The Limping Child (Case 21)

Chapter 52 The Limping Child (Case 21)



Christopher P. Raab, MD




Case


Parents report their 3-year-old child has a new limp.




Differential Diagnosis













Trauma Slipped capital femoral epiphysis (SCFE) Child abuse
Acute osteomyelitis Transient synovitis Septic arthritis


Speaking Intelligently


My first step in evaluating a limping child is a comprehensive history and examination, including ascertaining if the limp is painful. Duration of symptoms allows distinction between congenital and acquired problems. For a febrile or ill-appearing child, I order blood work including complete blood count (CBC), sedimentation rate, and C-reactive protein (CRP) to check for evidence of infection or inflammation. For suspected trauma, a radiograph is obtained to assess for fracture, whereas bone scan or magnetic resonance imaging (MRI) may help localize a lesion of uncertain location. Well-appearing children with painful, nontraumatic limps are often difficult cases. Diagnoses such as transient synovitis can usually be suggested by history and examination alone.



Patient Care



Clinical Thinking



• Do symptoms require immediate evaluation and treatment?

• Is prompt surgical intervention needed for possible SCFE, compound fracture, or septic joint?

• Is there concern for physical abuse?


History



• Is the limp painful?

• Fever and limp in an otherwise healthy child suggest an infection such as osteomyelitis or septic arthritis or possibly a rheumatic disease such as juvenile idiopathic arthritis (JIA)

• Inquire about trauma to suggest fracture, sprain, contusion, or SCFE.

• Inquire about recent viral illness to suggest transient synovitis.

• Inquire about additional systemic symptoms.

• Inquire about history of tick bite.

• Inquire about family history of rheumatologic disease.


Physical Examination



• Elevated heart rate and blood pressure may be secondary to pain.

• Although limp is generally of lower extremity origin, a complete examination is required.

• An older child may be able to pinpoint the site of pain with a single digit.

• Lower extremity pain can be referred from one joint to another (e.g., knee pain may indicate hip pathology).

• Each joint should be assessed for effusion and range of motion.

• Palpate all bony surfaces and prominences.

• Check for bruising, tenderness, or lesions. Some rashes are associated with specific disorders such as erythema migrans and Lyme disease.

• Muscle atrophy and/or weakness occur with neurologic processes.

• Abdominal pathology can present with limp.

• Gait analysis is done preferably over a long hallway. Gait has two major phases: stance and swing.
• With an antalgic gait, the stance phase is shortened, signifying pain.

• With a Trendelenburg gait, the pelvis drops during the swing phase signifying gluteal medius weakness or paralysis. It is associated with hip pathology such as Legg-Calvé-Perthes disease and developmental dysplasia of the hip (DDH).

• With a stiff gait, there is decreased pelvic rotation and a rigid trunk, typically signifying spinal pathology.

• With a spastic gait, there may be toe walking without heel strike caused by increased tone; increased adductor tone can result in a “scissor” gait.


Tests for Consideration



• CBC: Elevated white count in infection; anemia in systemic diseases such as malignancy or rheumatic disease; platelet elevation as an acute phase reactant $116

• Erythrocyte sedimentation rate (ESR): For inflammation $85

• CRP: For inflammation $69

• Lyme titers: If joint effusion $180

• Parvovirus B19 titers: If joint effusion $437

• Synovial fluid:
• Synovial fluid cell count, Gram stain $105

• Synovial fluid Lyme titers $180

• Synovial culture $152

• Blood culture: If ill appearing $152

• Antinuclear antibodies (ANA): If concern for rheumatic disorder $334

• Lactate dehydrogenase (LDH) and alkaline phosphatase: If concern for bone malignancy $140


Imaging Considerations


→ Plain radiographs: These are obtained first. Radiologic evidence of fracture or osteomyelitis may lag behind the clinical picture. Plain films assess fractures, joint pathology, and benign or malignant bony lesions. Include one joint above and below suspected site, 2 view AP and lateral (cost depending on anatomic location). $200-300


→ Technetium-99 bone scintigraphy (bone anatomic location): To assess inflammatory or infectious processes when lesion site is unknown. Cost varies by anatomical location. $1100 (leg)


→ MRI: The most specific tool to assess bony lesions. Cost varies by anatomical location. $1100 (leg)

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Related posts:

  1. The Special Needs Child
  2. Newborn Hearing Screen (Case 22)
  3. Pediatric Poisonings (Case 54)
  4. Note Writing

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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on The Limping Child (Case 21)

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