Approach to the child with a limp
- Mark C Clark, MD, FAAEM, FAAP, FACEP
Mark C Clark, MD, FAAEM, FAAP, FACEP
- Clinical Associate Professor of Emergency Medicine
- University of Florida College of Medicine
- Section Editors
- Gary R Fleisher, MD
Gary R Fleisher, MD
- Editor-in-Chief — Adult and Pediatric Emergency Medicine
- Section Editor — Pediatric Signs and Symptoms
- Egan Family Foundation Professor
- Harvard Medical School
- Jan E Drutz, MD
Jan E Drutz, MD
- Section Editor — General Pediatrics
- Professor of Pediatrics
- Baylor College of Medicine
- William Phillips, MD
William Phillips, MD
- Section Editor — Pediatric Orthopedics
- Professor of Pediatrics and Orthopedics
- Baylor College of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
The evaluation of the limping child is reviewed here. An overview of specific causes of limp in children is presented separately. (See "Overview of the causes of limp in children".)
Limp is defined as an uneven, jerky, or laborious gait, usually caused by pain, weakness, or deformity . It is a common complaint in childhood, accounting for 4 per 1000 visits in one pediatric emergency department . Limp can be caused by both benign and life-threatening conditions (table 1); the management varies from reassurance to major surgery depending upon the cause [2,3].
In the emergency department or primary care practice, minor trauma predominates as the typical etiology for limp. Observational studies of children without a clear history of trauma who were evaluated in tertiary care centers or orthopedic clinics tend to emphasize serious infectious disease diagnoses such as osteomyelitis or septic arthritis [2-5]. One prospective study that evaluated 243 children younger than 14 years of age who presented to a pediatric emergency department with limp and no history of trauma had the following findings :
●Boys outnumbered girls by almost two to one.
●Median age was four years.
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- Chung SM. Identifying the cause of acute limp in childhood. Some informal comments and observations. Clin Pediatr (Phila) 1974; 13:769.
- Illingworth CM. 128 limping children with no fracture, sprain, or obvious cause. Seven were found to have Perthes' disease, 76 seemed to have transient synovitis of the hip, and in 45 the cause seemed to be in the ankle or knee. Clin Pediatr (Phila) 1978; 17:139.
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- American College of Radiology. ACR appropriateness critieria. Limping Child - Ages 0-5 years. http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/LimpingChildAges0To5Years.pdf (Accessed on August 06, 2012).
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- Yang WJ, Im SA, Lim GY, et al. MR imaging of transient synovitis: differentiation from septic arthritis. Pediatr Radiol 2006; 36:1154.
- Kwack KS, Cho JH, Lee JH, et al. Septic arthritis versus transient synovitis of the hip: gadolinium-enhanced MRI finding of decreased perfusion at the femoral epiphysis. AJR Am J Roentgenol 2007; 189:437.
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- Plumb J, Mallin M, Bolte RG. The role of ultrasound in the emergency department evaluation of the acutely painful pediatric hip. Pediatr Emerg Care 2015; 31:54.
- Garrison J, Nguyen M, Marin JR. Emergency Department Point-of-Care Hip Ultrasound and Its Role in the Diagnosis of Septic Hip Arthritis: A Case Report. Pediatr Emerg Care 2016; 32:555.
- Kotlarsky P, Shavit I, Kassis I, Eidelman M. Treatment of septic hip in a pediatric ED: a retrospective case series analysis. Am J Emerg Med 2016; 34:602.
- Pain characteristics
- Other symptoms
- PHYSICAL EXAMINATION
- Gait evaluation
- - Gait physiology
- - Gait examination
- - Hip rotation
- - Galeazzi test
- - Trendelenburg test
- - FABERE test
- Other findings
- DIFFERENTIAL DIAGNOSIS
- Bacterial arthritis of the hip
- LABORATORY EVALUATION
- Blood studies
- Synovial fluid analysis
- RADIOLOGIC EVALUATION
- Plain radiograph
- - Comparison views
- - Children with isolated limp
- Magnetic resonance imaging (MRI)
- Radionuclide scan
- Computed tomography (CT)