Pediatric Limp

A brief hobble through

Goals:
Appreciate the large differential for

a limping child
Review basic approach to H&P and

workup of limping child and how to

narrow the differential
What are red flags not to miss

Differential for Limp

Broad categories for

differential
Gait Antalgic vs non-antalgic
Acute vs Chronic
I VINDICATE
Location (shin, knee, thigh, hip,

abdomen)
Age approach

AAFP

AAFP

AAFP

TNotes

ER approach to limp
New patient in room
Presenting complaint: Pediatric limp/hip

problem
Check CTAS level, Age, Gender
Before you see the child what is a broad
Category
Condition
DDx?
Septic arthritis, Osteomyelitis, Cellulitis
Infectious
Inflammatory

Transient (toxic) synovitis of hip, JIA, HSP, Bursitis,

Reactive arthritis, Kawasaki dz

Trauma

Traumatic injury, Toddler #

Malignancy

Leukemia, bone tumor, metastasis

Other

LCPD, SCFE, Osgood-Schlatter, DDH, Growing pains,

Referred abdo pain (appy)

ER approach to limp
ABCs, vital signs, gestault
History: Age, sex, onset, pain?, acute vs chronic,

trauma, night pain, arthralgia, swelling, morning

sickness, backache, ROS (fever, wt loss, rash)
PMHx of chronic illness, recent URTI
Drugs: prescription, antibiotics
Allergies
Developmental
Nutritional
Vaccination
FHX: Hemoglobinopathy, IBD, malignancy, RA, sickle, DDH
Social Hx HEADSSS in adolescent

ER approach to limp
On exam
General: Vitals, stable/unstable,
HEENT: conjunctivitis, pallor, tonisillar

exudate, mucosal lesions, lymphadenopathy

CV: tachycardia, pulses, CHF (myocarditis)
GI: peritonitis, HSM
DERM: rashes, nodules, swollen hands/feet
with desquamation
MSK

ER approach to limp
MSK:
Look:
Gait: smooth vs antalgic, Trendelenburg, toe-

walking. Walk on toes, heels, jump, ?asymmetry

SEADS to hip, knee, ankle, back
Tone
Feel:
Bony landmarks, effusion, swelling, temperature,

crepitus
Pain/tenderness bone, tendons, joints, muscles
Move (active/passive)
Back, hip, knee, ankle.
?limitation, guarding, discomfort

ER approach to limp
Neuro: CN II-XII, muscle tone/strength, sensation, DTR

Special tests:
Trendelenburg test assesses weakness in hip ADDuctors
Positive test = inability to keep pelvis parallel to the ground (lean to
compensate)

Galeazzi sign for conditions causing leg length discrepancy

Have child lie supine wit hips and knees flexed (affected side lower)

 Patrick test/FABER test to asses SI joint pathology

Positive test = pain to SI joint

Pelvic compression test: to assess SI joint pathology

Patient supine, compress iliac wings toward each other
Postive test: Pain at SI joint

Psoas sign: signal of psoas abscess or appendicitis

Patient decubitis, hip passively extended. Positive test = pain with

extension

Newborn hip stability

Barlow test is provocative test. Hip goes in

out.
Ortolani test of hip reduction. Hip goes out
in.

What do you order? Infection, inflammatory,

malignancy

Bloodwork:
CBC-d
ESR/CRP
C&S
MAYBE: coags, blood smear, sickle test, RF, ANA,

Cr
Joint aspiration:
WBC, differential, gram stain, cultures, protein, glucose

What do you order

Rads/imaging
Joint X-ray: AP, lateral, frog leg view of pelvis
Bone scan
Ultrasound/MRI?

What would you expect to

find?
Condition

Expected findings

Septic arthritis

ESR/CRP, WBC >75% PMN synovial fluid

Osteomyelitis

ESR/CRP, WBC, +blood C&S, often normal X ray,

Dx off bone scan or MRI

Transient
Synovitis

Minimal findings (clinical diagnosis)

LCPD

Limited IR of hip. Normal labs, X ray diagnostic

SCFE

Limited IR of hip. Normal labs, X ray diagnostic (frog-leg

views)

JIA

ESR/CRP, -ve RF, +ANA (50%)

Neoplasm

Hb/WBC/plts, X-ray may have poorly defined margins,

onion skin/sun burst appearance w/o sclerosis

Edmonton Manual of Common Clinical

Scenarios

Whats the limp?

This "frog-leg" plain x-ray of the pelvis demonstrates a slipped capital femoral
epiphysis (SCFE) of the left femoral head (arrow) in an adolescent with
complaints of thigh and knee pain.

