PEDBASE.org - The Pediatric Database - Detailed information of LIMP

LIMP

DEFINITION:

Pathologic alteration of the smooth, regular gait pattern.

EPIDEMIOLOGY:

incidence: ?
age of onset:
- childhood
risk factors:
- see differential diagnosis

DIFFERENTIAL DIAGNOSIS:

1. Spine

cystic astrocytoma
discitis
infections
spondylolisthesis
spondylolysis
stress fracture
tumor

2. Hip

Congenital Dislocation of the Hip
Legg-Calve-Perthes Disease
Slipped Capital Femoral Epiphysis (SCFE)
Epiphyseal Dysplasias
- Multiple Epiphyseal Dysplasia
- Spondyloepiphyseal Dysplasia

3. Knee (Overuse)

apophysitis
osteochondroses
- Osgood-Schlatter Disease, Osteochondritis Dissecans
patellar subluxation

4. Joints

trauma - foreign body, hemarthroses (SCD), stress
inflammatory - JRA, collagen vascular disease, SLE
synovitis - transient or reactive
- infectious (septic arthritis) - viral, TB, rheumatic fever, Lyme Disease
osteochondroses - Scheuermann's Disease (spine)
- Kohler's Disease (heel)
- Freiberg's Disease (metatarsal head)

5. Bone

trauma - fracture (shin splints), periostitis, Gaucher Disease
tumors - benign - cysts, eosinophillic granulosa, osteochondroma, osteoid osteoma, neurofibroma
malignant metastases - Ewing sarcoma, osteosarcoma, leukemia, lymphoma, neuroblastoma

6. Muscular

trauma - contusions and sprains
diseases - Muscular Dystrophy, Myopathies, Polymyositis
tendonitis

HISTORY:

age ( <5 years - CDH; 5-7 years - LCPD; toxic synovitis; adolescence - SCFE)
trauma, vigorous activity (stress #)
type of limp: antalgic, Trendelenburg
trunk, pelvis, knee, ankle involved
interfere with day to day activity
sudden vs gradual intermittent vs continuous morning vs evening season (spring)
pain (referred)

Note: First priority is to rule out conditions requiring immediate management: trauma, pyarthrosis, osteomyelitis, neoplasm, SCFE.

PHYSICAL:

1. Observe

two phases: stance and swing
four components: trunk, hips, knees, ankles
accentuate limp: on toes, heels, stairs, running
foot wear: signs/areas of wear and tear

2. Listen

slapping
scraping (spastic gait)
quick and soft (antalgic gait)

3. Examine

complete musculoskeletal exam
- joints - range of motion
- limb lengths and widths
- Thomas Test - fixes pelvis to spine for examining hip
- Anterior Cruciate - Lockman, Drawer, Pivot Shift
complete neurologic exam

CLINICAL FEATURES:

1. Gait

1. Normal

stance and swing phases

2. Abnormal

1. Antalgic Gait

short stance phase due to painful extremity

2. Pelvis

1. Trendelenburg Gait

gluteus medius weakness (hip abductor)
positive is contralateral hip drops down during stance phase with shift in trunk towards the weak side

2. Gluteus Maximus Limp

gluteus maximus weakness
hyperextension of the trunk over hips to maintain centre of gravity posteriorly over the hip joint - DMD, spinal muscular dystrophy

3. Knee

1. Stiff

circumduct - elevate pelvis and swing of leg outward

2. Quadriceps Femoris Limp

back-kneeing (lock) with hiking of opposite pelvis to "vault" up onto stair
prevents/interferes with stair climbing

4. Ankle

steppage gait
- lack of dorsiflexion with slap (foot hangs down)
"club" gait
- lack of plantarflexion
stiff ankle gait
- external rotation of foot
toe walking gait
- spasticity/contracture of gastroc/soleus
calcaneous gait
- excessive dorsiflexion

INVESTIGATIONS:

1. First Line

1. Imaging Studies

1. Skeletal X-Rays

hips, knees, femur

2. Serum

ZSR, CBC with differential

3. Joint

aspiration

2. Second Line

1. Imaging Studies

bone scan - neoplasms, avascular necrosis (LPD, sickle cell)

2. Serum

blood culture

MANAGEMENT:

1. Supportive

treat underlying disorder

Pediatric Database - LIMP

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