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

Tags:
Jun 22, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Limp

Full access? Get Clinical Tree
Get Clinical Tree app for offline access