AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Normal And Abnormal Gait
• Clinical Assessment
• Ancillary Testing
• Differential Diagnoses
• Anatomic Stratification Of Processes Causing A Limp
• Conclusion
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Normal And Abnormal Gait
• Clinical Assessment
• Ancillary Testing
• Differential Diagnoses
• Anatomic Stratification Of Processes Causing A Limp
• Conclusion
• Multimedia
• References

A child's first steps in life are a wonderment to the parents and are the beginning of new discoveries for the child. Naturally curious, the walking child begins an adventure that commonly leads him or her to the primary care practitioner, pediatrician, emergency physician, or orthopedist. In most instances, only brief therapy and reassurance are required. On occasion, more extensive treatment is necessary, including possible surgery. Fortunately, children rarely present with a limp and then subsequently succumb to a lethal illness.

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.

NORMAL AND ABNORMAL GAIT

Section 3 of 10  

• Authors and Editors
• Introduction
• Normal And Abnormal Gait
• Clinical Assessment
• Ancillary Testing
• Differential Diagnoses
• Anatomic Stratification Of Processes Causing A Limp
• Conclusion
• Multimedia
• References

Normal synchronous gait develops in the first 3 years of life and requires the child to meet numerous anatomic and physiologic milestones.

• At age 1 year, many children can walk without support. By age 18 months, most children walk, and many can run. Coordination with reciprocal arm swing develops by the time children are age 2 years.
• Appropriate gait is attained with adequate musculoskeletal development of the lower back, pelvis, and lower extremities.
• Normal neurologic growth is mandatory for coordination and balance.
• Myelinization in a cephalocaudal pattern may explain the lack of complete control over those muscles that are integral to adult gait.

Finer adjustments to the gait pattern may not occur until the child is age 8-10 years, when normal adult gait pattern is attained. Adult gait patterns assume coordination of 5 key maneuvers: cadence, stride length, walking velocity, single limb support time, and support base width. However, for the purposes of this article, a more simplistic view of normal gait is described.

Normal gait begins with the stance phase, which is the weight-bearing phase; it starts with the heel-strike. As the foot begins to plantarflex, the end of this phase culminates with the toe-off. The swing phase begins with toe-off and ends with the heel-strike. During the swing phase, coordinated gait requires forward rotation and tilting of the pelvis, as well as stability of the lumbar spine and abdomen. A limp or deviation from the normal expected walking pattern may be due to pain, weakness, or a structural abnormality.

• Antalgic gait is usually caused by pain but may be from any cause. With an antalgic gait, less time is spent in stance phase.
• A Trendelenburg limp is a stance-phase body sway away from the weak hip abductor and a swing-phase droop of the weak side.
• A waddling gait is seen with bilateral hip involvement or neurologic disease.
• A stiff-legged gait is manifested by knee extension and circumduction with pelvic elevation on the affected side.
• Toe walking may be habitual or due to muscle contractures, spasticity, or simply a puncture wound on the heel. Unilateral toe walking may indicate a lower extremity length inequality.
• Steppage gait is the result of difficulties with dorsiflexion of the foot, usually associated with peroneal neuropathies.
• Slow, deliberate gait associated with truncal stiffness may represent lumbosacral pathology.
• Stooped gait might indicate abdominal pathology.
• Generalized muscle weakness from muscular dystrophy or metabolic causes may present with varied patterns.

CLINICAL ASSESSMENT

Section 4 of 10  

• Authors and Editors
• Introduction
• Normal And Abnormal Gait
• Clinical Assessment
• Ancillary Testing
• Differential Diagnoses
• Anatomic Stratification Of Processes Causing A Limp
• Conclusion
• Multimedia
• References

History

Knowing the child's age is imperative when considering the cause of the limp. Parents' input is integral to obtaining an accurate perception of the complaint. A limp may originate from disorders affecting the abdomen, genitourinary tract, back, pelvis, hip, knee, foot, or elsewhere on the body. The historical assessment is primarily focused on the pain, weakness, or both surrounding the gait abnormality. The onset, quality, location, resolving or precipitating factors, and duration of pain and weakness are important. A review of systems may reveal weight loss, night sweats, fever, or psychosocial issues.

Physical examination

The physical examination may vary from very extensive to simplistic, depending on the presumed cause of the limp.

• The physical examination should begin with an overall assessment of the child, including his or her vital signs.
• The abdomen, pelvis, back, and extremities of the supine or sitting child should be inspected and palpated. Inspection and palpation are best accomplished when the child is sitting comfortably in the mother's lap.
• Neurovascular status, including strength, sensation, and reflexes, can also be assessed while the child is sitting or supine.
• The child should ideally be observed while barefoot and minimally clothed for assessment of stance and gait.
• Take the child into an open area to observe several gait cycles to elicit the gait abnormality and anatomic location. Running often accentuates subtle abnormalities.
• Each digit and joint should be examined for motion, ligamentous stability, and occult trauma.
• Measure and compare lower extremity lengths.
• Considering the child's age is imperative when determining the cause of a limp.

