Overview
Definition:
A limp is an abnormal gait characterized by uneven weight bearing, altered stride length, or decreased mobility in one or more limbs, often indicative of an underlying orthopedic, rheumatologic, neurologic, or systemic condition.
Epidemiology:
Limping is a common pediatric complaint, with incidence varying by age group and etiology
Transient synovitis is the most frequent cause in toddlers, while trauma and infection are significant contributors across all ages
Developmental abnormalities are more prevalent in infants.
Clinical Significance:
Prompt and accurate diagnosis of a limping child is crucial to differentiate benign, self-limiting conditions from serious pathologies like septic arthritis or osteomyelitis that can lead to irreversible joint damage, limb deformities, and long-term morbidity if not treated urgently
It is a high-yield topic for DNB and NEET SS examinations.
Age Considerations
Infants 0 1 Year:
Focus on congenital conditions like developmental dysplasia of the hip (DDH), arthrogryposis, and neuromuscular disorders
Trauma and infection are also important considerations.
Toddlers 1 3 Years:
Transient synovitis is highly prevalent
Septic arthritis, osteomyelitis, trauma (fractures, sprains), and Legg-Calve-Perthes disease are key differentials.
Preschoolers 3 6 Years:
Similar to toddlers, with increased incidence of trauma, Legg-Calve-Perthes disease, and early signs of juvenile idiopathic arthritis (JIA)
Slipped capital femoral epiphysis (SCFE) begins to emerge.
School Aged Children 6 12 Years:
SCFE becomes more common
JIA, Osgood-Schlatter disease, stress fractures, and recurrent trauma are important considerations
Tumor-related causes, though rare, should be considered.
Adolescents 12 18 Years:
SCFE is a significant concern
Osgood-Schlatter disease, Sever's disease, stress fractures, JIA, and infection remain relevant
Tumor surveillance is essential.
Diagnostic Approach
History Taking:
Detailed history should include: Onset (sudden vs
insidious)
Duration
Associated symptoms (fever, pain, swelling, rash, malaise)
Mechanism of injury (if any)
Previous episodes
Gait pattern description (antalgic, Trendelenburg)
Red flags: fever, refusal to bear weight, severe pain, decreased range of motion, signs of systemic illness.
Physical Examination:
Systematic examination: Observation of gait (if possible)
Palpation for warmth, tenderness, swelling
Assessment of range of motion (active and passive) of hip, knee, ankle, and foot
Leg length discrepancy
Examination of spine
Assess for erythema nodosum, joint effusions, muscle atrophy
Check neurovascular status.
Investigations:
Initial investigations: Complete blood count (CBC) with differential, Erythrocyte Sedimentation Rate (ESR), C-reactive protein (CRP) to assess for inflammation/infection
Radiographs (AP and lateral of affected limb, pelvis/hip views) to detect fractures, dislocations, bony abnormalities, effusions
Ultrasound of hip for effusion, synovitis, DDH
MRI for soft tissue injury, osteomyelitis, tumors, intra-articular pathology
Bone scan for occult fractures or osteomyelitis.
Differential Diagnosis:
Age-specific differentials: Infants: DDH, septic arthritis, osteomyelitis, trauma
Toddlers/Preschoolers: Transient synovitis, septic arthritis, osteomyelitis, Legg-Calve-Perthes disease, trauma
School-aged/Adolescents: SCFE, Osgood-Schlatter, JIA, stress fractures, tumors, trauma.
Clinical Presentation
Transient Synovitis:
Usually toddlers, following a viral illness
Sudden onset limp, hip pain (often anterior thigh/groin), decreased hip abduction and external rotation
Afebrile or low-grade fever
ESR/CRP usually mildly elevated.
Septic Arthritis:
Acute onset, severe pain, fever, refusal to bear weight
Swollen, warm, tender joint (hip most common)
Marked restriction of passive movement
Elevated WBC, ESR, CRP
Joint aspiration crucial for diagnosis.
Osteomyelitis:
Fever, localized bone pain, tenderness, swelling, erythema
Limp and refusal to bear weight
Subacute presentation possible
Elevated inflammatory markers
Radiographs may be normal early
bone scan or MRI diagnostic.
Legg Calve Perthes Disease:
Insidious onset limp, hip/groin/thigh/knee pain, often worse with activity
Age 4-8 years
Restricted abduction and internal rotation
Radiographs show flattened femoral head, fragmentation, widening of joint space.
Slipped Capital Femoral Epiphysis Scfe:
Adolescents, often obese
Insidious onset limp, hip/groin/thigh pain, external rotation deformity
Affected leg may appear shorter
Diagnosis confirmed by X-ray showing slippage of femoral epiphysis.
Management
Initial Management:
Assess for red flags: fever, septic signs, severe pain, inability to bear weight
Stabilize if trauma is suspected
Initial pain management
Urgent referral to orthopedic specialist if septic arthritis or SCFE suspected.
Medical Management:
For transient synovitis: rest, NSAIDs (e.g., Ibuprofen 5-10 mg/kg/dose TDS)
For JIA: NSAIDs, disease-modifying antirheumatic drugs (DMARDs), corticosteroids
For osteomyelitis: IV antibiotics (e.g., Vancomycin/Clindamycin pending culture).
Surgical Management:
Septic arthritis: urgent joint aspiration and irrigation/drainage
SCFE: surgical pinning in situ
DDH: casting, bracing, or surgery depending on severity and age
Fractures: casting, splinting, or surgical fixation
Tumors: biopsy and oncologic resection.
Supportive Care:
Pain control, physiotherapy for range of motion and strengthening exercises, crutches/wheelchair as needed, follow-up imaging and clinical assessment to monitor progress and detect complications.
Complications
Early Complications:
Joint damage from infection or delayed treatment
Deformity from SCFE or untreated DDH
Compartment syndrome from trauma
Significant pain and functional impairment.
Late Complications:
Chronic pain
Osteoarthritis
Leg length discrepancy
Stiffness
Limp recurrence
Functional disability
Avascular necrosis of femoral head (Perthes, SCFE).
Prevention Strategies:
Prompt recognition of red flags
Urgent evaluation for suspected infections or SCFE
Adherence to treatment protocols
Appropriate rehabilitation and physiotherapy
Close follow-up.
Key Points
Exam Focus:
Always consider septic arthritis and osteomyelitis in a febrile child who refuses to bear weight
SCFE is an emergency in adolescents
Transient synovitis is a diagnosis of exclusion.
Clinical Pearls:
A limp in a child under 3 years old warrants careful evaluation for DDH
The Trendelenburg gait suggests hip abductor weakness (e.g., SCFE, LCP, neuromuscular)
Always perform a complete orthopedic examination, including contralateral limb.
Common Mistakes:
Attributing all limps to minor trauma without adequate investigation
Delaying referral for suspected septic arthritis or SCFE
Misinterpreting X-rays in early stages of bone conditions
Inadequate follow-up leading to missed complications.