LIMPING CHILD

DEPARTMENT OF ORTHOPAEDICS
AFMC, PUNE
 LIMPING CHILD
 Gait is the rhythmic movement of
whole body in walking and a limp
is an abnormality of gait
 Causes of limping
Some cause are more commonly
seen at specific age groups

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Limping in Toddler (1– 3 yrs)

 Transient synovitis
 Septic arthritis
 Discitis
 Toddlers fracture
 Cerebral palsy
 Poliomyelitis
 Muscular dystrophy
 Developmental dysphasia of Hip
 Coxa vara
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 Children ( 4 –10 yrs)
 Transient synovitis
 Septic arthritis
 Poliomyelitis
 Legg – Calve Perthes disease
 Discoid meniscus
 Limb length discrepancy
 Kohlers disease
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Adolescent ( 11 – 15 yrs
 Slipped capital femoral epiphysis
 Hip dysplasia
 Chondrolysis
 Over use syndrome
 Osteochondritis dissecans
 Osgood schlatters disease
 Chondromalacia patella
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 All Age groups
 Trauma
 Osteomyelitis
 Arthritis
 Acute rheumatic fever
 Hyper mobility syndrome
 Stiff leg

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Miscellaneous causes
1. Infective
* Viral & pyogenic myositis
* Meningitis
* Rubella vaccination
2. Inflammatory
* Systemic lupus erythematosis
* Dermatomyositis
* Allergic reactions
* Inflammatory bowel disease

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Neoplastic
 Leukemia
 Lymphoma
 Spinal cord tumours
 Neuroblastoma
 Histiocytosis X

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 Bony tumours
Unicameral bone cyst, osteoid
osteoma
Osteogenic sarcoma
Ewing’s sarcoma
Chondrosarcoma
 Soft Tissue tumours
Rhabdo myosarcoma
Fibro sarcoma
Synovial cell sarcoma
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 Hematologic
Sickle cell anaemia
Hemophilia
 Endocrine
Hyperparathyroidism
Hypothyroidism
Osteoporosis
Myopathies
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NEUROMUSCULAR
Anterior horn cell disease
Transverse myelitis
Spondylo listhesis
NUTRITIONAL
Rickets
Survey
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CONGENITAL
 Tarsal coalition
 CTEV
 Congenital pseudarthrosis tibia
 Hemi atrophy
 Hemi hypertrophy

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CHILD ABUSE

REFERRED PAIN FROM

 Appendicitis
 Epididymitis

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DEVELOPMENTAL CAUSES
* MED
* SED
Connective Tissue Diseases
* Osteogenesis Imperfecta
Metabolic Diseases
* Morquio’s Diseases
* Goucher’s Diseases

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 UNKNOWN ORIGIN
Growing pains
Fibro myalgia
 PSYCHOSOMATIC
School phobia
Hysteria / conversion reactions

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Approach to a child
with limping
Approach to a child with limping

 A logical approach to the cause of

limp is directed towards the site of

the pathology systematic and

orderly manner

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COLLEGE, PUNE
 Limping is due to either
 Pain
 Weakness secondary to
Neuromuscular disorders
CNS disorder
Disuse atrophy
 Structural abnormalities

 SITE OF PAIN
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 Causes outside musculo
skeletal system
 Appendicitis
 Balanitis
 Inflamed lymph gland
 Unsuitable foot wear

A thorough history and physical

examination is the first step
towards diagnosis
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COLLEGE, PUNE
 History
 Age
 Onset of pain
 Duration of pain
 Quality pain
 Location of pain
 Aggravating factors
 Posture of child when limping
 History of trauma
 Constitutional symptoms
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 Pain worse in the morning – JRA
 Pain that worsens throughout the day –
Muscle fatigue
 Severe and constant pain - Fracture
dislocation, Septic arthritis, acute
rheumatic fever, Osteomyelitis
 Moderate intermittent pain - Perthe’s
disease, SCFE, transient synovitis or
Osgood schlatters disease
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 Referred Pain
 Hip lesion - Knee pain
 Spine lesion - Lower limp pain
 History of fever & chills - In infectious
process
 Malignancy and rheumatoid disease
may produces
Low grade fever
Weight loss
Malaise
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History of

 Prematurity
 Neonatal anoxia
 Jaundice
 Delay in developmental milestones
 Sudden progressive deterioration in gait pattern
may suggest a neuromuscular or CNS disorder
 Social History : If psychosomatic cause
suspected.
 Diagnosis of psychosomatic illness or
growing pains is by exclusion of other
pathology.

