Pediatric emergency medicine trisk 0899 0899
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CHAPTER 46 ■ LIMP
SUSANNE KOST, AMY D. THOMPSON
INTRODUCTION
Limping is a common complaint in the pediatric acute care setting. A limp is
defined as an alteration in the normal walking pattern for the child’s age. The
average child begins to walk between 12 and 18 months of age with a broadbased gait, gradually maturing into a normal (adult) gait pattern by the age of 3
years. A normal gait cycle can be divided into two phases: stance and swing. The
stance phase, the time from the heel striking the ground to the toe leaving the
ground, encompasses about 60% of the gait cycle. The swing phase involves a
sequence of hip then knee flexion, followed by foot dorsiflexion and knee
extension as the heel strikes the ground to begin the next cycle.
The causes of limping are numerous, ranging from trivial to life threatening,
but most children who limp do so as a result of pain, weakness, or deformity. Pain
results in an antalgic gait pattern with a shortened stance phase. The most
common causes of a painful limp are trauma and infection. Neuromuscular
disease may cause either spasticity (e.g., toe-walking) or weakness, which results
in a steppage gait to compensate for weak ankle dorsiflexion. Ataxia may be
interpreted by parents as a limp. A Trendelenburg gait is characterized by the
torso swinging back and forth to compensate for a pelvic tilt due to weak hip
abductors or hip deformities. A vaulting gait may be seen in children with limblength discrepancy or abnormal knee mobility. A stooped, shuffling gait is
common in patients with pelvic or lower abdominal pain.
The evaluation of a child with a limp demands a thorough history and physical
examination. A detailed history of the circumstances surrounding the limp should
be obtained, with focus on the issues of trauma, pain, and associated fever or
systemic illness. The physical examination must be complete because limping
may originate from abnormalities in any portion of the lower extremity, nervous
system, abdomen, or genitourinary tract. The location of the pain may not
represent the source of the pathology, for example, hip pain may be referred to the
knee area. Laboratory and imaging studies should be tailored to the findings in
the history and physical examination, keeping in mind an appropriate age-based
differential diagnosis.
DIFFERENTIAL DIAGNOSIS
