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ANSWERS TO CASE 37:
Limping in Children
Summary: A 12-year-old boy presents with
A limp and right knee pain
External rotation of the hip when passively flexed and pain on internal rotation of
the hip
No history of injury or trauma
Bearing weight more on his left leg than his right while walking
Overweight but well-appearing presentation
Most likely diagnosis: Stable slipped capital femoral epiphysis (SCFE).
Most appropriate test to order: Right hip x-ray with anteroposterior and frog leg
lateral views.
Complication that could occur: Avascular necrosis of the hip.
ANALYSIS
Objectives
1. Be able take a history and perform a physical examination for children with leg
pain and limping. (EPA 1, 2)
2. Be able to list common causes of leg pain and limping in children of different
ages. (EPA 2)
3. Be able to describe appropriate examination, laboratory, and radiologic evaluation for the limping child. (EPA 3)
Considerations
Leg pain is a common complaint in childhood. The most common causes of leg
pain in children are acute trauma (sprains, strains, contusions) or overuse injuries.
However, leg pain and limping can be a sign of a more serious, even life-threatening,
pathology. Learning an approach to the evaluation and the common diagnoses
involved may help in the identification of these problems earlier, when a better
outcome is more likely.
In the specific case presented, there are several symptoms and signs that make
the diagnosis of SCFE likely. The absence of a specific injury is significant, as SCFE
is the most common nontraumatic hip pathology in adolescents. The initial complaint of thigh pain may lead to other considerations, but hip pathology will fre-
quently present with pain in the groin, thigh, or even the knee. The patient’s age and
body habitus are typical for SCFE, which is classically described as occurring most
often in overweight adolescent males. Pain with internal rotation of the hip and the
finding of external rotation on passive flexion of the affected hip are also suggestive
of SCFE.
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APPROACH TO:
Limping in Children
DEFINITIONS
AVASCULAR NECROSIS: Death of living bone tissue caused by disruption of
blood flow.
DYSPLASIA: Abnormal growth or development.
CLINICAL APPROACH
Pathophysiology
There are many causes of limp with pain in children (Table 37–1). Some of the
more common causes may be broadly categorized as being primarily orthopedic,
reactive, infectious, rheumatologic, or neoplastic. The prevalence of the specific
diagnoses also varies by age. Limp without pain is usually due to congenital orthopedic anomalies or neuromuscular disorders.
Table 37–1 • COMMON CAUSES OF LIMP WITH PAIN IN CHILDREN
Orthopedic
• Fracture
• Stress fracture
• Pathologic fracture through tumor or cyst
• Sprain/strain/contusion
• Slipped capital femoral epiphysis
• Early Legg-Calvé-Perthes disease
Reactive
• Toxic synovitis
• Transient synovitis following viral infection
• Rheumatic fever
Infectious
• Septic arthritis
• Osteomyelitis
• Cellulitis
• Diskitis
• Gonococcal arthritis
Rheumatologic
• Juvenile rheumatoid arthritis
• Systemic lupus erythematosus
Tumor
• Benign tumors (osteoid osteoma, osteoblastoma)
• Ewing sarcoma
• Osteosarcoma
Other
• “Growing pains”
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To understand a limp, it is first important to understand the normal gait. Gait
is composed of two phases: the “swing” and the “stance” phases. The stance phase
is the weight-bearing phase. The swing phase is the non–weight-bearing phase,
when the foot lifts off the ground and is propelled forward. The antalgic gait
occurs when the stance phase of gait is shortened on the side of pain, usually because
of pain during weight-bearing. Antalgic gait is the most common type of limp and
is the type of gait described in this case.
Septic arthritis, fractures, neuromuscular disorders, and neoplasms can cause a
limp in children of all ages. Night sweats, anorexia, weight loss, and pain that awakens the child at night are suspicious for malignancy. “Growing pains” is a diagnosis
of exclusion. It should be considered if the pain is only at night, is bilateral, is not
present during the day, and if no other pathology is found.
Clinical Presentation
As always, the initial approach should include a good focused history and physical. The clinician should ask questions about recent trauma; onset and duration of
limp; and recent illnesses (viral, pharyngitis, rashes, tick bites, diarrhea, urethritis).
Past medical history, previous levels of function, and family history of musculoskeletal disorders can help with diagnosis. Associated symptoms of fever, weight loss,
anorexia, or pain are especially important.