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COLLEGE, PUNE
 Physical Examination
 Key elements are :
1. General Examination
Temperature
Abdomen
Genitalia
Back
Skin

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COLLEGE, PUNE
2. Observe Stance
- Pelvic tilting
- Scoliosis
- Knee flexion
- Asymmetry of legs
- Rotation of foot
3. Observe gait
- Stance phase
- Swing phase
- Stride length
- Movement of pelvis, Trunk, hip, knee or ankle
Child’s gait can be extremely helpful in diagnosing the
cause

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COLLEGE, PUNE
Classification of limp &
conditions associated

Antalgic limp
Due to pain
Stance phase shortened

Site of pain from History & Clinical

Examination
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 Seen in
 Irritable hip syndrome
 Stress fracture
 Acute infection
 Perthes disease
 SCFE
 Short leg limp
Limp length discrepancy
Fixed deformity
Shortening
 Seen in
 Congenital short femur
 Coxa Vara

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 Paralytic Limp
 Neurological abnormality
 Positive Gowers sign
Seen in :
 Spinabifida
 Progressive neuropathy
 Poliomyelitis
 Transverse myelitis
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 Spastic limp
 Hypertonicity
 Imbalanced muscle activity
 Seen in
Cerebral palsy
Mild hemiplegia
Uncoordinated gait may be due to :
Weakness
Loss of proprioception
Cerebellar lesion
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Trendelenberg limp
 Due to abnormal functioning of hip
abductors or liverarm
 Seen in :
DDH
Poliomyelitis
Coxa vara
Perthes
SCFE
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Stiff leg
 Swing phase is decreased in stiff
hip
 Listen for any particular sounds
during gait
Foot slapping from foot drop
Scraping sound from spastic gait
Soft slaps of antalgic gait

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COLLEGE, PUNE
Test Muscle Strength
 Stair climbing
 Squatting
 Trendelenberg test
 Hoping on one leg at a time
Spinal movements are tested, patient standing
 ASIS are palpated
 Look for
Scoliosis
Pelvic tilting
Knee flexion
Asymmetry of the legs

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 Hip is tested for Trendelenberg sign
Positive test in wasting of gluteal muscles.
 Examination in supine position
Examine the extremities for any
Erythema
Echymosis
Rashes
Puncture wounds
Swelling
Deformities

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Bone & Joint Examined for
 Tenderness
 Masses
 Effusion
 Warmth
Whole lower extremity and back should be evaluated
Joint laxity
Passive and active range of motion
Look for
 Painful joint
 Joint stiffness
 Muscle weakness

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COLLEGE, PUNE
Prone internal rotation of the hip. Any inflammation of the hip
manifests as decreased internal rotation of the hip.

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COLLEGE, PUNE
 Leg length measured
Slight shortening early feature in
 Perthes disease
 SCFE
 Hip dislocation
 Serious spinal or neurological
abnormality
Fixed flexion deformity of hip is sought
by Thomas test
Thigh and Calf measured
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Neurovascular
examination
 Sensory deficit
 Reflex abnormalities
 Peripheral pulses
 Capillary fill and colour
 Strength of muscle groups
 Spasticity of muscles - Cerebral palsy
 Tightness of the hamstring muscles with
limited SLR – Spinal problem
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 Abdomen, genitalia & back – To rule
out referred pain.
 Sole of the feet
Examined for
- Splinter
- Tenderness
 Shoes
 Abnormal wear on the outside
 Projection in the inside
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 INVESTIGATIONS
The need for ancillary diagnostic tests is
based on the history and clinical
examination
 ESR
 Complete blood cell count – In patients
with fever
 WBC increase in infection & inflammation
 Cell abnormal in sickle cell anemia & leukemia
 Blood culture
 Synovial fluid analysis
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 Gram Stain
 Aerobic and anaerobic culture
 Cell count
 Glucose & protein estimation
 Mucin clot test
 Analysis for crystal

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 Radiographic studies
 Minimum 2 views in perpendicular planes
 Screening views – Small Children
 Whole lower extremities & pelvis
 AP and frog leg view
 Older children- with hip pathology
 AP & frog leg views of hip and pelvis
 In Knee pathology
 AP & lateral views of knee & hip
 Tunnel view - osteochondritis dissecans
 Sulcus view for patello femoral joint
Skeletal survey for child under 2 years with suspected
child abuse
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 BONE SCAN: Reserved for patients
with normal X-ray and suspected
Stress fractures
Osteomyelitis
Metastatic disease
Avascular necrosis

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COLLEGE, PUNE
Additional tests in chronic diseases
 Rheumatoid factor In inflammatory
 Antinuclear antibody test disease
 Anti streptolysin O In A/c
 Hyaluronic titres Rheumatic fever

