Limp

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Limp
Limping
Specialty Neurology, pediatrics, orthopedics

A limp is a type of asymmetric abnormality of the gait. Limping may be caused by pain, weakness, neuromuscular imbalance, or a skeletal deformity. The most common underlying cause of a painful limp is physical trauma; however, in the absence of trauma, other serious causes, such as septic arthritis or slipped capital femoral epiphysis, may be present. The diagnostic approach involves ruling out potentially serious causes via the use of X-rays, blood tests, and sometimes joint aspiration. Initial treatment involves pain management. A limp is the presenting problem in about 4% of children who visit hospital emergency departments. [1]

Contents

Definition

A limp is a type of asymmetric abnormality of the gait. When due to pain it is referred to as an antalgic gait, in which the foot is in contact with the ground for a shorter duration than usual; in severe cases there may be a refusal to walk. [2] Hip deformities with associated muscular weakness, on the other hand, may be present with a Trendelenburg gait, with the body shifted over the affected hip. [2]

Differential diagnosis

The causes of limping are many and can be either serious or non-serious. It usually results from pain, weakness, neuromuscular imbalance, or a skeletal deformity. [2] In 30% of cases, the underlying cause remains unknown after appropriate investigations. [2] The most common underlying cause of limping in children is minor physical trauma. In those with no history of trauma, 40% are due to transient synovitis and 2% are from Legg–Calvé–Perthes syndrome. [3] Other important causes are infectious arthritis, osteomyelitis, and slipped capital femoral epiphysis in children. [4] [5]

Infection

Septic arthritis

Septic arthritis can be difficult to separate from less serious conditions such as transient synovitis. Factors that can help indicate septic arthritis rather than synovitis include a WBC count greater than 12×109/l, fever greater than 38.5 °C (101.3 °F), ESR greater than 40 mm/h, CRP greater than 2.0 mg/dL, and refusal to walk. [6] People with septic arthritis usually look clinically toxic or sick. [7] Even in the absence of any of these factors, however, septic arthritis may be present. [8] Joint aspiration is required to confirm the diagnosis. [8]

Other

Other infections that classically lead to a limp include Lyme disease (a bacterial infection spread by deer ticks) and osteomyelitis (an infection of the bone). [9]

Mechanical

Trauma

Accidental or deliberate physical trauma may result in either a fracture, muscle bruising, or a contusion. [9] It is the leading cause of a limp. [2] Deliberate abuse is important to consider.

Slipped capital femoral epiphysis

Slipped capital femoral epiphysis (SCFE) is a condition in which the growth plate of the head of the femur slips over the underlying bone. It most commonly presents with hip pain in males during puberty and is associated with obesity. [2] The majority of people affected have a painful limp and in half of cases both hips are affected. [2] Nearly a quarter of people present with only knee pain. [9] Treatment involves non-weight-bearing movement and surgery. [2] If not identified early, osteonecrosis or death of the head of the femur may occur. [9]

Other

A non-painful limp may be due to a number of mechanical conditions including hip dysplasia and leg length differences. [9]

Inflammatory

Transient synovitis

Transient synovitis is a reactive arthritis of the hip of unknown cause. [2] People are usually able to walk and may have a low grade fever. [2] They usually look clinically nontoxic or otherwise healthy. [7] It may only be diagnosed once all other potential serious causes are excluded. With symptomatic care it usually resolves over one week. [2]

Juvenile rheumatoid arthritis

Juvenile rheumatoid arthritis presents gradually with early morning stiffness, fatigue, and weight loss. [7]

Vascular

Legg–Calvé–Perthes syndrome

Legg–Calvé–Perthes syndrome is a degenerative disease of the head of the femur which results in bone loss and deformity. It usually presents as a chronic condition. [9]

Neoplastic

Cancers including acute lymphocytic leukemia, osteosarcoma, and Ewing’s sarcoma may result in a gradual onset of limping in children. It is often associated with night sweating, easy bruising, weight loss, and pain most prominent at night. [7] [9]