SCFE
Salter Harris 1 with displacement of femoral

epiphysis
Older children who are obese
M>F
Subtle changes can be hidden on 1 or 2 of
your views
Draw line along superior border of femoral

neck

Whats the limp

A septic joint is the result of hematogenous spread of infection to the joint, resulting in pus
formation and fluid distension. This is a pediatric emergency because significant joint
damage can occur within hours of infection. The most common organism causing septic joint
isStaphylococcus aureus, followed by meningococci,Escherichia coli, Klebsiella species, and
Enterobacter species. Gonococcal arthritis can be acquired in newborns at the time of
delivery, in teenagers who are sexually active, and in children who have been sexually
abused. This image is an emergency room photograph of an infant with septic arthritis of the
left hip who is holding his hip rigidly in the classic position of flexion, abduction, and external
rotation. This position maximizes capsular volume; the patient is relatively comfortable as

Septic joint
Medical emergency
Systemic signs of unwell
If hip: Child holding in position of maximum joint

space volume hip rigidly in the classic position

of flexion, abduction, and external rotation
(FABER). This position maximizes capsular
volume; the patient is relatively comfortable as
long as the hip joint remains immobile.
Obtain culture and start antibiotics

Septic joint

The natural history of inadequately treated septic arthritis can be

devastating. The x-ray on the left is from a 22-month-old child with
left hip pain for 1 week, showing no gross abnormality. The x-ray on
the right was taken 3 weeks after and shows soft-tissue swelling,
lateral hip dislocation, indistinctness of the growth plate, and
considerable periosteal reaction of the proximal femoral shaft,
characteristic of an associated osteomyelitis

Septic joint

Follow-up films from the same patient are shown, demonstrating the natural
history of septic arthritis. The film on the left, from 5 months after onset of
infection, shows complete resorption of the femoral head and regeneration of the
femoral shaft. The film on the right, from 9 years after onset of infection, shows
destruction and deformity of the left hip. There is also superior subluxation of the
femoral shaft with pseudoarticulation, resulting in profound limb-length
discrepancy.

Septic Arthritis organisms

Bugs and Drugs

Bugs and Drugs

Bugs and Drugs

Whats the limp?

Osgood-Schlatter disease is one of the most frequent causes of knee pain in

adolescents. The condition is probably related to repetitive trauma (as from
chronic jumping or similar strenuous exercise) on a developing tibial tuberosity.
This can lead to avulsion or fragmentation of the tibial tuberosity, heterotopic
bone formation, thickening of the distal patellar tendon, and considerable softtissue swelling. Osgood-Schlatter disease presents with considerable focal pain
and a palpable subcutaneous lump in the region of the tibial tuberosity. The
condition is often seen in association with a rapid growth spurt. The x-ray on the
left demonstrates fragmentation of the tibial tubercle (arrow) with overlying
soft-tissue swelling, consistent with Osgood-Schlatter disease. The x-ray on the
right demonstrates an enlarged tibial tubercle with an ossicle in a skeletally

Whats the limp

Developmental dysplasia of the hip is characterized by abnormal development

of the acetabulum, femur, labrum, or capsule. The etiology is not clear, but
factors like intrauterine position, ethnicity, genetics, musculoskeletal disorders,
oligohydramnios, cerebral palsy, Ehlers-Danlos, and Marfan syndrome have all
been associated with this condition.
This x-ray in a 1-year-old child demonstrates dislocation of the right hip,
associated with a hypoplastic femoral capital epiphysis and malformed

Whats the limp

Legg-Calv-Perthes disease is osteonecrosis of the capital femoral epiphysis. It

is a self-limited disease that affects 1 in 1200 children in the 5- to 10-year age
range, with a median age of 7 years. It is 4-5 times more frequent in males and
is usually unilateral.

Whats the limp?

Whats the limp?

Leukemias are neoplastic proliferations of white blood cells. The acute forms,
especially the acute lymphoblastic leukemias, which are the most common in
children, may present with bleeding, anemia, or infiltration of different organs.
Infiltration of the bone marrow may present with bone pain or pathologic
fracture. These frontal and oblique knee x-rays in a child with leukemia
demonstrate lucent metaphyseal bands (arrows), a finding present in 90% of
patients with leukemia

RED FLAGS
Fever
Pinpoint pain/tenderness
Pain out of proportion to degree of

inflammation
Weight loss
Erythema
Systemically unwell
Pathologic fractures
Certain lab patterns

Its not so bad

Infectious
Inflammatory
Trauma
Malignancy
Other

Questions?

Helpful sources:
AAFP papers, TNotes, Bugs and Drugs, Edmonton

Manual, UpToDate, Medscape