 CT, MRI, myelography and

arthrography may be diagnostic for
some condition but are not
routinely done.
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DIFFERENTIAL DIAGNOSIS
 Differential Diagnosis
Common orthopaedic cause of limping
Transient synovitis :
• Most common cause of painful
limping
• Usual age : 3- 8 yrs
• History of preceding viral infection in
about 50% cases
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Clinical presentation :
 May mimic septic arthritis
 Painful leg
 Inability to bear weight
 Limp
 Mild fever
 All movements restricted
 Especially abduction in flexion
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Investigation
 Blood counts may be mildly elevated
 Radiographs typically normal
 USG may show effusion of hip joint
The investigation of choice in early stage.
 Septic arthritis ruled out by joint
aspiration.
 Aspirate shows : WBC count between
5000 – 15000/cells/ml. more than 25%
polymorphs.
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 Treatment
 Symptoms settles in few days with
Bed rest
NSAID
Skin traction of the affected limp
 If not resolved. Do
 Radiologic examination
 Joint aspiration
Use crutches until limp is no longer present
In the absence of any abnormality reassure the
parents but follow up with X-rays.
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 SEPTIC ARTHRITIS
 Must be differentiated from transient synovitis
 Requires urgent medical management
 Potential for significant joint destruction
 Presentation
Acute onset of joint pain
Limping or refuse to walk
May be history of mild trauma or concurrent
infection
 Progress
To Febrile systemic illness

ARMED FORCES MEDICAL

COLLEGE, PUNE
 Clinical Examination
 Hold affected limb immobile
 Swelling of the joint
 Erythema and warmth
 Tenderness on palpation
 Passive movements painful
Less dramatic findings in partially
treated cases.
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 Investigations
 Elevated Blood count
 Blood culture positive in about 50%
 RADIOGRAPHY
 Early stage - Soft tissue swelling
 Bony change - After 7 – 10 days
 In advanced case
Erosion of articular margin
Joint space narrowing
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Bone Scan
 Useful in early diagnosis
 Localisation of infection
Joint Aspiration :
 To confirm diagnosis
 To identify bacteria

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COLLEGE, PUNE
Aspirate. Do
Cell count : WBC between 80000 –
200000 cell / ml > 75% polymorphs
 Gram staining
 Bacterial DNA tests
Organism
 Staphylococcus
 Homophiles influenza
 Group B streptococcus
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 TREATMENT
 General supportive care :-
 Analgesics
IV F
 Splintage :- Joint must be rested.
With hip infection – Traction in abduction and 300
flexion to prevent dislocation.
 Antibiotics
Started empirically changed after c & s study.
 Drainage
Joint opened and washed with saline
Suction irrigation for 2-3 days

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 After care
If articular cartilage preserved.
Gentle and gradually
increasing active movements
If articular cartilage destroyed

Splintage in optimum position for sound

ankylosis
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 OSTEOMYELITIS
 Child may present with
Localized swelling
Pain
Pseudo paralysis
Sudden onset of fever or toxic state
 Older Children
More indolent course

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 INVESTIGATION -
Radiography
 Earliest changes : Deep localized
soft tissue swelling
 Late Feature :- Bone destruction
 Bone scan :- Diagnose the
condition as early as 24 – 48 hours

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 SLIPPED CAPITAL
FEMORAL EPIPHYSIS
 Common in adolescent
 Boys more affected
 Epiphysis slips posteriorly and inferiorly
 PRESENTATION
 Obese and sexually immature
 Excessive tall and thin
 History of trauma
 Constant mild pain – Hip or groin
 Antalgic gait

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 ON EXAMINATION
Leg externally rotated
1-2 cm short
Limitation of flexion, abduction and
internal rotation
 CLASSIC SIGN
Increasing external rotation on hip
flexion

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COLLEGE, PUNE
 Diagnosing slipped capital femoral epiphysis. Obligate
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external rotation of the hip is noted while the hip is passively
COLLEGE, PUNE
flexed.
Diagnosis by Radiography
 AP view of Hip
Blurring of metaphysis
Epiphyseal height reduced
Widening of growth plate
Shentons line may be broken
Positive Trethowan’s sign
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Billings lateral view
 Shows tilting of epiphysis back
wards

 Both hips should be examined

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COLLEGE, PUNE
 a

a) AP view pelvic X-ray SCFE right

b) Frog leg pelvic X-ray of theARMED
same FORCES
patientMEDICAL
demonstrates a more obvious slip
COLLEGE, PUNE
LEGG – CALVE - PERTHES

DISEASE
Painful hip disorder of child
hood
Avascular necrosis of femoral
head
Usual age - 4- 8 yrs
Boys more affected
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COLLEGE, PUNE
 PRESENTATION
 PAIN
 LIMPING – ANTALGIC
 EXACERBATED BY ACTIVITY
 ON EXAMINATION
 LIMITATION OF HIP MOVEMENT
ABDUCTION IN FLEXION AND INTERNAL
ROTATION
 DISCOMFORT DURING PASSIVE MOVEMENT
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Radiography – AP view & Lateral View
 Early features
 Widening of joint space
 Smaller ossifice nucleous and increased density
 Subchondral lucency in femoral head
 Late Features
 Rarefaction and widening of metaphysis
 Collapse and fragmentation of femoral epiphysis
 Early diagnosis
 Bone scan – Void in the anterolateral part of
femoral head
 MRI

