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 — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
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].
The cause of limp usually can be determined by obtaining a careful history and physical examination. Radiographic studies often are necessary to confirm clinical suspicions, but diagnostic procedures rarely are required. Although most cases of limp are caused by trauma or benign self-limiting conditions, life- or limb-threatening conditions must be diagnosed promptly (table 2) [4,5].
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".)
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 [2,3,6,7]. 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.
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- Caird MS, Flynn JM, Leung YL, et al. Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am 2006; 88:1251.
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- 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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- 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)