Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Overview of the causes of limp in children

INTRODUCTION

Limp is defined as an uneven, jerky, or laborious gait, usually caused by pain, weakness, or deformity [1]. It is a common complaint in childhood, accounting for 4 per 1000 visits in one pediatric emergency department [2]. Limp is caused by benign and life-threatening conditions (table 1), and the management varies from reassurance to major surgery depending upon the cause [2,3].

The cause of limp usually can be determined through a careful history and physical examination. Radiographic studies often are necessary to confirm clinical suspicions, but diagnostic procedures rarely are required. While most cases of limp are caused by trauma or benign self-limiting conditions that resolve spontaneously [4], life- or limb-threatening conditions (table 2) must be diagnosed promptly [5].

An overview of the major causes of limp in children is presented here. The approach to the child with a limp is discussed separately. (See "Approach to the child with a limp".)

INFECTION

Septic arthritis — Septic bacterial arthritis is one of the diagnoses that must not be missed in the evaluation of a child with a limp, given the potential for rapid joint destruction and long-term morbidity with delayed diagnosis. Early diagnosis and treatment are the single most important factors in determining the outcome of septic arthritis. The knee and hip are the joints most commonly affected; involvement of the hip is seen more commonly in infants and young children [6]. In one review of 425 children who were admitted or seen in the emergency department during a 12-month period for a gait disturbance, 14 (3 percent) had septic arthritis [2].

Children with septic arthritis of the hip typically are febrile and ill-appearing, although occasionally the presentation is more subtle [7]. Neonates and infants with septic arthritis of the hip may present with irritability and pseudoparalysis of the affected limb, with or without fever [8-10]. Weightbearing and motion of the affected hip are quite painful and strongly resisted in all patients [11]. Other joints typically are spared, although up to 8 percent of septic arthritis in children is multifocal [12,13]. The presentation of septic arthritis can be altered by recent use of antibiotics.

                                       