Assessing Pain. A key characteristic in the evaluation of the child with a limp is
assessing whether there is pain or no pain. In an antalgic gait, the cause of the pain
may range from the back to the foot. Therefore, unless there is an obvious source of
pain, the examination should include assessment of the back, pelvis, buttock, leg,
and foot. In the child who clings to the parent, separating the child from the parent
will allow the clinician to observe the child’s gait when they walk back to the parent.
The child who walks stiffly may be avoiding moving the spine, indicating a possible
diskitis. Those with nonantalgic gait abnormalities (Trendelenburg gait [hip drop],
inability to dorsiflex the foot, locked knees, toe walking) can have congenital, neurologic, or limb length disorders. Inspecting the feet may show clawing of the toes
or cavus deformity, which are signs of neuromuscular conditions.
Hip Evaluation. Because hip pathology often presents with vague pain and hip
conditions are likely to need emergent treatment, evaluation of the hip may be the
most important part of the examination of a patient in whom the site of pathology is
not immediately obvious. Restricted internal rotation appears to be the most sensitive
marker of hip pathology in children, followed by a lack of abduction. Internal rotation
of the hip increases the intracapsular pressure within the acetabulum. Pain during a
leg roll and limited internal rotation of less than 30 degrees may indicate infectious
or orthopedic hip pathology. A leg roll is performed by having the child supine with
the hip and knee extended, and then one examiner stabilizes the pelvis while another
rolls the leg internally and externally. The FABER test (flexion, abduction, external
rotation—the ipsilateral ankle placed on the contralateral knee and mild downward
pressure placed on the ipsilateral knee) can find pathology located in the sacroiliac
joint, which is often seen in rheumatologic disorders. Bone pain or point tenderness
can indicate osteomyelitis or malignancy. Limps from overuse injuries of the foot (eg,
Sever disease) and knee disorders (eg, Osgood-Schlatter) can occur.
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Imaging and Laboratory Values. X-rays should be obtained when the differential indicates a likelihood of bony abnormalities. An ultrasound of the hip is more
sensitive for an effusion of the hip and can be considered. In nonverbal children,
x-rays from hip to feet can find a fracture in a significant number of children with
limp. A complete blood count (CBC) should be drawn if there is concern of an
infection, inflammatory arthritis, or malignancy. Erythrocyte sedimentation rate
(ESR) and C-reactive protein (CRP) levels should be considered in evaluating
infectious and rheumatologic etiologies. Consider Lyme disease in endemic areas,
as this can mimic both infectious and rheumatologic causes of hip disorders. If
there was recent pharyngitis, consider antistreptolysin titers. In teens with a history of urethritis or febrile diarrhea, consider urine chlamydial antigens or stool
cultures for possible Reiter syndrome. Any joint where septic arthritis is considered
should have a joint aspiration and evaluation of synovial fluid. Fever greater than
99.5 çF and ESR greater than 20 mm/hr is 97% sensitive for septic hip joint. Testing
of the fluid should include culture for gonorrhea in teens who are sexually active.
Limping Without Pain. The evaluation of limping without pain (Table 37–2)
should include measurements for leg length discrepancies (measure anterior supe-
rior iliac spine or umbilicus to medial malleolus) and observation for muscular atrophy or limb deformity. Barlow (hip and knee flexed 90 degrees, hold the knee and
attempt to displace the thigh posterior), Ortolani (guided abduction), and Galeazzi
(knee height discrepancy when patient lies supine with ankles to buttocks and hips
and knees flexed) tests can be used to assess for congenital hip abnormalities and
femoral length discrepancies.
Infants and Toddlers
Common causes of limping in children in the infant and toddler age group are septic
arthritis, fractures, and complications of congenital hip dysplasia. Septic arthritis
is usually monoarticular and associated with systemic signs such as fever. In young
infants, the symptoms may be less obvious, such as crying, irritability, and poor
feeding. Children who are ambulatory (crawlers or walkers) will often refuse to do
anything that puts weight on the affected joint because of pain. Infection of a joint
Table 37–2 • COMMON ORTHOPEDIC CAUSES OF LIMP WITHOUT PAIN
IN CHILDREN
Congenital dislocation (developmental dysplasia) of the hip
Spastic hemiplegia (cerebral palsy)
Legg-Calvé-Perthes (subacute and chronic)
Leg-length discrepancy
Proximal focal femoral dysplasia
Congenital short femur
Congenital bowing of the tibia
Data from Hay WW, Levin MJ, Sondheimer JM, et al, eds. Current Pediatric Diagnosis and Treatment. 15th ed. 2001.
