A Systematic Approach to the Evaluation of a Limping Child

 

Am Fam Physician. 2015 Nov 15;92(10):908-918.

Author disclosure: No relevant financial affiliations.

A limp is defined as a deviation from a normal age-appropriate gait pattern resulting in an uneven, jerky, or laborious gait. It can be caused by pain, weakness, or deformity as a result of a variety of conditions. Transient synovitis is the most common diagnosis. Other causes of acute limp include contusion, foreign body in the foot, fracture, osteomyelitis, septic arthritis, reactive arthritis, and Lyme arthritis. Causes of chronic limp include rheumatic disease, dermatomyositis, acute rheumatic fever, inflammatory bowel disease, and systemic lupus erythematosus. Evaluation of a limping child should begin with a history focused on identifying pain, trauma, and associated systemic symptoms. For a limping child with focal findings on physical examination, initial imaging includes anteroposterior and lateral radiography of the involved site. If there are no focal findings on physical examination, radiography of both lower extremities should be performed. Laboratory testing is guided by history and physical examination findings. Septic arthritis of the hip should be suspected in a child with an oral temperature more than 101.3°F (38.5°C), refusal to bear weight, erythrocyte sedimentation rate more than 40 mm per hour, peripheral white blood cell count more than 12,000 per mm3 (12 × 109 per L), or C-reactive protein level more than 20 mg per L (180.96 nmol per L).

A limp, which is a deviation from a normal age-appropriate gait pattern resulting in an uneven, jerky, or laborious gait, can be caused by pain, weakness, or deformity as a result of a variety of conditions. The exact incidence of limping in children is unknown. One study of children younger than 14 years presenting to an emergency department with an acute atraumatic limp reported an incidence of 1.8 per 1,000 children, a male-to-female ratio of 1.7:1, and a median age of 4.4 years.1 The right and left limbs were nearly equally involved, and 80% of the children reported pain. Transient synovitis was the most common diagnosis. Other common causes of acute limp include contusion, foreign body in the foot, fracture, osteomyelitis, septic arthritis, reactive arthritis, and Lyme arthritis. Common causes of chronic limp include rheumatic disease, dermatomyositis, acute rheumatic fever, inflammatory bowel disease, and systemic lupus erythematosus.

A systematic approach to the evaluation of the limping child can reduce the overall time patients spend in the acute care setting, ensure that only appropriate testing is performed, and increase the likelihood of a correct diagnosis.2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In a child with a limp and no localized pathology on clinical examination, plain radiography of both lower extremities should be performed.

C

14

If localized pathology is suggested on clinical examination, anteroposterior and lateral radiography of the affected areas should be performed.

C

14

Ultrasonography is recommended over plain radiography for detecting hip effusions because of its high sensitivity.

C

14

Bone scintigraphy is recommended for detecting underlying pathology when history, physical examination,

C

6, 14

The following clinical features make septic arthritis more likely than transient synovitis: oral temperature more than 101.3°F (38.5°C), refusal to bear weight on the affected leg, erythrocyte sedimentation rate more than 40 mm per hour, peripheral white blood cell count more than 12,000 per mm3 (12 × 109 per L), or C-reactive protein level more than 20 mg per L (180.96 nmol per L).

C

6, 11, 22, 23


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In a child with a limp and no localized pathology on clinical examination, plain radiography of both lower extremities should be performed.

C

14

If localized pathology is suggested on clinical examination, anteroposterior and lateral radiography of the affected areas should be performed.

C

14

Ultrasonography is recommended over plain radiography for detecting hip effusions because of its high sensitivity.

C

14

Bone scintigraphy is recommended for detecting underlying pathology when history, physical examination,

C

6, 14

The following clinical features make septic arthritis more likely than transient synovitis: oral temperature more than 101.3°F (38.5°C), refusal to bear weight on the affected leg, erythrocyte sedimentation rate more than 40 mm per hour, peripheral white blood cell count more than 12,000 per mm3 (12 × 109 per L), or C-reactive protein level more than 20 mg per L (180.96 nmol per L).

C

6, 11, 22, 23


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C =

The Authors

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SAMEER NARANJE, MD, is an orthopedic surgeon at Forrest City (Ark.) Medical Center....

DEREK M. KELLY, MD, is a pediatric orthopedic surgeon. He is an associate professor of orthopedic surgery at the University of Tennessee–Campbell Clinic in Memphis and director of the Orthopedic Newborn Clinic at Le Bonheur Children's Hospital in Memphis.

JEFFREY R. SAWYER, MD, is a pediatric orthopedic surgeon. He is a professor of orthopedic surgery at the University of Tennessee–Campbell Clinic and a staff member at Le Bonheur Children's Hospital and St. Jude's Children's Hospital in Memphis.

Author disclosure: No relevant financial affiliations.