ANCILLARY TESTING

Section 5 of 10  

• Authors and Editors
• Introduction
• Normal And Abnormal Gait
• Clinical Assessment
• Ancillary Testing
• Differential Diagnoses
• Anatomic Stratification Of Processes Causing A Limp
• Conclusion
• Multimedia
• References

Radiographic evaluations are essential. Occasionally, laboratory studies are necessary. For evaluations related to particular anatomic sites and causes, please see Anatomic Stratification of Processes Causing a Limp.

Imaging studies

• Plain radiographic assessment should be the initial study in most instances.
  • Screening anteroposterior (AP) radiographs of the pelvis and AP and lateral views of both lower extremities have been recommended, particularly in very young children, due to the frequency of referred pain and missed injuries.
  • A study from Scotland (Fischer and Beattie, 1999) using a protocol that radiographically assessed only the affected anatomic site had good success diagnosing the cause of limp.
  • Obtain a minimum of 2 orthogonal views. More may be required in the hip and knee.
  • As many as 20% of children have unsuspected fractures (Allen, 1987; Renshaw, 1995).
• Ultrasound is a valuable diagnostic tool. It is used in the newborn to evaluate developmental dysplasia of the hip but can also be of assistance in aspiration of joints, especially the hip.
• Bone scintigraphy using technetium highlights areas of increased bone metabolism and may help to identify occult fractures, osteomyelitis, and Legg-Calvé-Perthes disease.
• Computed tomography (CT) scanning is effective for abdominal and pelvic pathology (eg, sacroiliac trauma) and bony pathology of the hip, knee, spine, and foot.
• Magnetic resonance imaging (MRI) is the study of choice for soft-tissue pathology. MRI is used for evaluation of bone tumors.

Laboratory studies

• Laboratory assessment often begins with a complete blood count (CBC) and differential white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and possibly a C-reactive protein.
• Blood cultures often are obtained when the index of suspicion is high for septic arthritis or osteomyelitis .
• Common tests, such as electrolyte levels (eg, calcium), coagulation studies, and uric acid levels (to assess for gout) are rarely necessary.
• Sickle cell tests, Lyme disease titers, immunologic lab studies (eg, lupus antibodies, anti–double stranded DNA, rheumatoid factor, human leukocyte antigen, creatine kinase) are even more rarely needed.

Procedures

• For patients with suspected septic arthritis, the joint or joints are aspirated. The technique for aspiration varies according to the surgeon's preference.
  • Synovial fluid analysis should include cell count and differential WBC count, glucose, culture and Gram stain, and crystal examination.
  • Mucin clot formation suggests a noninfectious etiology, as bacteria break down the normal hyaluronic acid found in synovial fluid.
  • Bone aspirates can be assessed with Gram stain and culture for identification of the bacteria that is causing the osteomyelitis.

DIFFERENTIAL DIAGNOSES

Section 6 of 10  

• Authors and Editors
• Introduction
• Normal And Abnormal Gait
• Clinical Assessment
• Ancillary Testing
• Differential Diagnoses
• Anatomic Stratification Of Processes Causing A Limp
• Conclusion
• Multimedia
• References

Knowing the child's age is imperative when considering the cause of a limp. A brief summary of common disease states as determined by age is listed in the table below.

Common Causes of Limping in Children

ANATOMIC STRATIFICATION OF PROCESSES CAUSING A LIMP

Section 7 of 10  

• Authors and Editors
• Introduction
• Normal And Abnormal Gait
• Clinical Assessment
• Ancillary Testing
• Differential Diagnoses
• Anatomic Stratification Of Processes Causing A Limp
• Conclusion
• Multimedia
• References

Foot

Most pathologic processes of the foot are nontraumatic in toddlers. Examining the children's shoes and feet is imperative. Possible causative entities include the following:

• Avascular necrosis of the navicular head (Köhler disease) or second metatarsal (Freiberg infarction) may occur.
• Microtrauma to the foot can result in stress fractures. Bone scans may be necessary for identification.
• Ingrown toenails may cause limping. Standard incision and drainage and appropriate nail care are recommended.
• Osteomyelitis may require both medical and surgical therapies, depending on the area of the foot involved.
• Puncture wounds can be managed conservatively with good local wound care and close follow-up. Patients who return with a wound infection or persistent pain should be evaluated for osteomyelitis, particularly that caused by Pseudomonas aeruginosa.