Diagnostic approach

The diagnosis of the cause of a limp is often made based on history, physical exam findings, laboratory tests, and radiological examination. If a limp is associated with pain it should be urgently investigated, while non-painful limps can be approached and investigated more gradually. [7] Young children have difficulty determining the location of leg pain, thus in this population, knee pain equals hip pain. [9] SCFE can usually be excluded by an x-ray of the hips. [2] An ultrasound or x-ray guided aspiration of the hip joint maybe required to rule out an infectious process within the hip. [2]

Epidemiology

A limp at one hospital emergency department was the presenting complaint in 4% of children. [1] It occurs twice as commonly in boys as in girls. [3]

Related Research Articles

<span class="mw-page-title-main">Legg–Calvé–Perthes disease</span> Osteochondrosis that results in death and fracture located in hip joint

Legg–Calvé–Perthes disease (LCPD) is a childhood hip disorder initiated by a disruption of blood flow to the head of the femur. Due to the lack of blood flow, the bone dies and stops growing. Over time, healing occurs by new blood vessels infiltrating the dead bone and removing the necrotic bone which leads to a loss of bone mass and a weakening of the femoral head.

<span class="mw-page-title-main">Canine hip dysplasia</span> Joint abnormality in dogs

In dogs, hip dysplasia is an abnormal formation of the hip socket that, in its more severe form, can eventually cause lameness and arthritis of the joints. It is a genetic (polygenic) trait that is affected by environmental factors. It is common in many dog breeds, particularly the larger breeds, and is the most common single cause of arthritis of the hips.

An osteotomy is a surgical operation whereby a bone is cut to shorten or lengthen it or to change its alignment. It is sometimes performed to correct a hallux valgus, or to straighten a bone that has healed crookedly following a fracture. It is also used to correct a coxa vara, genu valgum, and genu varum. The operation is done under a general anaesthetic.

<span class="mw-page-title-main">Coxa vara</span> Deformity of the hip

Coxa vara is a deformity of the hip, whereby the angle between the head and the shaft of the femur is reduced to less than 120 degrees. This results in the leg being shortened and the development of a limp. It may be congenital and is commonly caused by injury, such as a fracture. It can also occur when the bone tissue in the neck of the femur is softer than normal, causing it to bend under the weight of the body. This may either be congenital or the result of a bone disorder. The most common cause of coxa vara is either congenital or developmental. Other common causes include metabolic bone diseases, post-Perthes deformity, osteomyelitis, and post traumatic. Shepherd's Crook deformity is a severe form of coxa vara where the proximal femur is severely deformed with a reduction in the neck shaft angle beyond 90 degrees. It is most commonly a sequela of osteogenesis imperfecta, Paget's disease, osteomyelitis, tumour and tumour-like conditions.

<span class="mw-page-title-main">Septic arthritis</span> Inflammation of a joint due to infection

Acute septic arthritis, infectious arthritis, suppurative arthritis, pyogenic arthritis, osteomyelitis, or joint infection is the invasion of a joint by an infectious agent resulting in joint inflammation. Generally speaking, symptoms typically include redness, heat and pain in a single joint associated with a decreased ability to move the joint. Onset is usually rapid. Other symptoms may include fever, weakness and headache. Occasionally, more than one joint may be involved, especially in neonates, younger children and immunocompromised individuals. In neonates, infants during the first year of life, and toddlers, the signs and symptoms of septic arthritis can be deceptive and mimic other infectious and non-infectious disorders.

<span class="mw-page-title-main">Genu valgum</span> Abnormal inward turning of the knees when straightening the legs

Genu valgum, commonly called "knock-knee", is a condition in which the knees angle in and touch each other when the legs are straightened. Individuals with severe valgus deformities are typically unable to touch their feet together while simultaneously straightening the legs. The term originates from Latin genu 'knee' and valgus 'bent outwards', but is also used to describe the distal portion of the knee joint which bends outwards and thus the proximal portion seems to be bent inwards.