Address correspondence to Jeffrey R. Sawyer, MD, University of Tennessee–Campbell Clinic, 1211 Union Ave., Ste. 510, Memphis, TN 38104 (e-mail: jsawyer@campbellclinic.com). Reprints are not available from the authors.

REFERENCES

show all references

1. Fischer SU, Beattie TF. The limping child: epidemiology, assessment and outcome. J Bone Joint Surg Br. 1999;81(6):1029–1034....

2. McCanny PJ, McCoy S, Grant T, Walsh S, O'Sullivan R. Implementation of an evidence based guideline reduces blood tests and length of stay for the limping child in a paediatric emergency department. Emerg Med J. 2013;30(1):19–23.

3. Chambers HG, Sutherland DH. A practical guide to gait analysis. J Am Acad Orthop Surg. 2002;10(3):222–231.

4. Sutherland DH, Olshen R, Cooper L, Woo SL. The development of mature gait. J Bone Joint Surg Am. 1980;62(3):336–353.

5. Delaney RA, Lenehan B, O'Sullivan L, McGuinness AJ, Street JT. The limping child: an algorithm to outrule musculoskeletal sepsis. Ir J Med Sci. 2007;176(3):181–187.

6. Flynn JM, Widmann RF. The limping child: evaluation and diagnosis. J Am Acad Orthop Surg. 2001;9(2):89–98.

7. Oestreich AE, Bhojwani N. Stress fractures of ankle and wrist in childhood: nature and frequency. Pediatr Radiol. 2010;40(8):1387–1389.

8. Peck D. Slipped capital femoral epiphysis: diagnosis and management. Am Fam Physician. 2010;82(3):258–262.

9. Herman MJ, Martinek M. The limping child. Pediatr Rev. 2015;36(5):184–195.

10. Krul M, van der Wouden JC, Schellevis FG, van Suijlekom-Smit LW, Koes BW. Acute non-traumatic hip pathology in children: incidence and presentation in family practice. Fam Pract. 2010;27(2):166–170.

11. Sawyer JR, Kapoor M. The limping child: a systematic approach to diagnosis. Am Fam Physician. 2009;79(3):215–224.

12. Kodner C, Wetherton A. Diagnosis and management of physical abuse in children. Am Fam Physician. 2013;88(10):669–675.

13. Storer SK, Skaggs DL. Developmental dysplasia of the hip. Am Fam Physician. 2006;74(8):1310–1316.

14. Milla SS, Coley BD, Karmazyn B, et al. ACR Appropriateness Criteria limping child—ages 0 to 5 years. J Am Coll Radiol. 2012;9(8):545–553.

15. Liberman B, Herman A, Schindler A, Sherr-Lurie N, Ganel A, Givon U. The value of hip aspiration in pediatric transient synovitis. J Pediatr Orthop. 2013;33(2):124–127.

16. Kwack KS, Cho JH, Lee JH, Cho JH, Oh KK, Kim SY. 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(2):437–445.

17. Yang WJ, Im SA, Lim GY, et al. MR imaging of transient synovitis: differentiation from septic arthritis. Pediatr Radiol. 2006;36(11):1154–1158.

18. White PM, Boyd J, Beattie TF, Hurst M, Hendry GM. Magnetic resonance imaging as the primary imaging modality in children presenting with acute non-traumatic hip pain. Emerg Med J. 2001;18(1):25–29.

19. Ishibashi Y, Okamura Y, Otsuka H, Nishizawa K, Sasaki T, Toh S. Comparison of scintigraphy and magnetic resonance imaging for stress injuries of bone. Clin J Sport Med. 2002;12(2):79–84.

20. Aronsson DD, Loder RT, Breur GJ, Weinstein SL. Slipped capital femoral epiphysis: current concepts. J Am Acad Orthop Surg. 2006;14(12):666–679.

21. Futami T, Suzuki S, Seto Y, Kashiwagi N. Sequential magnetic resonance imaging in slipped capital femoral epiphysis: assessment of preslip in the contralateral hip. J Pediatr Orthop B. 2001;10(4):298–303.

22. 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(9):1289–1293.

23. 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(11):1556–1561.

24. Fernandez M, Carrol CL, Baker CJ. Discitis and vertebral osteomyelitis in children: an 18-year review. Pediatrics. 2000;105(6):1299–1304.

25. An HS, Seldomridge JA. Spinal infections: diagnostic tests and imaging studies. Clin Orthop Relat Res. 2006;444:27–33.

26. Jones OY, Spencer CH, Bowyer SL, Dent PB, Gottlieb BS, Rabinovich CE. A multicenter case-control study on predictive factors distinguishing childhood leukemia from juvenile rheumatoid arthritis. Pediatrics. 2006;117(5):e840–e844.

27. Song J, Letts M, Monson R. Differentiation of psoas muscle abscess from septic arthritis of the hip in children. Clin Orthop Relat Res. 2001;(391):258–265.


 

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