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Aug 2014. | This topic last updated: Aug 5, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Brady M. The child with a limp. J Pediatr Health Care 1993; 7:226.
  2. Singer JI. The cause of gait disturbance in 425 pediatric patients. Pediatr Emerg Care 1985; 1:7.
  3. Chung SM. Identifying the cause of acute limp in childhood. Some informal comments and observations. Clin Pediatr (Phila) 1974; 13:769.
  4. Fischer SU, Beattie TF. The limping child: epidemiology, assessment and outcome. J Bone Joint Surg Br 1999; 81:1029.
  5. Phillips WA. The child with a limp. Orthop Clin North Am 1987; 18:489.
  6. Shaw BA, Kasser JR. Acute septic arthritis in infancy and childhood. Clin Orthop Relat Res 1990; :212.
  7. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am 1999; 81:1662.
  8. Allen BL Jr, Ferguson RL. Topics of interest in pediatric orthopedics. Pediatr Clin North Am 1985; 32:1333.
  9. Shetty AK, Gedalia A. Septic arthritis in children. Rheum Dis Clin North Am 1998; 24:287.
  10. Asmar BI. Osteomyelitis in the neonate. Infect Dis Clin North Am 1992; 6:117.
  11. Sutherland DH, Olshen R, Cooper L, Woo SL. The development of mature gait. J Bone Joint Surg Am 1980; 62:336.
  12. Nelson JD. Skeletal infections in children. Adv Pediatr Infect Dis 1991; 6:59.
  13. Welkon CJ, Long SS, Fisher MC, Alburger PD. Pyogenic arthritis in infants and children: a review of 95 cases. Pediatr Infect Dis 1986; 5:669.
  14. 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.
  15. Kallio MJ, Unkila-Kallio L, Aalto K, Peltola H. Serum C-reactive protein, erythrocyte sedimentation rate and white blood cell count in septic arthritis of children. Pediatr Infect Dis J 1997; 16:411.
  16. Levine MJ, McGuire KJ, McGowan KL, Flynn JM. Assessment of the test characteristics of C-reactive protein for septic arthritis in children. J Pediatr Orthop 2003; 23:373.
  17. Taekema HC, Landham PR, Maconochie I. Towards evidence based medicine for paediatricians. Distinguishing between transient synovitis and septic arthritis in the limping child: how useful are clinical prediction tools? Arch Dis Child 2009; 94:167.
  18. Sultan J, Hughes PJ. Septic arthritis or transient synovitis of the hip in children: the value of clinical prediction algorithms. J Bone Joint Surg Br 2010; 92:1289.
  19. Del Beccaro MA, Champoux AN, Bockers T, Mendelman PM. Septic arthritis versus transient synovitis of the hip: the value of screening laboratory tests. Ann Emerg Med 1992; 21:1418.
  20. Kunnamo I, Kallio P, Pelkonen P, Hovi T. Clinical signs and laboratory tests in the differential diagnosis of arthritis in children. Am J Dis Child 1987; 141:34.
  21. Capitanio MA, Kirkpatrick JA. Early roentgen observations in acute osteomyelitis. Am J Roentgenol Radium Ther Nucl Med 1970; 108:488.
  22. Aronson J, Garvin K, Seibert J, et al. Efficiency of the bone scan for occult limping toddlers. J Pediatr Orthop 1992; 12:38.
  23. Bower GD, Sprague P, Geijsel H, et al. Isotope bone scans in the assessment of children with hip pain or limp. Pediatr Radiol 1985; 15:319.
  24. Fleisher GR. Infectious disease emergencies. In: Textbook of Pediatric Emergencies, 5th, Fleisher GR, Ludwig S, Henretig FM. (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.783.
  25. Harris JC, Caesar DH, Davison C, et al. How useful are laboratory investigations in the emergency department evaluation of possible osteomyelitis? Emerg Med Australas 2011; 23:317.
  26. Mall S, Buchholz U, Tibussek D, et al. A large outbreak of influenza B-associated benign acute childhood myositis in Germany, 2007/2008. Pediatr Infect Dis J 2011; 30:e142.
