Limp in children

Probability diagnosis

Post trauma/intense exercise causing strain syndromes Ill-fitting shoes

Hip disorders, esp. transient synovitis

Heel disorders (12–14 years)

Serious disorders not to be missed

Pitfalls (often missed)

Foreign body (e.g. in foot)

Osteochondritis (aseptic necrosis):

• femoral head: Perthes’ disorder

• knee: Osgood–Schlatter disorder

• calcaneum: Sever disorder

• navicular: Köhler disorder

Myalgia = ‘growing pains’

Overuse syndrome (esp. adolescent):

• patellar tendonopathy (jumper’s knee)

Stress fractures (e.g. tibia, femoral neck, navicular)

Key history

Ask about a history of trauma, foci of infection including the skin and any unusual developmental problems. Trauma, sepsis, synovitis and DDH are perhaps the most common reasons for a child to limp and refuse to walk. A painless waddling gait suggests DDH or Perthes’ disorder.

   The limp must be considered to be due to a definite organic cause. It is appropriate to focus initially on the hip. Ask about the relationship of the limp to exercise and footwear.

Key examination

• The hip and the knee joints should be examined carefully if the source of the limp has no specific localisation

• Get the child to walk and run on the toes and heels. Note the gait and check whether it is antalgic (painful), hemiplegic (arm held out in a balancing action) or Trendelenburg (classic for DDH). Look for evidence of muscle dystrophy

• Never forget to examine the soles of the feet and between the toes

Key investigations

Consider:

• FBE and ESR/CRP

• blood culture

• needle aspiration of joint

• radiological: plain X-ray, ultrasound, bone scan, CT or MRI scan.

Diagnostic tips

• Multiple fractures and epiphyseal separations in toddlers are highly suggestive of child battering—order a skeletal survey if suspected.

• An acute limp may be due to injury, infection (osteomyelitis, septic arthritis), spinal injuries, a fracture or an irritable hip (synovitis).

• Chronic cases include cerebral palsy, DDH, Perthes’ disorder and chronic SCFE.

• Infections of and around the hip joint are most common in infancy. Classically, the hip is held immobile in about 30% of flexion with slight abduction and external rotation.

• Hip pathology can cause pain in the ...