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Smaller and denser left femoral head compatible
with early
ARMEDPerthes disease
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Developmental dysplasia of hip
 Some delay in walking
 Pain less limp in toddler
 ON EXAMINATION
 May have a shortened lower extremity
 One sided toe walking with a limp
 Abductor lurch to the affected side
 IF bilateral – Waddling gait
Trendlenberg sign is positive
Restricted abduction of hip
mild flexion contracture

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Asymmetric abduction suggesting
developmental dysplasia of the hip
A Galeazzi test suggesting
developmental dysplasia

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COLLEGE, PUNE
 Diagnosis
 Radiograph of pelvis is usually diagnostic
 Ultrasound,CT, MRI are not usually required
in ambulant child.
 In Delayed presentation
 Limb pain & Limping : Apparent only at
adolescence
 Diagnosis is confirmed by standing radiographs
of the pelvis

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 POLIOMYELITIS
 Viral infection of anterior horn cells
 Rare now
 Cause LMN paralysis
 Limping due to
 Scoliosis with pelvic obliquity
 Muscle imbalance at hip joint
 Subluxation or dislocation of hip
 Abnormal growth of proximal femur
 Quadriceps weakness at knee
 Fixed flexion deformity of knee
 Foot instability
DIAGNOSIS

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 CEREBRAL PALSY
 Is the persistent disorder of posture and or
movement due to non progressive lesion of the
brain acquired during the stages of rapid brain
development.
 Child will have :
Gait disturbances
Severity of limp depends upon degree of
neurological involvement
Limited range of movements
Hyper reflexia
Clonus
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 Diagnosis
 Diagnostic challenge is posed when there is
mild cerebral palsy with minor muscle
imbalance and limp.
 Thorough history and examination -
invaluable
 Radiographs
Unremarkable in most cases
Other diagnostic tests are usually not
necessary
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 TODDLERS FRACTURE
 Torsion injury to the lower extremity
 Spiral fracture of tibia without concomitant
fracture fibula
 PRESENTATION : Limp; Resist weight
bearing on affected limb
 DIAGNOSIS : X-ray may be normal initially.
Sub periosteal new bone formation after
1- 2 wks
 TREATMENT : Short term immobilisation
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 OVERUSE SYNDROME
 In organized sports activities
 Produce
Patellar tendinitis
apophysitis
 On palpation - Point Tenderness

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COLLEGE, PUNE
 DIAGNOSIS
 Radiography
 Fragmentation of tibial tubercle
 Subperiosteal reaction
 BONE SCAN : Confirms the diagnosis
 TREATMENT : Rest ;
Anti. Inflammatory medication
 For long term alleviation change
Activities
Equipment
Training programmes
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NEOPLASM
 Below 5 yrs - Metastatic lesion like neuroblastoma
Leukemia
 Older children
 Osteoid osteoma
 Simple bone cyst
 Osteochondroma
 Lymphomas
 Deterioration of gait or loss of previously achieved
milestone suggests
 CNS tumour
 Neuromuscular disease

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 LEUKEMIA
Think of Leukemia
 Fever
 Joint symptoms
 Bone pain
 Skin bruising and bleeding
 Lethargy and pallor
 hepatosplenomegaly
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 INVESTIGATION
 Anaemia
 Abnormal WBC count
 Raised ESR
 RADIOGRAPHY
 Transverse zones of lucent metaphyseal
bands adjacent to growth plate
 Diagnosis confirmed by bone marrow
studies
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Metaphyseal bands on both distal femurs and
proximal tibias suggestive of leukemia

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COLLEGE, PUNE
 CHILD ABUSE
 Fractures are second to soft tissue
injuries in child abuse
 Common below 2 years
 Think of child abuse
History incompatible with physical
findings
H/o repeated trauma
Delay in seeking treatment

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CERTAIN SPECIFIC FRACTURES
 Metaphyseal
 Epiphyseal
 Posterior rib
 Multiple skull
SUSPECTED CASES
 Completed skeletal survey
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 PSYCHOSOMATIC LIMP
Think of psychosomatic limp
 H/o pain that does not fit with any anatomic
of physiologic process
 Occurring only at night
 Only on school days
 Bilateral
 Between joints
 Physical findings inconsistent with normal
physiologic functioning
 Complaint out of proportion
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 IMPORTANCE
Diagnose these children rapidly
Provide appropriate speciality
consultation

To maximize opportunity for normal

growth and development of child

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COLLEGE, PUNE
 CONCLUSION
Even though only few cases
require emergent treatment,
limping is never normal and
regardless of final diagnosis all
patients need appropriate referral
for follow up evaluation and care
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