Limp

Limp
Leah Harrington
Introduction
  • Common presentation to emergency department
  • May be difficult to localize source of pain (e.g., hip pain may be referred to knee)
  • Young children often not able to localize pain
Table 41.1 Motor Development Milestones

10-12 mo

Cruising: walks holding onto stationary objects for support

12-18 mo

Walks independently

36 mo

Mature walking pattern

Table 41.2 Common Abnormal Gaits

Antalgic

Shortened stance phase gait associated with pain (e.g., septic hip, transient synovitis, fracture)

Trendelenburg

Side lurching gait, trunk shifts toward and pelvis tilts away from painful or weak extremity, decreasing force transmitted through extremity (e.g., congenital hip dislocation, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis)

History
  • Age: diagnosis by age groups—see Table 41.3
  • Onset of pain: sudden vs insidious
  • Duration of pain: intermittent vs constant
  • Quality of pain: severe vs mild
  • Location of pain: reproducible/localizable, referred pain common
  • History of trauma: accidental vs nonaccidental
    • Often not witnessed
    • Does trauma mechanism match development abilities?
  • Constitutional symptoms: fever, weight loss, night sweats, malaise (neoplasms and rheumatologic infections)
Physical Examination
  • General: vital signs, adenopathy, organomegaly, skin changes
  • Stance: pelvic tilt, scoliosis, knee flexion, leg asymmetry, rotation of foot
  • Gait: shortened stance phase, antalgic, Trendelenburg, slap foot
  • Muscle strength: Trendelenburg test children > 3 yrs, school age heel-toe walk
  • Passive/active limitation of range of motion or pain
  • Measure leg length discrepancy, calf and thigh diameter
  • Neurovascular exam: reflexes, sensation, tone, power
Table 41.3 Differential Diagnoses by Age

BIRTH-2 YEARS

2-10 YEARS

10-18 YEARS

Septic arthritis

Septic arthritis

Fractures

Toddler’s fracture (spiral fracture of tibia in ambulating child)

Transient synovitis

Slipped capital femoral Epiphysis (SCFE)

Osteomyelitis

Osteomyelitis

Osteomyelitis

Congenital hip dislocation

Legg-Calvé-Perthes

Patellofemoral problems

Nonaccidental trauma

Juvenile idiopathic arthritis

Tumors

Leukemia

Sickle cell crisis

Fractures

Sickle cell crisis

Table 41.4 Differential Diagnoses: Systems Approach

INFECTIOUS

MUSCULOSKELETAL

INFLAMMATORY

HEMATOLOGICAL

NEUROMUSCULAR

Osteomyelitis

Child abuse

JRA

Sickle cell crisis

Guillain-Barré

Septic arthritis

SCFE

Myositis

Hemophilia

Tick paralysis

Cellulitis

CHD

Transient synovitis

Leukemia

Discitis

Fractures

Abscess

Neoplasms

CNS infections

Appendicitis

Epididymitis

Specific Conditions
Transient Synovitis
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Jun 22, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Limp

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