Limping Child

A limp is an abnormal gait pattern, as a result of pain, weakness or deformity of the musculoskeletal system.

It is useful to assess the child by considering common presenting conditions at each age group.

• Toddler (1 - 4 years)
• Child (4 - 10 years)
• Adolescent (10 - 16 years)
  

At all ages the following MUST be considered

• TRAUMA
• TUMOUR
• INFECTION

Type of Limp:

The gait has two phases - stance phase and swing phase.

• Antalgic gait - the stance phase is shortened and the patient hurries off the painful side.
• Trendelenburg gait - is due to weakness of the hip abductor muscles and the body tends to lurch to the affected side. The lurching gait may be unilateral or bilateral. If the condition is bilateral, waddling is seen, with the trunk swaying from side to side. The causes may involve an abnormal hip joint such as in developmental dysplasia of the hip, congenital coxa vara or Perthes’ disease. It may also be caused by muscle weakness such as in polio, cerebral palsy or spina bifida.
• Stiff knee gait - is characterised by loss of knee motion resulting in circumduction and pelvic elevation on the affected side during the swing phase. This may be caused by knee disorders to minimise the motion of a painful knee.
• Short-leg gait - the head and pelvis fall as the body weight is taken on the short leg. This may be difficult to detect if the discrepancy is less than 2 cm. The gait may be disguised by tilting of the pelvis and by holding the ankle of the short leg in a plantar flexed position. To compensate for difference in leg lengths, circumduction of the leg on the long side may occur instead. A heel raise corrects the gait.

Common Causes of Limping in Children:
Toddler (1 - 4 years)

• Developmental - Developmental dysplasia of the hip,Perthes disease
• Infection - Osteomyelitis, Septic arthritis
• Inflammatory - Irritable hip (transient synovitis)
• Trauma - Accidental or non-accidental
• Tumour - Ewing's sarcoma, Secondaries
• Neurological - Cerebral palsy

Child (4 - 10 years)

• Developmental - Perthes disease
• Infection - Osteomyelitis, Septic arthritis
• Inflammatory - Juvenile rheumatoid arthritis, Irritable hip (transient synovitis)
• Trauma - Accidental or non-accidental
• Tumour - Ewing's sarcoma, Secondaries

Adolescent (10 - 16 years)

• Developmental - Residual effects from childhood and toddler conditions, Tarsal coalition, Slipped upper femoral epiphysis (SUFE)
• Infection - Osteomyelitis, Septic arthritis
• Inflammatory - Juvenile rheumatoid arthritis, Irritable hip (transient synovitis)
• Trauma - Accidental ( sport related )
  
• Tumour - Osteosarcoma

Clinical Assessment:
History including antenatal, perinatal and postnatal history, developemental history, trauma and features of infection
Examination:

• Gait
• Walk on toes and heel
• Trendelenburg test
• Spine examination
• An assessment of leg lengths can be determined by palpating the anterior superior iliac spines or the posterior superior iliac spines. If there is any significant tilting of the pelvis, level the pelvis by placing an appropriate height block under the foot on the short side.
• The hip, knee and ankle joints are examined and a neurological assessment is undertaken.