<span class="mw-page-title-main">Genu varum</span> Varus deformity marked by (outward) bowing at the knee

Genu varum is a varus deformity marked by (outward) bowing at the knee, which means that the lower leg is angled inward (medially) in relation to the thigh's axis, giving the limb overall the appearance of an archer's bow. Usually medial angulation of both lower limb bones is involved.

<span class="mw-page-title-main">Proximal femoral focal deficiency</span> Medical condition

Proximal femoral focal deficiency (PFFD), also known as Congenital Femoral Deficiency (CFD), is a rare, non-hereditary birth defect that affects the pelvis, particularly the hip bone, and the proximal femur. The disorder may affect one side or both, with the hip being deformed and the leg shortened.

<span class="mw-page-title-main">Slipped capital femoral epiphysis</span> Medical condition

Slipped capital femoral epiphysis is a medical term referring to a fracture through the growth plate (physis), which results in slippage of the overlying end of the femur (metaphysis).

<span class="mw-page-title-main">Synovitis</span> Inflammation of the synovial membrane within a joint

Synovitis is the medical term for inflammation of the synovial membrane. This membrane lines joints that possess cavities, known as synovial joints. The condition is usually painful, particularly when the joint is moved. The joint usually swells due to synovial fluid collection.

<span class="mw-page-title-main">Femoral head ostectomy</span> Surgical removal of the head and neck of the femur

A femoral head ostectomy is a surgical operation to remove the head and neck from the femur. It is performed to alleviate pain, and is a salvage procedure, reserved for condition where pain can not be alleviated in any other way. It is common in veterinary surgery. Other names are excision arthroplasty of the femoral head and neck, Girdlestone's operation, Girdlestone procedure, and femoral head and neck ostectomy.

<span class="mw-page-title-main">Transient synovitis</span> Inflammation of the inner lining (synovium) of the hip joint capsule

Transient synovitis of hip is a self-limiting condition in which there is an inflammation of the inner lining of the capsule of the hip joint. The term irritable hip refers to the syndrome of acute hip pain, joint stiffness, limp or non-weightbearing, indicative of an underlying condition such as transient synovitis or orthopedic infections. In everyday clinical practice however, irritable hip is commonly used as a synonym for transient synovitis. It should not be confused with sciatica, a condition describing hip and lower back pain much more common to adults than transient synovitis but with similar signs and symptoms.

Protrusio acetabuli is an uncommon defect of the acetabulum, the socket that receives the femoral head to make the hip joint. The hip bone of the pelvic bone/girdle is composed of three bones, the ilium, the ischium and the pubis. In protrusio deformity, there is medial displacement of the femoral head in that the medial aspect of the femoral cortex is medial to the ilioischial line. The socket is too deep and may protrude into the pelvis.

An antalgic gait is a gait that develops as a way to avoid pain while walking. It is a form of gait abnormality where the stance phase of gait is abnormally shortened relative to the swing phase. It is a good indication of weight-bearing pain.

<span class="mw-page-title-main">Pigeon toe</span> Medical condition affecting the feet

Pigeon toe, also known as in-toeing, is a condition which causes the toes to point inward when walking. It is most common in infants and children under two years of age and, when not the result of simple muscle weakness, normally arises from underlying conditions, such as a twisted shin bone or an excessive anteversion resulting in the twisting of the thigh bone when the front part of a person's foot is turned in.

<span class="mw-page-title-main">Index of trauma and orthopaedics articles</span>

Orthopedic surgery is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal injuries, sports injuries, degenerative diseases, infections, bone tumours, and congenital limb deformities. Trauma surgery and traumatology is a sub-specialty dealing with the operative management of fractures, major trauma and the multiply-injured patient.

