Approach to the Limping Child by Dr. Virteeka Sinha

Limping is one of the most common complaints in the Pediatric Emergency Department. Most children will have a limp at some point or another in their lives. Limping poses a challenge in the pediatric population, as it is difficult to diagnose, given the variable causes for it in a growing child.

Accurate and timely diagnosis can be both limb and life saving. Fortunately the most common cause of limp in pediatrics is minor trauma, which resolves spontaneously. Intensive work up and evaluation is often required in the absence of trauma or when certain red flags are present.

HISTORY should focus on the primary complaint and the perception of the limp as per the parent and the child. Details should be obtained with respect to the pain: onset and duration (episodic or continuous?) Are there systemic complaints: fever/weight loss?

Is there associated trauma? Is there a pattern (cyclic/recurrent)? What is the child’s activity level? What is the family perception of the problem? Focus should also lie on the social aspect of the family, any positive family history or any other associated complaints.

Physical examination should focus on the detailed exam of the child. Gait should be evaluated bare foot, if possible. All four extremities should be examined and as should the spine/ joints and muscle bulk. One key examination often missed is the evaluation of the abdomen and genitalia. Testicular torsion and hernia have been reported in literature with the initial presentation of a limping child.

Examination of the shoes!!!!! gives valuable information about the gait- abnormality and can sometimes be the isolated cause of a limp in a child.

The laboratory evaluation should be tailored to the differentials considered. The causes of limp can vary from a benign normal finding to a septic joint. Categorizing them into essentially emergent vs non-emergent can help tailor management.

The broad categories involved are Infection, Inflammatory, Trauma, Bony deformities, Aseptic necrosis, Tumors, Neuromuscular or Neurological abnormalities.

Limb or life threatening causes that require prompt attention are Septic arthritis, Osteomyelitis, Tumor, Developmental dysplasia of the hip, SCFE, Epidural abscess and Appendicitis. Care should be taken to identify the red flags associated with these problems and consider expert or specialist consultation.

In summary, most cases of limping resolve spontaneously and require no additional work up. It is important to be able to identify limb and life threatening causes of limp. A good history and physical exam can help ease the challenge of diagnosis in a young child but can be limited and radiographs can vary according to the age of the child. Most cases do not need expert or specialist consultation. However surgical and orthopedic consultation sought in time can make a difference between permanent disability, sometimes even death, and complete resolution and well-being.