Copyright © McGraw Hill LLC. All rights reserved; Leet AI, Skaggs DL. Evaluation of the acutely limping child. Am Fam
Physician. 2000;61:1011–1018; and Rudolph CD, Rudolph AM, Hostetter MK, eds. Rudolph’s Pediatrics. 21st ed. 2003.
Copyright © McGraw Hill LLC. All rights reserved.
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causes a septic effusion, which raises the pressure inside of the joint capsule. Children with a septic hip joint will often lay with their hip flexed, abducted, and externally
rotated, which helps to reduce the pain, and they will have significant pain with any
internal rotation or extension of the joint. Children with a septic joint will usually
have an elevated white blood cell (WBC) count, ESR, and CRP. Definitive diagnosis
comes from joint aspiration. Any suspected septic joint must be aspirated. In younger
infants (4 months or younger), group B Streptococcus and Staphylococcus aureus are
the most common pathogens involved. In older infants and children under the age
of 5 years, S. aureus and Streptococcus pyogenes are the usual causes. Treatment is
urgent surgical irrigation and debridement, along with antibiotics.
Unsuspected fractures—either stress fractures or traumatic fractures—can
present with pain and limping. Abuse must be suspected if the injury is inconsistent with the history presented, if the history changes with repeated questioning, if
the child is said to have performed an act outside of his or her developmental ability, or if a fracture usually associated with abuse is found (see Case 36). However,
the history may not reveal the source of the injury, as a child may fall outside of the
view of the parent (see Table 37–3). A traumatic injury may not result in limping
or in complete immobility, but it may cause a change in how the child ambulates. For
example, a child who previously walked and now refuses to walk but will crawl may
have an injury of the lower leg or foot.
A toddler’s fracture is one example of an unsuspected fracture that may present
primarily as a limp or a refusal to walk. This fracture is a spiral fracture of the tibia
that results from twisting while the foot is planted. The diagnosis may be suspected
in the setting of an acute limp or change in ambulation, a normal examination of
the knee and upper leg, and tenderness of the tibia. It can be confirmed with a plain
film x-ray.
Undiagnosed developmental dysplasia of the hip may present as a painless limp
that is present from the time that the child learns to walk. The American Academy
of Pediatrics recommends that newborns and infants up to age 12 months should
have their hips examined for instability or dislocation at well-child visits. If undiagnosed, contractures may form that limit movement of the hip. When the child
learns to walk, the child will have a painless limp. The diagnosis may be confirmed
by x-rays showing abnormal hip alignment. If the problem is found in the first few
weeks of life, the child can be treated with splinting of the hip, and normal development usually follows. If diagnosed late, the treatment is often surgical.
Table 37–3 • RED FLAGS REQUIRING IMMEDIATE THOROUGH
INVESTIGATION IN A CHILD WITH NONTRAUMATIC LIMP
Child < 3 years old
Child unable to bear weight
Fever in child with limp
Child with comorbid systemic illness
Child > 9 years old with pain or restricted hip movements
Data from Perry DC, Bruce C. Evaluating the child who presents with an acute limp. BMJ.2010;341:c4250. doi:10.1136/
bmj.c4250
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Young Children
Transient synovitis is a self-limited inflammatory response that is a common cause
of hip pain in children. It occurs typically in children ages 3 to 10 years, is more
common in boys than in girls, and often follows a viral infection. It is frequently
seen as gradually increasing hip pain that results in a limp or refusal to walk. These
children have a low-grade or no fever, a normal WBC count, and a normal ESR. On
examination, there is pain with internal rotation of the hip, and the overall range
of motion is limited by pain. X-rays either are normal or show some nonspecific
swelling.
In a situation where the patient is afebrile; has pain-free rotation of the hip
greater than 30 degrees; has a normal WBC count, normal ESR and CRP; and
short-term follow-up can be ensured, the patient can be followed clinically and
should improve in a few days. If these conditions are not met and the diagnosis of
a septic joint is considered or if a patient followed expectantly continues to worsen,
an aspiration should be done. Kocher criteria are often utilized to assess risk for
septic arthritis in children. The four criteria are fever > 101.3 °F (38.5 °C), non–
weight-bearing status, ESR > 40 mm/hr, and WBC count > 12,000 cells/mm3.
Zero criteria present equals < 0.2% risk, one criteria is 3%, two criteria present
is 40%, three criteria present is 93%, and four criteria present is almost a 100%
chance of septic arthritis. A septic joint will have a purulent aspirate with a WBC
count greater than 50,000 cells/mm3; transient synovitis will have a yellow/clear aspirate with a lower WBC count (< 10,000 cells/mm3).
