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the limping child

all ages:

  • trauma:
    • fracture
    • occult growth plate trauma - esp. distal fibula
    • haemarthrosis - usually underlying intra-articular fracture
  • foreign body:
    • esp. feet/knees eg. occult sewing needles, rose thorns (either may be intra-articular!!)
  • new shoes, local foot painful lesions (eg. paronychia, bunions, warts, insect bites)
  • haemarthrosis due to haemophilia (males)
  • septic arthritis
  • osteomyelitis (usually in metaphyses of long bones if haematogenous)
  • discitis
  • tumor - musculoskeletal, spinal, leukaemia, neuroblastoma (infants)
  • reactive arthritis: eg. urticaria, erythema multiforme, serum sickness, post-infectious, Henoch-Schonlein purpura (HSP)
  • rheumatic fever
  • juvenile chronic arthritis
  • haemoglobinopathy (eg. sickle cell crisis)
  • long-standing, congenital, birth or genetic lesions:
    • cerebral palsy
    • spina bifida
    • cong. dislocation hip
    • muscular dystrophy
    • talipes (eg. Charcot-Marie-Tooth peroneal atrophy)
    • severe scoliosis
    • referred pain from back to hips/thighs & from hip to knees!!!
    • thus examine spine, sacro-iliac joints too!!


  • toddler's fracture tibia:
    • often no history of trauma although Hx of tripping over is common
    • usually non-tender but will not weight bear
    • classically only seen on one view of xrays - often faint spiral # mid-tibia
    • Rx AKPOP 3wks if # evident, otherwise consider re-XR in 10 days looking for periosteal reaction
  • other commonly missed, common fractures lower limbs:
    • base or necks of 2nd-4th MTs
    • greenstick fractures: femoral shaft, upper tibial metaphysis
    • occult fractures:
      • only evident on XR 10days later & even then only if not growth plate injury
  • “irritable hip” / “viral” synovitis hip:
    • usually lasts several days
    • pain/spasm on int/ext. rotation of hip
    • Mx:
      • XR hips to exclude other pathology (trauma, early-onset Perthe's, cong. dislocation hip)
      • consider US hips:
        • not usually needed if Dx of irritable hip clinically obvious
        • reserve for cases where hard to localise pain in lower limb
      • FBE, ESR, CRP, BC if suspicion of sepsis (eg. fever, malaise or unwell)
      • if sepsis/trauma excluded then non-wt bear until better, regular review (eg. daily) to watch for evidence of sepsis.
      • consider avoiding analgesics if child is then likely to run around!

school age:

  • commonly missed, common fractures lower limbs:
    • base or necks of 2nd-4th MTs
    • greenstick fractures: femoral shaft, upper tibial metaphysis
  • benign hypermobility syndrome:
    • esp. if recurrent pattern
    • usually 1-4 week cycles of episodic, nocturnal, post-activity, bilateral, ill-defined pain of lower extremities
  • Perthe's disease (avascular necrosis femoral head):
    • initially unilateral, early xray changes may be subtle
    • usually 5-9yr olds but may have onset at 3-4yrs age


  • slipped femoral epiphysis:
    • extremely important not to miss as needs early internal fixation & non-wt bearing pre-op
    • classically in obese boys 10-15yrs age but can occur in in thin girls 9yrs old!
    • often presents as knee pain!!
  • other commonly missed, common fractures lower limbs:
    • base 5th MT (don't confuse with epiphysis which is longitudinal not transverse line)
    • avulsion tibial spines (assume in all adolescents who have acute haemarthrosis knee after falling off bikes or motorbikes, until proven otherwise)
  • patello-femoral pain / chondromalacia (esp. in females)
  • Osgood-Schlatters disease:
    • over-use osteochondritide of tibial tuberosity
  • other osteochondritidies:
    • often follows minor trauma
    • sweaty, tender, mottled, cold skin
  • rarely:
    • Reiter's syndrome
    • Gonococcal arthritis
limp_paed.txt · Last modified: 2009/09/10 11:37 by

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