Pediatric emergency medicine trisk 0900 0900
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The extensive differential diagnosis of the child with a limp may be approached
from several angles: disease category, location of pathology, or age of the child.
Table 46.1 presents the differential diagnosis by disease category; Table 46.2
organizes the differential diagnosis by age and the location of pathology. This
section reviews the differential diagnosis within the framework of an algorithmic
approach ( Fig. 46.1 ).
The most common cause of limping in all ages is trauma, either acute or
repetitive microtrauma (e.g., stress fractures). Older children who limp as a result
of trauma can generally describe the mechanism of injury and localize pain well.
The toddler and preschool age groups, with their limited verbal ability and
cooperation skills, often provide a diagnostic challenge. A common type of injury
in this population (often not witnessed) is the aptly named “toddler’s fracture,” a
nondisplaced spiral fracture of the tibial shaft that occurs as a result of torsion of
the foot relative to the tibia. Occult fractures of the bones in the foot also occur in
young children. Initial plain radiographic findings may be subtle, or at times
nonexistent, but will become apparent in 1 to 2 weeks. Another fracture often
lacking initial radiographic confirmation is a Salter–Harris type I fracture, which
presents as tenderness over a physis after trauma to a joint area. Stress fractures
may also lack overt radiographic findings. Common sites for overuse injury
include the tibial tubercle (Osgood–Schlatter disease), the anterior tibia (shin
splints), and the calcaneus at the insertion of the Achilles tendon (Sever disease).
More information on the subject of fractures is found in Chapter 111
Musculoskeletal Trauma .
Trauma may also induce limping as a result of soft tissue injury. Although
young children are more likely to sustain fractures than sprains and strains, the
latter can occur. Joint swelling and pain out of proportion to the history of injury
raises the possibility of a hemarthrosis as the initial presentation of a bleeding
disorder (see Chapter 93 Hematologic Emergencies ). Severe soft tissue pain and
swelling in the setting of a contusion or crush injury suggests possible
compartment syndrome. With compartment syndrome, pain is exacerbated by
passive extension of the affected part; pallor and pulselessness are late findings.
Severe pain of an entire limb out of proportion to the history of injury suggests
complex regional pain syndrome. In pediatrics, this entity is most common in
young adolescent girls. It may be accompanied by mottling and coolness of the
extremity, presumably as a result of abnormalities in the peripheral sympathetic
nervous system.
A limp that is accompanied by a history of fever or recent systemic illness is
likely to be infectious or inflammatory in origin. However, the absence of fever
