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Editors
Limp or Refusal to Walk in Children
Essentials
- Limping is a deviation from the normal gait pattern.
- Limping may be caused by pain, weakness, restricted joint movement or deformity.
- The doctor should be able to suspect the condition and refer for further emergency investigations children with a bacterial infection of the bones or joints, leukaemia or malignant tumours, hip epiphysiolysis or suspected physical abuse.
History
- How did limping start?
- Suddenly/gradually
- After injury/exercise
- When does limping occur?
- General symptoms
- Fever (bacterial infection)
- Weight loss, nocturnal sweating (malignancies)
- Preceding respiratory/intestinal infection (reactive arthritis)
- Pain at rest
- Painless limp
- Mild normal variation in childhood growth and development (genu valgum, genu valgum, low plantar arch, walking with the feet turned inward) does not generally cause or explain limping.
Clinical examination
- Clinical examination must be carried out in a systematic way.
- Small children cannot localise pain.
- Referred pain is common (hip joint problems in particular are typically felt as pain in the thigh or knee).
- The history given by parents may be misleading.
- The systematic approach should always include
- examining small children in particular in their underwear
- an examination of the back and a bilateral examination of hips, knees, lower legs and feet regardless of the site of the pain.
- Small children should first be allowed to play freely in the examination room while you observe how they move.
- During the actual examination, depending on the child's age, the child can either be held by a parent or on the examination table.
- The symptomatic limb should be examined last.
- The child should be asked to walk (including on the toes and on the heels) and to squat.
- When limping, the child will try to reduce the heel strike by lowering the foot with the ball of the foot first and make sure that their weight will be on the painful leg as briefly as possible.
- The Trendelenburg sign is positive if the pelvis tilts towards the symptomatic limb (Image 1).
- When the weight is on the healthy limb
- An abnormal Trendelenburg's test result 1 is suggestive of hip pathology or weakened muscle power in the pelvic region.
- Inability to walk on the toes or heels is suggestive of foot pain, limited range of motion or reduced muscle power. The child may compensate for the difference in length of their lower limbs by standing on the toes of the shorter limb.
- Spinal mobility and postural defects (scoliosis Scoliosis and Kyphosis) can be checked by inspecting the back from behind as the child bends forward. Any limb length discrepancy should be noted at the same time.
- Limb examination
- Muscle atrophy
- Local swelling/masses
- Intra-articular effusion, redness and heat
- Signs of injury
- Foreign bodies in the sole of the foot
- Ranges of joint motion (comparing the symptomatic side to the healthy side)
Further investigations
- If the child has no general symptoms and there are no abnormal findings, the situation can be monitored.
- If there are any abnormal findings in the above examinations, x-ray examination of the symptomatic area is indicated.
- Ultrasonography can be used to examine hip joint effusion, soft tissue lesions and any foreign bodies in particular.
- Clear joint swelling or restricted joint movement in the absence of abnormal x-ray findings suggests arthritis Articular Status of a Child with Arthritic Symptoms Arthritis in Children.
Arrangement of care
- Patients treated in primary care
- Emergency referral to specialized care
- Child with general and joint or bone symptoms
- Urgent referral to specialized care
References
- Payares-Lizano M. The Limping Child. Pediatr Clin North Am 2020;67(1):119-138 [PubMed]
- Bartoloni A, Aparisi Gómez MP, Cirillo M, et al. Imaging of the limping child. Eur J Radiol 2018;109():155-170 [PubMed]