5 Tips for Evaluating the Limping Child

A limping child can be one of the most stressful diagnostic dilemmas in clinical practice. While many conditions that produce a limp are fleeting and/or benign, you don’t want to miss some serious conditions that may have major consequences if diagnosis is delayed.  

Here are 5 tips to consider when evaluating the limping child either in the outpatient or emergency department setting.

1.  Obtain a good history and develop a thorough differential diagnosis.
Take the time to obtain a thorough history from both the caregivers and the patient (as able). 
  • Is there a history of trauma? Think about a fracture / soft tissue injury
  • Is the limp most pronounced in the morning with stiffness/swelling? Consider rheumatologic disease
  • Is there a preceding illness? Consider transient synovitis.
  • Has the child had known tick bites?  Think about Lyme disease.
  • Is the child “sick?” Think about myositis, osteomyelitis and/or septic arthritis. 
  • Are there constitutional symptoms and/or night pain?  Consider oncologic processes.
  • Has the limp been present since age of walking? Think hip dislocation, leg length difference
  • Does the child have a history of prematurity? Think hemiplegia or neurologic condition
2.  Perform a physical examination (in proper attire) and watch the kid walk!
Be sure to examine the entire child, including the spine.  Obtain vital signs to evaluate for (and document) the presence of a fever. Ensure that the patient is in proper attire (shorts +/- gown) so that you can evaluate the entire limb for effusions, deformity, masses, or skin changes.   Take each major joint through a full range of motion and evaluate for contractures, asymmetry, or induced pain compared to the uninvolved limb.  Palpate entire limb for areas of tenderness.  Perform detailed neurologic exam looking for weakness, abnormal tone or signs of spasticity.  In younger children, do not forget a Gower’s test to evaluate for proximal weakness that could indicate a muscular dystrophy.
Watch the patient walk in shorts up and down a long hallway several times from multiple views.  Not all limps are noticeable right away.  Have the child walk for a long time as fatigue may accentuate a limp.  Also have the child run as this can accentuate gait abnormalities as well.  Inspect the position of each joint during the gait cycle which may give clues to the etiology of the limp. 

3. Knee pain? Don't forget the hip!
Hip pathology in children may present exclusively as knee pain. If your knee exam and imaging are normal, consider getting hip/pelvis x-rays to rule out hip pathology such as a slipped capital femoral epiphysis (SCFE) Perthes Disease, or hip dysplasia.

4. Growing Pains? 
While a child with growth related pains may have intermittent limping associated with painful episodes, a limp is not the typical presentation.  If a child is limping, look for another reason.

5.  Plan to regroup
If x-rays and laboratory studies are initially normal and the child otherwise appears well, plan a repeat evaluation in 1-2 weeks.  If indicated based on examination, repeat x-rays may show callus in a child with a non-displaced fracture or bony changes consistent with osteomyelitis that are not apparent for 7-10 days after onset of symptoms.  If a limp persists or worsens, advanced imaging and/or additional laboratory testing may be warranted based on your clinical judgement.   
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