- Septic arthritis
- Acute rheumatic fever
- Juvenile rheumatoid arthritis
- Developmental dysplasia of the hip
- Hemarthrosis
- Systemic Lupus Erythematosis
3. SOFT TISSUE
- Viral myositis
- Intramuscular vaccination
- Cellulitis
4. NEUROLOGICAL
- Cerebral Palsy
- Peripheral Neuropathy
- Meningitis
- Epidural Abscess of the spine
5. NON-INFECTIOUS
- Inflammation
- Trauma
- Tumor
- Bony deformity
- Aseptic necrosis
6. INFECTIOUS
- Septic arthritis
- Osteomyelitis
AGE SPECIFIC CONDITIONS
1-3 YEARS
- Developmental Dysplasia of the Hip
- Child Abuse
- Neuromuscular disease
- Leg Length Discrepancy
- Infections
4-10 YEARS
- Transient Synovitis
- Perth's Disease
- Infections
- Leg Length Discrepancy
>10 YEARS
- Slipped capital femoral epiphysis
- Overuse Syndrome
ALL AGES
- Trauma
- Tumors
PATHOLOGICAL GAIT PATTERNS
1. ANTALGIC GAIT
- child limits the weight bearing time on the painful leg during stance
2. LEG LENGTH DISCREPENCY
- patient will walk tip toe on the short side, sometimes supination of the foot
- patient will present with slight hip and knee flexion on the longer side, sometimes pronation of foot
3. TRENDELENBURG
- weakened hip abductor muscles to which patient leans to the affected side
4. SPASTIC - CEREBRAL PALSY
- brain lesion with secondary spastic muscle contracture, compensatory scissoring or crossin of knees
5. FOOT SLAP OR DROP FOOT - STEPPAGE GAIT
- weakness of ankle dorsiflexors, foot drops during swing phase
6. CALCANEAL GAIT
- Weakness of Calf or Achilles tendon, loss of plantarflexion and heel off
7. HIP HIKE - CIRCUMDUCTION GAIT
- presents with stiff knee, elevates same side pelvis to hold foot up
8. WIDE BASED
- the width of the base presents more than 4 inches, likely a cerebellar lesion resulting in loss of coordination and shifting the center of gravity