A clinical approach to a child with a limp

1. A clinical approach to a child with a limp By: Dr. Landuleni W. Benjamin

2. Background A limp is a common problem in paediatrics. It is any deviation in walking pattern away from the expected normal pattern for the child’s age. Children begin to walk at 12 to 14 months. Normal gait pattern is achieved at 3 yrs. Mature gait comprise of two phases: 60% of the time in stance phase (from heel strike to toe off) 40% of the time in swing phase (from toe off to the next heel strike).

3. Three categorical processes: Pain (antalgic gait), decrease stance phase of the affected limb. Structural abnormalities (congenial or acquired) Neuromuscular problems, including weakness or ataxia (cerebellar or sensory)

4. Differential Diagnosis by age • All ages Septic arthritis • Osteomyelitis • Cellulitis • Stress fracture • Neoplasm (including leukemia) • Neuromuscular • Toddler (ages one to three) • Septic hip • Developmental dysplasia of the hip • Occult fractures • Leg-length discrepancy • Child (ages four to 10) • Legg-Calvé-Perthes disease • Transient synovitis • Juvenile rheumatoid arthritis • Adolescent (ages 11 to 16) • Slipped capital femoral epiphysis • Avascular necrosis of femoral head • Overuse syndromes • Tarsal coalitions • Gonococcal septic arthritis

5. History: Obtained from child or caregiver. Onset and duration. Association of limp pain. Getting better, worse or staying the same. If signs of improvement, patient may be observed as long there are no constitutional sympt0ms (fatigue, weight loss, loss of appetite, night sweats). Can pain be localised to a painful joint or focal area? Consider referred pain eg hip causing knee pain.

6. History Child prefers to crawl or walk on his or her knees? Positive response makes foot pathology likely. Limp worse in the morning suggests JIRA. Night pain especially pain that wakes up the child from sleep is worrisome of malignant process. Unilateral vs bilateral. Growing pain must meet the following criteria: Leg pain is bilateral Pain occurs only at night. Patient has no limp, pain or symptoms during the day.

7. History: Constant limp may suggest structural cause including tumours. Systematic review: eg. Recent fever, chills or other signs of infections. Recent upper respiratory tract infection: transient viral synovitis, septic process, post streptococcal reactive arthritis. Fever points to an infection or inflammatory condition. Family history of rheumatologic or neuromuscular.

8. History Dietary intake including supplementation with vitamin D. A deficiency can lead to pathological fractures and rickets. Bleeding tendencies may suggest haemophiliac in males. Country of origin eg. West Africa may suggest sickle cell disease. Constitutional signs may suggest TB or malignancy.

9. Physical Examination Inspection: exposure the child properly. Minimal clothing and child should be barefoot in order to observe the feet and toes. Gait: ask child to walk barefoot while noting any abnormalities in gait. Focus on each movement of hip, knee, ankle, joints through all phases of the gait. If abnormalities found classify types of abnormal gait as: Antalgic gait, Trendlenburg gait, Steppage gait, and Toe walking gait.

10. Physical examination Can the child run, stand on one foot, hop on one foot, walk on hells and toes, squat? Have the child stand on one foot (Trendelenburg test) to assess hip abductor strength. Note muscle bulk, swelling, erythema, deformities, asymmetry of trunk, hips and lower extremities. Evaluate the shoes for the unusual wear pattern. Measure true and apparent leg length. Assess spine for deformities, scoliosis, ROM or pain.

11. Physical Examination Palpation: assess any suspected joints for tenderness to palpation. Palpate over the hip joints, sacro-iliac joints, greater trochanters, knees, and ankles. Test for joint effusions, especially knees. Range of motion: assess range of motion, laxity, stiffness and guarding at all suspected joints. Full neurological Evaluation: test lower extremities for strength, sensation (eproprioception), deep tendon reflexes, cerebellar testing.

12. Special Test Prone Faber test Galeazzi test Measurement of circumference of calves and thighs to look for atrophy.

13. Prone internal rotation of the hip. This is the most sensitive test for the intra-articular hip pathology. In this test, any inflammation of the hip manifests as decreased internal rotation of the hip.

14. The FABER test is specific for sacroiliac joint pathology. A positive test causes pain at the sacroiliac joint when the patient lies supine with the ipsilateral ankle placed on the contralateral knee and mild downward pressure placed on the ipsilateral knee. (FABER = hip flexion, abduction and external r otation)

15. The Galeazzitest is performed by putting the child in a supine position and bringing the ankles to the buttocks with the hips and knees flexed

16. Hip abduction may also be tested with the hips flexed and extended, again making certain the pelvis remains level. Asymmetric abduction suggesting developmental dysplasia of the hip or any condition irritating the hip.

17. A modified log-roll test may be helpful in differentiating the degree of hip irritation.

18. CORRELATING HISTORY, EXAMINATION AND DIAGNOSTIC STUDIES .

20. Investigation Full blood count and differential count (FBC+diff). Erythrocyte sedimentation Rate (ESR).C reactive protein (CRP). Joint aspiration for all cell count, gram stain, culture and sensitivity, protein, glucose and crystals. Blood culture Imaging: plain x-ray film (AP and lateral) X-ray joint above and below the area in question. Ideal done weight bearing when possible.

21. Imaging Hip film should have AP and frog leg lateral. Ultrasound of suspected septic joint , joint effusion or abscess. Bone scan, increased uptake in area with increased metabolic activities seen in: stress fractures, infections, fractures and most tumours. CT and MRI when indicated.

22. Anteroposterior (left) and lateral (right) views of a patient with spiral fracture (arrow) of the tibia. Note that the anteroposterior view alone would most likely have been considered normal.

23. An anteroposterior view (left) of the pelvis in an adolescent with slipped capital femoral epiphysis. Note that the left hip has a slightly wider physis (large arrow), and slightly less femoral head is visible lateral to Kline's line (the line drawn along the lateral femoral neck). On the frog-leg view (right), the posterior slippage of the femoral head is more obvious (arrow).

24. Lateral radiograph of the spine revealing decreased disc space (arrow) between L4 and L5. In a patient with a clinical picture of decreased spinal motion and elevated erythrocyte sedimentation rate, a diagnosis of diskitis may be made.

25. Treatment According to causes multidisplinary Acute: Medical (ivi antibiotics and pain management vs Surgical decompression /drainage Physiotherapy

26. Take home message A limp is common in children Challenge is to identify cause of the limp and determine if further observation or immediate diagnostic work up is indicated.

27. THANK YOU!