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Saturday, October 6, 2012

The Limping Child

A limp in children is a fairly common problem that has many causes.  Many of these causes are not dangerous, but all limping children should be evaluated by a health care provider to be sure there isn't anything more serious requiring treatment.  Our office has recently seen a surge of limping kids from various causes, so I thought I'd review many of them here. They are in order of body location, but symptoms of all may include a limp. This list is not comprehensive... although it is long, there are other causes I have left off. I have linked many of the causes to more information, just click on the diagnosis name.

limp


Fever, weight loss, poor feeding, or night sweats suggest infection or malignancy and should be evaluated as soon as possible. History of trauma of course increases the likelihood of traumatic injury and if stable, can wait overnight to avoid an ER trip, but if any gaping open skin, excessive bleeding, disfigurement, or excessive pain warrants immediate evaluation and treatment.

Hips:

Developmental dysplasia of the hip involves the abnormal formation of the hip socket and a flattening of the top of the thigh bone (femur).  Babies who are born breech, especially females, are at increased risk. Family history and some genetic conditions also can show a predisposition to this condition. All babies are routinely screened with a hip check during their physical exam until they are well into walking. Sometimes even with a shallow hip socket the exam can appear normal, so high risk infants are often sent for hip ultrasounds (sonograms) or x-ray (if over 6 months). If this condition is recognized, these babies should be treated by a pediatric orthopedic surgeon. 

Transient synovitis (also called toxic synovitis) is found in children 3-10 years of age. It typically follows an infection. They have pain in the hip and don't want to move the hip in its full range of motion. It self-resolves in about a week. Non-steroidal anti-inflammatory medications can help with the pain. Although it resolves without treatment, a thorough physical exam by a medical provider is important to evaluate for other causes. 

Septic arthritis, on the other hand, is an acute infection of the hip joint. This is a very serious condition because without treatment the hip joint (or other affected joints) is destroyed by the infection.  Several bacteria can cause this type of infection, so culture of the pus is obtained and antibiotics are required. Classically these infants and children hold their leg at a flexed position and don't want to move the leg. This helps reduce the pain by giving the hip joint as much open space for the pus to decrease the pressure and relieve the pain.

Legg-Calve-Perthes disease is found in males more than females, typically 4-10 years of age. It is usually on one side, and results from an interrupted blood supply to the top of the femur (thigh bone). This leads to a flattening of the top of the femur and cysts in the bone. Physical therapy, casting, traction, or surgical correction are various treatment options, depending on age and severity. Pediatric orthopedists are consulted to manage the treatment of this process.

Slipped capital femoral epiphysis (SCFE) tends to occur in early teen years, males more than females, and obese children are at increased risk. It often happens in both hips and is caused by pressure on the growth plate at the top of the femur (thigh bone).  Pain can be felt at the hip, thigh, or knee. It can be sudden or gradual. It requires surgery to pin the top of the bone (above the growth plate) in line with the rest of the bone, so pediatric orthopedists are consulted to treat this condition.

Knees:

Osgood-Schlatter disease is fairly common in athletic teens. Knee pain is caused from traction on the growth plate on the tibia (one of the shin bones). Pain is felt directly below the knee at the top of the shin bone. Many people have a boney bump that doesn't hurt after growth is complete and the growth plate is no longer present. Rest, ice, and non-steroidal anti-inflammatories are the treatment.  Unfortunately symptoms can last for several years until growth is complete, but it is not a concerning process for overall bone health. 

Sprains involve stretched or torn ligaments. Often a popping sound is heard at the time of injury and pain is immediate. Swelling from fluid behind the kneecap is common. The knee can seem unstable and weight bearing is painful.  Strains are a tear of the muscle or tendon. Symptoms are similar to sprains but also involve bruising. For more information on both sprains and strains see KidsHealth.

Tendonitis is an inflammed tendon. It is a common overuse injury. Pain or tenderness with movement of the joint or walking is noted. Rest, ice, wraps, elevation of the leg, and anti inflammatory medications can help. Physical therapy to strengthen muscles to support the knee is recommended for most of these overuse injuries, but surgery is sometimes required.