The Kocher criteria are a tool useful in the differentiation of septic arthritis from transient synovitis in the child with a painful hip. They are named for Mininder S. Kocher, an orthopaedic surgeon at Boston Children's Hospital and Professor of Orthopaedic Surgery at Harvard Medical School.

<span class="mw-page-title-main">Klein's line</span> Medical condition

Klein's line or the line of Klein is a virtual line that can be drawn on an X-ray of an adolescent's hip parallel to the anatomically upper edge of the femoral neck. It was the first tool to aid in the early diagnosis of a slipped capital femoral epiphysis (SCFE), which if treated late or left untreated leads to crippling arthritis, leg length discrepancy and lost range of motion. It is named after the American orthopedic surgeon Armin Klein at Harvard University, who published its description and usefulness in 1952. Subsequent modification of its use has increased the sensitivity and reliability of the tool.

<span class="mw-page-title-main">Hip pain</span>

Pain in the hip is the experience of pain in the muscles or joints in the hip/ pelvic region, a condition commonly arising from any of a number of factors. Sometimes it is closely associated with lower back pain.

Bone malrotation refers to the situation that results when a bone heals out of rotational alignment from another bone, or part of bone. It often occurs as the result of a surgical complication after a fracture where intramedullary nailing (IMN) occurs, especially in the femur and tibial bones, but can also occur genetically at birth. The severity of this complication is often neglected due to its complexity to detect and treat, yet if left untreated, bone malrotation can significantly impact regular bodily functioning, and even lead to severe arthritis. Detection throughout history has become more advanced and accurate, ranging from clinical assessment to ultrasounds to CT scans. Treatment can include an osteotomy, a major surgical procedure where bones are cut and realigned correctly, or compensatory methods, where individuals learn to externally or internally rotate their limb to compensate for the rotation. Further research is currently being examined in this area to reduce occurrences of malrotation, including detailed computer navigation to improve visual accuracy during surgery.

References

  1. 1 2 Singer JI (March 1985). "The cause of gait disturbance in 425 pediatric patients". Pediatr Emerg Care. 1 (1): 7–10. doi:10.1097/00006565-198503000-00003. PMID   3843430. S2CID   1198461.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 Laine JC, Kaiser SP, Diab M (February 2010). "High-risk pediatric orthopedic pitfalls". Emerg. Med. Clin. North Am. 28 (1): 85–102, viii. doi:10.1016/j.emc.2009.09.008. PMID   19945600.
  3. 1 2 Fischer SU, Beattie TF (November 1999). "The limping child: epidemiology, assessment and outcome". J Bone Joint Surg Br. 81 (6): 1029–34. doi:10.1302/0301-620X.81B6.9607. PMID   10615981. S2CID   2141675.
  4. ↑ "Septic Arthritis & Osteomyelitis". www.pmmonline.org. Retrieved 21 October 2024.
  5. ↑ "Slipped Capital Femoral Epiphysis (SCFE)". MSD Manual Professional Edition. Retrieved 21 October 2024.
  6. ↑ Kocher MS, Mandiga R, Zurakowski D, Barnewolt C, Kasser JR (August 2004). "Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children". J Bone Joint Surg Am. 86-A (8): 1629–35. doi:10.2106/00004623-200408000-00005. PMID   15292409.
  7. 1 2 3 4 5 Sawyer JR, Kapoor M (February 2009). "The limping child: a systematic approach to diagnosis". Am Fam Physician. 79 (3): 215–24. PMID   19202969.
  8. 1 2 Caird MS, Flynn JM, Leung YL, Millman JE, D'Italia JG, Dormans JP (June 2006). "Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study". J Bone Joint Surg Am. 88 (6): 1251–7. doi:10.2106/JBJS.E.00216. PMID   16757758.
  9. 1 2 3 4 5 6 7 8 Frick SL (April 2006). "Evaluation of the child who has hip pain". Orthop. Clin. North Am. 37 (2): 133–40, v. doi:10.1016/j.ocl.2005.12.003. PMID   16638444.
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