2. Case scenario
• 5 year old boy brought to ER with walking difficulty and
difficulty in bearing weight on right leg.. O/E he is febrile,
unwell looking, swelling of right knee with restricted
movements.
• Lab: TLC 26000 . Neu 78%
• CRP 89
• ESR 112
• How to evaluate and treat the child?
3. Case 2
• 8 years old boy presented with sudden onset of pain in
left leg and walking difficulty.
• Examination unremarkable
• TLC 58000
• Lymphocytes predominently
• Periphral film : blast cells
• Wht you suspect and how to evaluate
4. Definition
• Limp is defined by a deviation from the normal gait pattern
expected for a child's age
• Incidence :180 cases per 100,000
• males > females
• Median age 4.4 years
• Right> left
5. The Normal Gait Cycle
• Begins to walk at 12 to 14 months
• Mature adult gait pattern : 3 years
• Infant gait: Wide based externally rotated gait
• Mature adult gait :
60% of the time in the stance phase (from heel
strike to toe off)
40% of the time in the swing phase (from toe off to
the next heel strike).
6. Causes of limp
• Pain (Antalgic gait):
( traumatic, infectious, inflammatory, or
neoplastic)
• Structural Abnormalities:
(limb length discrepancies, angular limb deformities)
• Neuromuscular problems
(ataxia, muscle injury)
7. Etiology
• Toddler: 1-3 Years Old
• □ Toddlers’ Fracture
• □ Transient Synovitis
• □ Septic Arthritis
• □ Developmental Dysplasia of the Hip
• □ Leg-length discrepancy
11. Questions to ask
• Onset, Duration and Progression
• History of Trauma
• Constitutional symptoms
• Diurnal variation of pain
• Family history
• Nutritional history
• Daily activity level
12. Examination
• Inspection
• proper exposure
• Look for muscle bulk
• Swelling & erythema
• Deformities
• Asymmetries of the trunk, hips, and lower extremities
• Gait
• Measure Leg Lengths
• Assess the spine
13. • Antalgic Gait: less time spent in stance phase of the
affected limb
• Trendelenburg Gait: the pelvis tilts away from the
pathologic hip during stance on the ipsilateral side
• Steppage Gait: foot drop due to injury to the peroneal
nerve or weakness of the tibialis anterior muscle
.
• Toe-walking gait: leg length discrepancy,short Achilles
tendons, behavioral phenomenon.
14. Approach to antalgic gait
• Painful limp
• Trauma
1. Abnormal radiographs
(fracture, slipped capital femoral epiphysis)
2. Normal radiographs
contusion, sprain, muscle injury
22. imaging
• Begin with standard radiographs
• Children too young to localize pain or give a reliable
history, the entire lower legs should be imaged
• Initial radiographs may be normal in children with stress
fractures, toddler’s fracture, Legg disease, osteomyelitis,
or septic arthritis.
23. imaging
• Frog-leg lateral radiograph of a patient with slipped capital
femoral epiphysis. Note the slip in the patient’s right hip
(arrow) compared with the normal left hip.
24. Ultrasound
• Sensitive for detecting effusion in the hip joint
• Ultrasound-guided aspiration
• Hip dislocation in neonatal period
25. Magnetic resonance imaging
• Excellent visualization of joints, soft tissues, cartilage, and
medullary bone
Sensitivity and specificity
Osteomyelitis, malignancies, identifying stress fractures,
slipped capital femoral
27. Prehospital Care
• Splinting and transportation make up the majority of
services that prehospital personnel render to a limping
patient.
28. Emergency care
• Relief of acute pain
• Identification of the cause
• Referral to the appropriate health care professional
• Reduction of dislocations and displaced fractures
• Suspected osteomyelitis, diskitis, or septic joint,
intravenous antibiotics
• Immobilization
30. Further Outpatient Care
• All children with a limp should have close follow-up visits
with their pediatrician or primary care physician within 24
hours of their visit. Any persistence of a limp without
cause should be investigated further.
31. Complications
• Left untreated, a slipped capital femoral epiphysis can
result in permanent gait abnormalities
• Necrosis of femoral head
• Early treatment of several disorders that may cause
limping can result in resolution or at least limit the extent
of the injury
• Prognosis depends on underlying cause