Meniscal tears are common sports injuries from sudden change in speed or side to side movement. Tenderness, tightness, and swelling of the knee are noted. Initial treatment is the same as the tendonitis treatment above, but surgery is required for large tears.

Osteochondritis dessicans (OCD) occurs when a piece of bone or cartilage breaks off the bone and causes long-term knee pain. It often occurs with swelling, inability to extend the knee fully, stiff knee, and popping of the knee. Treatment involves casting and sometimes surgery.

Feet and Ankles:

Tarsal coalition is a condition where 2 or more bones are joined in the midfoot or hindfoot. Pain in the midfoot or a spastic or fixed flatfoot are symptoms. This is a congenital (birth) condition, but symptoms don't develop until late childhood or adolescence. It is sometimes found incidentally on xray for another issue. Conservative treatment involves splinting, and surgical correction is also available.

Plantar Fasciitis is pain in the bottom of the foot or heel pain. Tight calf muscles or Achilles tendons often are associated with this. It occurs in toe-walkers, overweight people, people who wear shoes without sufficient support, and athletes who fail to adequately stretch.  Stretching, non-steroidal anti-inflammatory medications, and heel inserts often help relieve pain. Physical therapy can be helpful.

Achilles Tendonitis is an overuse injury of the Achilles tendon. Runners and jumpers are often affected.  Pain tends to worsen with time, especially after running or jumping. It is treated with rest, ice, wrapping, elevation of the foot, anti-inflammatory medicines, stretching, and shoe inserts.

Sprained ankles are very common. They happen when the ligaments of the ankle get stretched.  Elevation of the foot, ice, non-steroidal anti-inflammatories, and rest help it heal. 

Bones:

Fractures (see also fractures) after injury are not always easily identifiable in young children who are not able to state what happened. Initial xrays might appear normal if there is only a subtle fracture. If limp persists, follow up xrays in one week can show signs of a healing fracture more readily than the initial fracture.

Overuse injuries and stress fractures are becomming more common as younger kids are getting into more highly competitive sports. X-rays may be normal or show mild changes. If history of training and pain/limp is consistent with stress fracture, MRI or bone scans might be required to show bone injury.

Bone tumors can originate in the bone or from other cancers metastasizing to the bone. Leukemia involves production of abnormal blood cells in the bone marrow, and leg pain is often a common finding. Bone pain, fracture from mild trauma, and other symptoms of the primary cancer are all presenting signs.

Leg length discrepancy can cause a limp that typically does not hurt. Most of these can be managed with shoe inserts to "lengthen" the short leg. Surgery is sometimes recommended.

Multiple joints:

Arthritis can affect a single or multiple joints. Morning stiffness that gradually lessens as the day progresses and the joint "warms up" is common. Swelling might be minimal or great. Family history is often a clue, but some kids have no family history of arthritis. Other symptoms, such as rash, fever, eye changes, are possible.

Abdominal and back issues: 

Constipation, appendicitis, abdominal muscle (psoas) abcess, tumors in the abdomen, inflammation of the disc spaces in the vertebral column, and tumors of the spinal cord are other possible causes of limp or refusal to walk. History and exam will help to identify these causes.

Muscles:

Hamstring strain happens when muscles in the back of the leg stretch and tear.  Sudden thigh pain, sometimes with a popping sensation and bruising, are symptoms. Treatment involves rest, ice, wrapping the muscle, elevation of the leg, and non-steroidal anti-inflammatory medications. 

Quadriceps contusion happens after a hit to the muscles of the thigh. Rest, ice, wraps, elevation of the leg, massage, and non-steroidal anti-inflammatories can help relieve pain. Physical therapy can be initiated when swelling is decreased. Slow return to sports is important to allow complete healing.

Post-viral myositis is muscle inflammation after an infection with a virus. Affected kids will have severe pain in the calf muscles, typically within a couple of days of a resolving viral illness (often influenza, but other viruses too). This is a condition that resolves over about 10 days, but medical providers should help with the evaluation of this to be sure the kidneys are not involved. If the urine is very dark it should be evaluated immediately.

And one more thing...

A cause of leg pain that doesn't cause limp is Growing Pains.

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