  27. Middleton PJ, Alexander RM, Szymanski MT. Severe myositis during recovery from influenza. Lancet 1970; 2:533.
  28. Farrell MK, Partin JC, Bove KE. Epidemic influenza myopathy in Cincinnati in 1977. J Pediatr 1980; 96:545.
  29. Dietzman DE, Schaller JG, Ray CG, Reed ME. Acute myositis associated with influenza B infection. Pediatrics 1976; 57:255.
  30. Mackay MT, Kornberg AJ, Shield LK, Dennett X. Benign acute childhood myositis: laboratory and clinical features. Neurology 1999; 53:2127.
  31. Ruff RL, Secrist D. Viral studies in benign acute childhood myositis. Arch Neurol 1982; 39:261.
  32. Leet AI, Skaggs DL. Evaluation of the acutely limping child. Am Fam Physician 2000; 61:1011.
  33. Singer J. Evaluation of acute and insidious gait disturbance in children less than five years of age. Adv Pediatr 1979; 26:209.
  34. Lawrence LL. The limping child. Emerg Med Clin North Am 1998; 16:911.
  35. Kehl DK. Other conditions of the hip. In: Pediatric Orthopaedics, 3rd, Morrissy RT. (Ed), Lippincott, Philadelphia 1990. p.905.
  36. Kunnamo I, Kallio P, Pelkonen P. Incidence of arthritis in urban Finnish children. A prospective study. Arthritis Rheum 1986; 29:1232.
  37. Landin LA, Danielsson LG, Wattsgård C. Transient synovitis of the hip. Its incidence, epidemiology and relation to Perthes' disease. J Bone Joint Surg Br 1987; 69:238.
  38. Haueisen DC, Weiner DS, Weiner SD. The characterization of "transient synovitis of the hip" in children. J Pediatr Orthop 1986; 6:11.
  39. Do TT. Transient synovitis as a cause of painful limps in children. Curr Opin Pediatr 2000; 12:48.
  40. Ehrendorfer S, LeQuesne G, Penta M, et al. Bilateral synovitis in symptomatic unilateral transient synovitis of the hip: an ultrasonographic study in 56 children. Acta Orthop Scand 1996; 67:149.
  41. Singhal R, Perry DC, Khan FN, et al. The use of CRP within a clinical prediction algorithm for the differentiation of septic arthritis and transient synovitis in children. J Bone Joint Surg Br 2011; 93:1556.
  42. Terjesen T, Osthus P. Ultrasound in the diagnosis and follow-up of transient synovitis of the hip. J Pediatr Orthop 1991; 11:608.
  43. Swischuk LE. Limp in young child. Pediatr Emerg Care 1990; 6:65.
  44. Kermond S, Fink M, Graham K, et al. A randomized clinical trial: should the child with transient synovitis of the hip be treated with nonsteroidal anti-inflammatory drugs? Ann Emerg Med 2002; 40:294.
  45. Taylor GR, Clarke NM. Recurrent irritable hip in childhood. J Bone Joint Surg Br 1995; 77:748.
  46. Kallio P, Ryöppy S, Kunnamo I. Transient synovitis and Perthes' disease. Is there an aetiological connection? J Bone Joint Surg Br 1986; 68:808.
  47. Tenenbein M, Reed MH, Black GB. The toddler's fracture revisited. Am J Emerg Med 1990; 8:208.
  48. Mellick LB, Milker L, Egsieker E. Childhood accidental spiral tibial (CAST) fractures. Pediatr Emerg Care 1999; 15:307.
  49. Swischuk LE. Painless limp. Pediatr Emerg Care 1992; 8:105.
  50. Dunbar, JS, Owen, HG, Nogrady, MB, et al. Obscure tibial fracture of infants: the toddler's fracture. J Can Assoc Radiol 1963; 25:136.
  51. Halsey MF, Finzel KC, Carrion WV, et al. Toddler's fracture: presumptive diagnosis and treatment. J Pediatr Orthop 2001; 21:152.
  52. Shravat BP, Harrop SN, Kane TP. Toddler's fracture. J Accid Emerg Med 1996; 13:59.
  53. Starshak RJ, Simons GW, Sty JR. Occult fracture of the calcaneus--another toddler's fracture. Pediatr Radiol 1984; 14:37.
  54. Blumberg K, Patterson RJ. The toddler's cuboid fracture. Radiology 1991; 179:93.