Legg-Calvé-Perthes (LCP) disease is an avascular necrosis of the femoral head
that typically occurs in children ages 4 to 8 years. It is much more common in
boys than in girls. Any disruption of blood flow to the femoral capital epiphysis,
such as trauma or infection, may cause avascular necrosis. In LCP, the etiology
of the disruption of blood flow is unknown. Children typically have a gradual
onset of hip, thigh, or knee pain and limping over a few months. Early in the
course, x-rays of the hip may appear normal. Later radiographic findings include
collapse, flattening, and widening of the femoral head. Bone scans or magnetic
resonance imaging (MRI) may be necessary to confirm the diagnosis. The treat-
ment is usually conservative, with protection of the joint and efforts to maintain
range of motion. Children who develop more severe necrosis or who develop the
disease at older ages may have a worse outcome and a higher risk of developing
degenerative arthritis.
Adolescents
The capital femoral epiphysis is the growth plate that connects the metaphysis
(femoral head) to the diaphysis (shaft of the femur). A SCFE is a separation of
this growth plate, which results in the femoral head being medially and posteriorly
displaced. This may be caused by an acute injury, but more often is not. It is most
often seen in overweight adolescent boys and presents as pain in the hip, thigh, or
knee along with a limp. Examination reveals limited internal rotation and obligate
external rotation when the hip is passively flexed. Early x-rays may show only widening of the epiphysis; later x-rays can show the slippage of the femoral head in
relation to the femoral neck. The treatment is surgical single-screw pinning of the
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femoral head. These patients must be closely followed, as up to 50% will develop
SCFE in the contralateral hip. Unstable SCFE separations (unable to bear weight
on presentation) have a 20% to 50% rate of avascular necrosis developing.
Other causes of limb pain are common in adolescents. Sprains, strains, and overuse injuries are the most common cause of limb pain in this population and are
usually readily diagnosed on history and examination (see Case 12). Sexually active
adolescents or teens are at risk for sexually transmitted infections (STIs) and their
complications, including gonococcal arthritis. In this population, an appropriate
history, sexual history, and review of systems are necessary.
CASE CORRELATION
See Case 12 (Musculoskeletal Injuries) and Case 36 (Family Violence).
COMPREHENSION QUESTIONS
37.1 A 6-year-old boy is brought in for evaluation of a painful right hip. He has
been limping and not wanting to walk for the past 2 days. He has had no
obvious injury. He feels a little better if he is given some ibuprofen. He has
not had a fever and does not have any other current symptoms, although he
had “the flu” last week. On examination, his vital signs are normal, including
a temperature of 98.8 °F. His right hip has some pain with internal rotation,
but there is full range of motion. He walks with a pronounced limp. Which of
the following statements is most appropriate?
A. Send patient home with instructions to take ibuprofen
B. Complete blood count and ESR
C. Aspiration of his hip in the office
D. X-ray of both hips
37.2 An 18-month-old girl is brought into your office because she has been cry-
ing and stopped walking today. She will crawl, however. Her mother denies
any injury to the child. On examination, she is crying but consolable in her
mother’s arms. She has bruising and swelling just proximal to the left ankle.
An x-ray reveals a spiral fracture of the tibia. Which of the following best
describes your advice to the mother of the patient?
A. You are going to report this to child protective services (CPS) as sus-
pected abuse.
B. You are going to refer the child for a bone biopsy because this is a patho-
logic fracture that may represent a neoplasm.
C. This is a common fracture resulting from twisting on a planted foot.
D. You will draw blood to evaluate for sickle cell disease, which may cause
infarction of the bone.
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37.3 A 2-year-old boy is brought into the emergency center for fever and poor
feeding. He started getting sick yesterday and has worsened significantly
today. He has had no recent illnesses or injuries and no known ill contacts.
On examination, his temperature is 101 °F (38.3 °C), he is tachycardic, and
he appears ill. He is lying on his back with his left leg flexed and abducted at
the hip. A head, ears, eyes, nose, and throat (HEENT) examination is normal, the heart is tachycardic but regular, and the lungs are clear. The abdomen
is nontender, and there are normal bowel sounds. He screams in pain when
you move his left leg from its resting position. Blood work reveals an elevated
WBC count of 15,000 cells/mm3 and an ESR of 45 mm/h (normal 0-10). An
x-ray of his left hip shows a widened joint space but no fractures. Which of
the following is your next step at this point?