Leg and knee

• Toddler's fracture, a spiral fracture of the distal one third of the tibia, is often stable and incomplete and may be the result of a trivial injury, which is often not witnessed.
• Torus fractures resulting from impaction, spiral fractures resulting from torsional injury, and greenstick fractures resulting from direct trauma occur commonly in children.
• Physeal injuries are more commonly seen in the older child following a rotational injury.
• The knee and patellofemoral joints are common sites of pain, particularly in the older child and adolescent.
• Sports-related injuries and overuse syndromes as well as infection may affect the knee area.
• A popliteal, or Baker, cyst may rupture. These cysts are found along the inferomedial aspect of the knee.
• Osteochondritis dissecans represents separation of articular cartilage, usually of the distal femur from underlying bone.
• Osgood-Schlatter disease, affecting the patellar tendon insertion into the tibial tubercle, usually occurs in adolescents.
• Patellofemoral syndrome is often the result of tracking abnormalities of the patella or patellofemoral instability. Jumping, running, and climbing may all be affected as the articular surface of the patella becomes inflamed.
• Knee effusions may be related to overuse, trauma, or systemic disease. Thorough history taking, laboratory screening, and arthrocentesis with appropriate referral are suggested. The differential diagnoses include juvenile arthritis, lupus erythematosus, and infectious arthritis (including Lyme disease).
• Lyme disease can present in a variety of ways; synovitis, pauciarticular arthritis, and polyarticular arthritis may occur.
• Bloody effusions may be associated with trauma. Possible traumatic causes include distal femur and proximal tibia fractures, tibial spine avulsions, patella fractures, and, rarely, knee dislocations.

Thigh and femur

• Trauma, metabolic diseases, neoplasia, congenital deformities, and infection affect the thigh and femur.
• Pathologic fractures related to tumors (benign or malignant), metabolic bone disease, or child abuse should be suspected with femoral shaft fractures. A fracture through a unicameral bone cyst in the proximal femur is not uncommon.
• Metaphyseal beak fractures and rotational injuries that cause spiral deformities suggest possible child abuse.
• Contusions of the thigh musculature are common in patients of all ages but may occasionally be debilitating and serious.
• The distal femoral physis grows faster than any other physis in the body. According to Phemister's law, malignant and benign bone tumors occur in regions of the most rapid growth. Malignant tumors, including osteogenic sarcoma and Ewing sarcoma, generally produce more cortical destruction and periosteal reaction on radiographs than do benign lesions.
• Osteomyelitis is usually due to hematogenous seeding, but it may also be the result of direct inoculation. Because of the rich vascular supply at the metaphysis and epiphysis, particularly in long bones, pain and swelling at the distal femur may represent osteomyelitis. In half of cases, the causative organism is Staphylococcus aureus. No organism is identified in up to one quarter of cases. Examine radiographs of the affected bone for abnormalities within the soft-tissue planes, cortical destruction, and periosteal elevation or thickening. Technetium bone scanning may assist in localization.

Hip

• Developmental dysplasia of the hip is thought to be due, in part, to laxity of the hip joint capsule, prenatal and postnatal position, and genetic and environmental factors. When recognized and treated early, most dislocatable hips stabilize in the first 4-6 weeks of life and develop without sequelae. On occasion, the femoral head remains dislocated, thereby precluding normal development. Useful physical examination tests include the Ortolani maneuver, Barlow test, and Galeazzi sign. Ultrasound or plain radiography may confirm the findings. Patients with late or undiagnosed dysplasia often present with a waddling gait or a painful limp.
• In children, trauma to the hip is more likely to result in a dislocation than a fracture. Prompt reduction of the dislocated hip usually results in few complications.
• Hip fractures in children are associated with numerous complications, including avascular necrosis, premature closure of the epiphyseal plate, coxa vara, and nonunion.
• Older children may experience avulsion of muscular attachments to the pelvis or proximal femur. Avulsion of the iliopsoas from the lesser trochanter or disruption from the ischial apophysis can occur (especially after sporting-event injuries).
• Differentiating between transient synovitis and septic arthritis of the hip can be challenging. Both present with the leg held in flexion, abduction, and external rotation, representing the position of largest capsular volume. Clinically, most children with septic arthritis are toxic and present with fever, anorexia, and joint pain. Features of septic arthritis include hematogenous spread and purulent effusion. Articular destruction is due to proteolytic enzymes, most commonly S aureus. The hip, knee, and ankle are most commonly affected.
  • Ultrasound of the hip has been shown to be effective to assess for osteomyelitis, septic arthritis, transient synovitis, Legg-Calvé-Perthes disease, and developmental dysplasia of the hip.
  • Kocher et al (1999) proposed a clinical prediction algorithm to help differentiate between transient synovitis and septic arthritis of the hip. The probability of septic arthritis was predicted based on 4 factors: history of fever higher than 38.5°C in the last week, non–weight-bearing status, sedimentation rate higher than 40 mm/h, and WBC count higher than 12X10⁶ cells/dL. This algorithm has not been prospectively tested. Kocher et al recommended diagnostic arthrocentesis in patients with 2-4 positive factors and close observation for patients with no predictors. Patients with only 1 positive variable had a 5% or less chance of having septic arthritis.
  • An elevated C-reactive protein has been shown to be a good indicator of septic arthritis and should be included as part of the evaluation.
  • Synovial fluid analysis: WBC count higher than 50,000 with a predominance of polymorphonuclear (PMN) cells favors a diagnosis of septic arthritis, which is a surgical emergency. Transient synovitis is generally associated with lower counts and fewer PMN cells. Gram stain and culture help guide antibiotic therapy.
• Legg-Calvé-Perthes disease typically affects boys in the first decade. Avascular necrosis of the capital femoral epiphysis results in remodeling of the femoral head and acetabulum over 1-3 years. Flattening of the femoral head may be a late finding. Acute presentations are associated with synovitis of the hip.
• Slipped capital femoral epiphysis usually affects large-for-age adolescents. It presents with a limp associated with hip pain or referred pain to the thigh or knee. Delayed diagnosis is not uncommon due to referred symptoms. Most cases are unilateral, but bilateral involvement is possible. The second slip often presents 6-18 months later. Anteroposterior pelvic radiographs may reveal subtle widening of the physis, although the frog lateral projection may be more helpful at identifying subtle slips. A Klein line, drawn along the superior femoral neck, may intersect less or none of the femoral head on the affected side.
• Hip pathology often presents with thigh or knee pain.

