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儿童跛行的病因概述

Author
Mark C Clark, MD, FAAEM, FAAP, FACEP
Section Editors
Gary R Fleisher, MD
Jan E Drutz, MD
Deputy Editor
James F Wiley, II, MD, MPH
Translators
曾伟锋, 主治医师

引言

跛行被定义为一种不平衡的、一瘸一拐或费力的步态，通常由疼痛、肌无力或畸形引起[1]。跛行是儿童时期常见的疾病，在一个儿科急诊科室中，占了就诊患者的4/1000[2]。跛行可由良性和危及生命的疾病引起的(表 1)，而其处理方法根据其病因从宽慰患者使其安心至进行大手术不等[2,3]。

跛行的病因通常可通过仔细询问病史和体格检查来确定。放射影像学检查对证实临床怀疑通常是必要的，但很少需要诊断性操作。虽然大多数跛行病例是外伤或可自行缓解的良性自限性疾病引起的[4]，但是危及生命或肢体的疾病(表 2)必须迅速得到诊断[5]。

本文将概述儿童跛行的主要病因。跛行儿童的评估将单独讨论。 (参见“儿童跛行的诊断方法”)

感染

脓毒性关节炎 — 在评估跛行儿童时，脓毒性细菌性关节炎是绝对不能漏掉的诊断之一，因为延迟诊断可能会带来快速的关节破坏和关节长期病残。早期诊断和治疗是决定脓毒性关节炎结局的最重要的单个因素。膝关节和髋关节是最常受影响的关节，髋关节受累更常见于婴儿和年幼儿童[6]。一项研究纳入了在12个月期间因步态障碍入院或就诊于急诊科的425例儿童患者，其中14例(3%)有脓毒性关节炎[2]。

尽管髋关节脓毒性关节炎患儿偶见较轻微的临床表现，但通常会表现为发热和一般状况较差[7]。有髋关节脓毒性关节炎的新生儿及婴儿可能出现伴或不伴发热的易激惹和受累肢体的假性麻痹[8-10]。受累的髋关节进行负重和运动是相当痛苦的，并且所有患者均会强烈抗拒[11]。虽然高达8%的儿童脓毒性关节炎为多灶性，但其他关节通常不受累及[12,13]。近期使用抗生素会使脓毒性关节炎的临床表现发生改变。

                                       

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Literature review current through: 2017-06 . | This topic last updated: 2017-01-10.
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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. Carty HM. Fractures caused by child abuse. J Bone Joint Surg Br 1993; 75:849.
  67. Merten DF, Radkowski MA, Leonidas JC. The abused child: a radiological reappraisal. Radiology 1983; 146:377.
  68. Merten DF, Carpenter BL. Radiologic imaging of inflicted injury in the child abuse syndrome. Pediatr Clin North Am 1990; 37:815.
  69. 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.
  70. Dabney KW, Lipton G. Evaluation of limp in children. Curr Opin Pediatr 1995; 7:88.
  71. Kraft DE. Chronic foot and ankle injuries. In: Care of the Young Athlete, 2nd ed, Harris SS, Anderson SJ (Eds), American Academy of Orthopedic Surgeons and American Academy of Pediatrics, Park Ridge 2010. p.457.
  72. Zaw H, Calder JD. Tarsal coalitions. Foot Ankle Clin 2010; 15:349.
  73. Tarsal coalition. In: Essentials of Musculoskeletal Care, 2nd ed, Green WB. (Ed), American Academy of Orthopedic Surgeons, Rosemont 2001. p.715.
  74. Wenger DR, Ward WT, Herring JA. Legg-Calvé-Perthes disease. J Bone Joint Surg Am 1991; 73:778.
  75. Sherry DD, Malleson PN. Nonrheumatic musculoskeletal pain. In: Textbook of Pediatric Rheumatology, 4th, Cassidy JT, Petty RE. (Eds), WB Saunders, Philadelphia 2001. p.362.
  76. Wang NH, Lee FT, Chin LS, Lo WH. Legg-Calve-Perthes disease: clinical analysis of 57 cases. J Formos Med Assoc 1990; 89:764.
  77. Weinstein SL. Legg-CalvePerthes disease. In: Pediatric Orthopedics, 3rd, Lippincott, Philadelphia 1990. p.852.
  78. 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.
  79. 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.
  80. Yrjönen T. Long-term prognosis of Legg-Calvé-Perthes disease: a meta-analysis. J Pediatr Orthop B 1999; 8:169.
  81. Sullivan JA. Ankle and foot injuries in the pediatric athlete. Instr Course Lect 1993; 42:545.
  82. Medlar RC, Lyne ED. Sinding-Larsen-Johansson disease. Its etiology and natural history. J Bone Joint Surg Am 1978; 60:1113.
  83. 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.
  84. Binek R, Levinsohn EM, Bersani F, Rubenstein H. Freiberg disease complicating unrelated trauma. Orthopedics 1988; 11:753.
  85. Griffin LY. Common sports injuries of the foot and ankle seen in children and adolescents. Orthop Clin North Am 1994; 25:83.
  86. Staheli LT. The lower limb. In: Pediatric Orthopaedics, 3rd, Morrissy RT. (Ed), Lippincott, Philadelphia 1990. Vol 2, p.41.
  87. 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.
  88. Krause BL, Williams JP, Catterall A. Natural history of Osgood-Schlatter disease. J Pediatr Orthop 1990; 10:65.
  89. 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.
  90. Clark, MC, Iwinski, HJ. The limping child: The challenges of an accurate assessment and diagnosis. Pediatr Emerg Med 1997; 2:123.
  91. Dunn JF. Osgood-Schlatter disease. Am Fam Physician 1990; 41:173.
  92. Cohen MD, Harrington TM, Ginsburg WW. Osteoid osteoma: 95 cases and a review of the literature. Semin Arthritis Rheum 1983; 12:265.
  93. Kaweblum M, Lehman WB, Bash J, et al. Diagnosis of osteoid osteoma in the child. Orthop Rev 1993; 22:1305.
  94. Conrad EU 3rd. Pitfalls in diagnosis: pediatric musculoskeletal tumors. Pediatr Ann 1989; 18:45.
  95. 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.
  96. Rogalsky RJ, Black GB, Reed MH. Orthopaedic manifestations of leukemia in children. J Bone Joint Surg Am 1986; 68:494.
  97. 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.
  98. 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.
  99. 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.
  100. 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.
  101. Emery AE. The muscular dystrophies. Lancet 2002; 359:687.
  102. Gardner-Medwin D. Clinical features and classification of the muscular dystrophies. Br Med Bull 1980; 36:109.
  103. Schwartzman RJ, McLellan TL. Reflex sympathetic dystrophy. A review. Arch Neurol 1987; 44:555.
  104. Bernstein BH, Singsen BH, Kent JT, et al. Reflex neurovascular dystrophy in childhood. J Pediatr 1978; 93:211.
  105. 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.
  106. Stanton RP, Malcolm JR, Wesdock KA, Singsen BH. Reflex sympathetic dystrophy in children: an orthopedic perspective. Orthopedics 1993; 16:773.
  107. Murray CS, Cohen A, Perkins T, et al. Morbidity in reflex sympathetic dystrophy. Arch Dis Child 2000; 82:231.
  108. 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.
  109. Dietz FR, Mathews KD, Montgomery WJ. Reflex sympathetic dystrophy in children. Clin Orthop Relat Res 1990; :225.