  55. Moss EH, Carty H. Scintigraphy in the diagnosis of occult fractures of the calcaneus. Skeletal Radiol 1990; 19:575.
  56. Schindler A, Mason DE, Allington NJ. Occult fracture of the calcaneus in toddlers. J Pediatr Orthop 1996; 16:201.
  57. Englaro EE, Gelfand MJ, Paltiel HJ. Bone scintigraphy in preschool children with lower extremity pain of unknown origin. J Nucl Med 1992; 33:351.
  58. Johnson, LC, Stradford, HT, Geis, RW, et al. Histogenesis of stress fractures (abstract). J Bone Joint Surg Br 1963; 45:1542.
  59. Hulkko A, Orava S. Stress fractures in athletes. Int J Sports Med 1987; 8:221.
  60. Yngve DA. Stress fractures in the pediatric athlete. In: The Pediatric Athlete, Sullivan JA, Grana WA. (Eds), American Academy of Orthopedic Surgeons, Park Ridge 1988. p.235.
  61. Engh CA, Robinson RA, Milgram J. Stress fractures in children. J Trauma 1970; 10:532.
  62. Orava S, Jormakka E, Hulkko A. Stress fractures in young athletes. Arch Orthop Trauma Surg 1981; 98:271.
  63. Coady CM, Micheli LJ. Stress fractures in the pediatric athlete. Clin Sports Med 1997; 16:225.
  64. Meyer SA, Saltzman CL, Albright JP. Stress fractures of the foot and leg. Clin Sports Med 1993; 12:395.
  65. Spitz DJ, Newberg AH. Imaging of stress fractures in the athlete. Radiol Clin North Am 2002; 40:313.
  66. Lennox IA, McLauchlan J, Murali R. Failures of screening and management of congenital dislocation of the hip. J Bone Joint Surg Br 1993; 75:72.
  67. Dabney KW, Lipton G. Evaluation of limp in children. Curr Opin Pediatr 1995; 7:88.
  68. Sullivan JA. Foot. In: Care of the Young Athlete, Sullivan JA, Anderson SJ. (Eds), American Academy of Orthopedic Surgeons and American Academy of Pediatrics, Park Ridge 2000. p.425.
  69. Zaw H, Calder JD. Tarsal coalitions. Foot Ankle Clin 2010; 15:349.
  70. Tarsal coalition. In: Essentials of Musculoskeletal Care, 2nd, Green WB. (Ed), American Academy of Orthopedic Surgeons, Rosemont 2001. p.715.
  71. Wenger DR, Ward WT, Herring JA. Legg-Calvé-Perthes disease. J Bone Joint Surg Am 1991; 73:778.
  72. Sherry DD, Malleson PN. Nonrheumatic musculoskeletal pain. In: Textbook of Pediatric Rheumatology, 4th, Cassidy JT, Petty RE. (Eds), WB Saunders, Philadelphia 2001. p.362.
  73. Wang NH, Lee FT, Chin LS, Lo WH. Legg-Calve-Perthes disease: clinical analysis of 57 cases. J Formos Med Assoc 1990; 89:764.
  74. Weinstein SL. Legg-CalvePerthes disease. In: Pediatric Orthopedics, 3rd, Lippincott, Philadelphia 1990. p.852.
  75. Uno A, Hattori T, Noritake K, Suda H. Legg-Calvé-Perthes disease in the evolutionary period: comparison of magnetic resonance imaging with bone scintigraphy. J Pediatr Orthop 1995; 15:362.
  76. Weinstein SL. Bristol-Myers Squibb/Zimmer award for distinguished achievement in orthopaedic research. Long-term follow-up of pediatric orthopaedic conditions. Natural history and outcomes of treatment. J Bone Joint Surg Am 2000; 82-A:980.
  77. Yrjönen T. Long-term prognosis of Legg-Calvé-Perthes disease: a meta-analysis. J Pediatr Orthop B 1999; 8:169.
  78. Sullivan JA. Ankle and foot injuries in the pediatric athlete. Instr Course Lect 1993; 42:545.
  79. Medlar RC, Lyne ED. Sinding-Larsen-Johansson disease. Its etiology and natural history. J Bone Joint Surg Am 1978; 60:1113.
  80. Gillespie H. Osteochondroses and apophyseal injuries of the foot in the young athlete. Curr Sports Med Rep 2010; 9:265.
  81. Mubarak SJ. Osteochondrosis of the lateral cuneiform: another cause of a limp in a child. A case report. J Bone Joint Surg Am 1992; 74:285.
  82. Binek R, Levinsohn EM, Bersani F, Rubenstein H. Freiberg disease complicating unrelated trauma. Orthopedics 1988; 11:753.