Pelvis, spine, and abdomen

• Infection, rheumatologic disease, microtrauma, and neoplasia of the spine, pelvis, or abdomen may result in a limp. In general, these disease processes are more common in the older child or adolescent.
• Juvenile ankylosing spondylitis and rheumatoid arthritis may cause back pain.
• Neoplastic diseases affecting the pelvis, spine, and abdomen include neuroblastoma, leukemia, osteogenic sarcoma, and renal tumors.
• Overuse syndromes are common in active adolescents.
• Spondylolysis due to a stress fracture of the pars interarticularis is found most commonly at the fifth lumbar vertebrae.
• Herniated nucleus pulposus in the older child or adolescent presents in a similar fashion as in adults but is much less common.
• Discitis, inflammation of the intervertebral disc, may be infectious or, less likely, may be sterile. MRI may be necessary to identify the pathology.
• Abdominopelvic lesions, which manifest solely as a limp, are uncommon. Such pathology often involves the retroperitoneum and includes appendicitis, psoas abscess, retroperitoneal hematoma, and renal/ureteral inflammation.
• Pelvic entities include osteomyelitis, genitourinary infections, and tumors or hernias.
• Skin and lymphatic diseases in the inguinal region may cause pain, swelling, and a limp.

CONCLUSION

Section 8 of 10  

• Authors and Editors
• Introduction
• Normal And Abnormal Gait
• Clinical Assessment
• Ancillary Testing
• Differential Diagnoses
• Anatomic Stratification Of Processes Causing A Limp
• Conclusion
• Multimedia
• References

Various pathologies are responsible for limping in children. At times, differentiating normal developmental changes from disease states presents a difficult dilemma. Establishing a diagnosis can be quite challenging, and these patients often require assessment by more than 1 physician in more than 1 visit. Aggressively pursuing the source of a child's limp at the first visit is essential to ensure optimal outcomes in the most patients.

Appropriate and early referral to an orthopedic specialist can benefit selected patients tremendously. However, in many instances, a conscientious physician can accurately assess and treat many of the conditions discussed in this article. Regardless, successful treatment of the child presenting with a limp demands sound clinical judgment, judicious ancillary testing, understanding of the possible differential diagnoses, and knowledge of therapeutic options.

For excellent patient education resources, visit eMedicine's Arthritis Center. Also, see eMedicine's patient education article Juvenile Rheumatoid Arthritis.

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Normal And Abnormal Gait
• Clinical Assessment
• Ancillary Testing
• Differential Diagnoses
• Anatomic Stratification Of Processes Causing A Limp
• Conclusion
• Multimedia
• References

Media file 1:  Landmarks for left hip aspiration. The horizontal line indicates the inguinal ligament, and the vertical line indicates the common femoral artery. A needle is inserted approximately 2 cm lateral to the pulse and inferior to the inguinal ligament and is directed medially. An arthrogram confirms intra-articular placement.
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Media type:  Photo

Media file 2:  Distal femur fracture due to child abuse.
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Media type:  X-RAY

Media file 3:  Slipped capital femoral epiphysis.
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Media type:  X-RAY

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Normal And Abnormal Gait
• Clinical Assessment
• Ancillary Testing
• Differential Diagnoses
• Anatomic Stratification Of Processes Causing A Limp
• Conclusion
• Multimedia
• References

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Article Last Updated: Mar 9, 2007