A. Oral antibiotic and follow-up in 1 day
B. MRI of the hip and referral to an orthopedist
C. Anti-inflammatory medication and close follow-up
D. Hip joint aspiration
37.4 A 6-year-old boy is being seen in the office for a 2-month history of a slight
limp. He has no significant past medical history and takes no medications. He
has normal vital signs, including a temperature of 98.7 °F. The child is noted
to have antalgic gait and decreased range of motion in the left hip (internal
rotation more limited). He has mild pain on palpation of the anterior capsule
on the left side. X-ray shows fragmentation of the femoral head. Which of the
following is the most likely diagnosis?
A. Toxic synovitis of hip
B. Avascular necrosis of hip (LCP)
C. Slipped capital femoral epiphysis
D. Femoral shaft fracture
ANSWERS
37.1 B. The case presented is suspicious for transient synovitis following a viral
illness. Blood should be drawn for CBC and ESR evaluation. If the CBC
and ESR are normal and follow-up can be ensured, this child could be
treated expectantly with an oral nonsteroidal anti-inflammatory drug and
an expected recovery in a few days (answer A). Although the most common condition is transient synovitis, septic arthritis must be identified and
treated or the patient may lose function of the joint or even die. The lack
of fever, redness or swelling of the joint, and good range of motion speak
against septic joint; nevertheless, the CBC is useful to further assess for
possible bacterial infection. If septic joint were suspected, joint aspiration
should be performed (answer C). Likewise, SCFE must be identified or avascular necrosis of the hip may ensue. In a child less than age 5, the risk of
SCFE is very low, and an x-ray does not need to be performed (answer D),
assuming that the range of motion is normal.
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37.2 C. The case presented (isolated tibial spiral fracture) is classic for a toddler’s fracture, which is an accidental fracture due to tripping or falling.
Spiral fractures of other long bones (femur, humerus) are more suspicious
for abuse. Orthopedic referral is appropriate for management, but a bone
biopsy (answer B) or further workup (answer D) is not necessary at this time.
Answer A (report to CPS) would be indicated for injuries that would be more
suspicious for child abuse, behavior of the child that may indicate abuse, or
presence of other injuries, especially in different stages of healing.
37.3 D. The child in this case has all of the symptoms and signs of a septic hip joint
with the fever, severe joint pain, and x-ray showing increased hip joint space.
This situation demands a joint aspiration to confirm the diagnosis. If it is
confirmed, he should be promptly referred for urgent surgical management.
The reason is that an untreated infected joint will lead to joint destruction
and/or sepsis, which may be life threatening. Answer A (oral antibiotics) is
insufficient treatment. Answer B (MRI of joint and referral to orthopedist)
is somewhat reasonable, but the MRI would delay the management of the
patient; nevertheless, prompt referral to an orthopedist, meaning the surgeon would come to the patient’s bedside emergently, is an option. Answer
C (anti-inflammatory medication and close follow-up) may lead to a fatal
consequence.
37.4 B. This child is in the correct gender and age group with signs, symptoms, and
radiologic findings associated with LCP disease, an avascular necrosis of the
femoral head. It is often a self-healing disorder. Treatment is focused on limiting pain and avoiding functional loss. Depending on severity and age, treatment may include watchful waiting, physical therapy, casting, and surgery.
The radiological findings are inconsistent with the other conditions listed
(answer A, toxic synovitis of hip; answer B, slipped capital femoral epiphysis;
and answer D, femoral shaft fracture).
CLINICAL PEARLS
» The child with a limp is a common complaint, and the most common
cause is transient synovitis.
» The septic hip joint must be immediately recognized and treated to avoid
permanent joint destruction and/or sepsis.
» Hip pathology may not cause hip pain; it may cause groin, thigh, or knee
pain instead.
» Because of the high risk of bilateral disease, follow-up in SCFE cases
should include examination and x-rays of the unaffected hip until the
growth plate closes.
» A limp that is nonantalgic usually does not need urgent evaluation.
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REFERENCES
Dormans JP. Section 16: the musculoskeletal system. In: Rudolph CD, Rudolph AM, Lister G, et al, eds.
Rudolph’s Pediatrics. 23rd ed. New York, NY: McGraw Hill; 2018:931-1038.
Peck DM, Voss LM, Voss TT. Slipped capital femoral epiphysis: diagnosis and management. Am Fam
Physician. 2017;95(12):779-784.
Perry DC, Bruce C. Evaluating the child who presents with an acute limp. BMJ. 2010;341:c4250.
doi:10.1136/bmj.c4250
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