  83. Griffin LY. Common sports injuries of the foot and ankle seen in children and adolescents. Orthop Clin North Am 1994; 25:83.
  84. Staheli LT. The lower limb. In: Pediatric Orthopaedics, 3rd, Morrissy RT. (Ed), Lippincott, Philadelphia 1990. Vol 2, p.41.
  85. James AM, Williams CM, Haines TP. "Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever's disease): a systematic review". J Foot Ankle Res 2013; 6:16.
  86. Kujala UM, Kvist M, Heinonen O. Osgood-Schlatter's disease in adolescent athletes. Retrospective study of incidence and duration. Am J Sports Med 1985; 13:236.
  87. Krause BL, Williams JP, Catterall A. Natural history of Osgood-Schlatter disease. J Pediatr Orthop 1990; 10:65.
  88. Mital MA, Matza RA, Cohen J. The so-called unresolved Osgood-Schlatter lesion: a concept based on fifteen surgically treated lesions. J Bone Joint Surg Am 1980; 62:732.
  89. Clark, MC, Iwinski, HJ. The limping child: The challenges of an accurate assessment and diagnosis. Pediatr Emerg Med 1997; 2:123.
  90. Dunn JF. Osgood-Schlatter disease. Am Fam Physician 1990; 41:173.
  91. Cohen MD, Harrington TM, Ginsburg WW. Osteoid osteoma: 95 cases and a review of the literature. Semin Arthritis Rheum 1983; 12:265.
  92. Kaweblum M, Lehman WB, Bash J, et al. Diagnosis of osteoid osteoma in the child. Orthop Rev 1993; 22:1305.
  93. Conrad EU 3rd. Pitfalls in diagnosis: pediatric musculoskeletal tumors. Pediatr Ann 1989; 18:45.
  94. Rheingold SR, Lange B. Oncologic emergencies. In: Textbook of Pediatric Emergency Medicine, 3rd, Fleisher GR, Ludwig S, Henretig FM. (Eds), Williams & Wilkins, Baltimore 2006. p.1239.
  95. Rogalsky RJ, Black GB, Reed MH. Orthopaedic manifestations of leukemia in children. J Bone Joint Surg Am 1986; 68:494.
  96. Hann IM, Gupta S, Palmer MK, Morris-Jones PH. The prognostic significance of radiological and symptomatic bone involvement in childhood acute lymphoblastic leukaemia. Med Pediatr Oncol 1979; 6:51.
  97. Jonsson OG, Sartain P, Ducore JM, Buchanan GR. Bone pain as an initial symptom of childhood acute lymphoblastic leukemia: association with nearly normal hematologic indexes. J Pediatr 1990; 117:233.
  98. Heinrich SD, Gallagher D, Warrior R, et al. The prognostic significance of the skeletal manifestations of acute lymphoblastic leukemia of childhood. J Pediatr Orthop 1994; 14:105.
  99. Parmar R, Wadia F, Yassa R, Zenios M. Neuroblastoma: a rare cause of a limping child. How to avoid a delayed diagnosis? J Pediatr Orthop 2013; 33:e45.
  100. Emery AE. The muscular dystrophies. Lancet 2002; 359:687.
  101. Gardner-Medwin D. Clinical features and classification of the muscular dystrophies. Br Med Bull 1980; 36:109.
  102. Schwartzman RJ, McLellan TL. Reflex sympathetic dystrophy. A review. Arch Neurol 1987; 44:555.
  103. Bernstein BH, Singsen BH, Kent JT, et al. Reflex neurovascular dystrophy in childhood. J Pediatr 1978; 93:211.
  104. Wilder RT, Berde CB, Wolohan M, et al. Reflex sympathetic dystrophy in children. Clinical characteristics and follow-up of seventy patients. J Bone Joint Surg Am 1992; 74:910.
  105. Stanton RP, Malcolm JR, Wesdock KA, Singsen BH. Reflex sympathetic dystrophy in children: an orthopedic perspective. Orthopedics 1993; 16:773.
  106. Murray CS, Cohen A, Perkins T, et al. Morbidity in reflex sympathetic dystrophy. Arch Dis Child 2000; 82:231.
  107. Barbier O, Allington N, Rombouts JJ. Reflex sympathetic dystrophy in children: review of a clinical series and description of the particularities in children. Acta Orthop Belg 1999; 65:91.
  108. Dietz FR, Mathews KD, Montgomery WJ. Reflex sympathetic dystrophy in children. Clin Orthop Relat Res 1990; :225.