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2. Acute painful limp in children
Dr Sayed nasser Mostafavi
15/8/1392

3. Case 1
A 2 year old girl brought to emergency department with chief complaint of inability to walking and standing.
What's the common causes?
What's the emergency causes?
What's the major clues in history, physical examination, and para clinic evaluations?
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4. Common causes of limp in children
Painful limp(short stance phase on the affected limb, point tenderness, normal neurologic exam):
Bone: fracture, osteomyelitis, tumors
Joints: septic arthritis, toxic synovitis of hip, brucellosis, serum sickness, henoch-schoenline purpura, acute rheumatic fever
Muscles: trauma, viral myositis
Non-painful limp(Toe-to-heel sequence of gait):
guilain barre syndrom, transverse myelitis
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5. Emergency causes of limp in children
Painful limp:
Bone: fracture, osteomyelitis, tumors, cycle cell crisis,
Joints: septic arthritis, brucellosis, serum sickness, Henoch-Schonlein purpura, acute rheumatic fever, acute rheumatic fever, Hemarthrosis, Slipped capital femoral epiphysis, Legg-Calvé-Perthes disease
Intra-abdominal: Appendicitis, psoas abscess, testicular torsion
Non-painful limp:
Neurological: Guillain-Barré Syndrome, transverse myelitis, botulism
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6. Major clues in diagnosis of acute limp 1
Fracture, contusion, hemarthrosis
History of trauma immediately before limp, X ray with or without local tenderness
Septic arthritis
Fever, quite painful mono-arthritis, usually ↑ ESR
Osteomyelitis
local bone tenderness + fever or ↑ ESR
Tumors(Leukemia and neuroblastoma, bone tumors)
Bone pain/ sometimes arthritis which wake the child from sleep, Hepatosplenomegaly, lymphadenopathy, cytopenia, ↑ ESR , prolonged fever
Acute rheumatic fever
Age 5-15 yr( 3-40), poly arthritis, heart murmur, jones criteria, ↑ASO, ↑ ESR
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7. Major clues in diagnosis of acute limp 2
Henoch-Schönlein purpura
Age 3-10 yr, palpable purpura, colicky abdominal pain, hematuria, proteinuria), large joint arthritis
Serum sickness-like illness
8-12 days after drug ingestion, large joint arthritis, urticaria or morbiliform rashes, fever
Brucellosis
consumption of unpasturized milk, splenomegaly, fever, large joint and sacroiliac arthritis, positive wright test,
Slipped capital femoral epiphysis
Age 8-15 yr, overweight boys, Mostly chronic sometimes acute severe hip pain, Increasing pain with activity, specific by X ray
Legg-Calvé-Perthes disease
Age 3-12 yr, male sex, Insidious onset, recurrent painless hip pain, often NL initial x ray then fragmentation
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8. Toddlers fracture
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11. Major clues in diagnosis of acute limp 3
Transient synovitis of the hip
Age 3-8 yr , Acute hip pain, Mild restriction of ROM, no or mild fever, NL or mild ↑ WBC and ESR, no or mild hip effusion, sometimes bilateral
Reactive arthritis
Quite painful mono- or poly- arthritis, large joint, no or mild fever and leukocytosis, sometimes ↑ ESR,
Viral myositis
Muscle pain during influenza infection, severe calf pain, ↑ CPK and LDH,
Viral arthritis
Mild and transient arthritis or arthralgia during viral infection( rubella, 5th disease, varicella, …
foreign bodies, plantar warts, or calluses from poorly fitting shoe
Localized pain at the soles of the feet
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12. Physical exam
Observation of the gait, asking the child to run, hop on one leg and then the other, walk on his or her heels and then toes
Through exam of the CNS, spine, peripheral nervous system, abdomen, external genitalia , hips, knees, ankle, and feet
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13. Major clues in diagnosis of acute limp 4
Abdominal tenderness, rebound, guarding, or a positive psoas sign
appendicitis
Painful, swollen testicle and loss of the cremasteric reflex
Testicular torsion
Inability to standing, ↓ muscle tone, ↓ DTR
guilain barre syndrom, transverse myelitis
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14. Para clinic evaluation
Indication
X ray
Usually all acute limp especially if trauma or localizing point
Hip sonography and AP and frog leg views x ray
Abnormal hip exam
Joint fluid aspiration
Monoarticular arthritis with fever
Wright test
Usually all arthritis in endemic areas
CBC, ESR, CRP
Usually all, Suspected infectious, malignancy, rheumatologic
ECG, throat culture, ASO
Suspected acute rheumatic fever
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15. Conclusion
Limp can be created by many osseus, infectious, soft tissue, abdominal, and neurological diseases
Limp can be caused by both benign and life-threatening conditions
The cause of limp usually can be determined by obtaining a careful history and physical examination.
Radiographic and laboratory studies often are necessary to confirm clinical suspicions but diagnostic procedures rarely are required.
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16. Conclusion
Fever and history of trauma is two key factor in finding the cause of limping
Most cases had benign and self limited conditions and can be followed by NSAIDS and follow up
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