Limping in children

Limping in children is a common clinical presentation and can range from benign, self-limiting causes to serious underlying conditions requiring urgent intervention. It is defined as any deviation from a normal walking pattern, often resulting from pain, weakness, structural abnormalities, or neurological dysfunction. A thorough evaluation is essential to identify the underlying etiology and provide appropriate management.

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Causes of Limping in Children

1. Trauma and Injury

• Acute trauma such as fractures, sprains, ligament injuries, or contusions.

• Minor injuries like stubbed toes or falls.

• Non-accidental injury (child abuse) must be considered if the history is inconsistent with the injury.

2. Infection

• Septic arthritis – urgent cause; hip involvement can present with sudden severe limp, fever, inability to bear weight.

• Osteomyelitis – bone infection leading to pain, fever, and localized tenderness.

• Viral myositis – often post-infectious, causing calf muscle pain and difficulty walking.

3. Inflammatory and Autoimmune

• Transient synovitis – the most common cause in young children; usually follows a viral infection; hip joint inflammation causes painful limp.

• Juvenile idiopathic arthritis (JIA) – chronic joint inflammation with stiffness, morning limp, and swelling.

4. Orthopedic/Developmental Conditions

• Developmental dysplasia of the hip (DDH) – presents in toddlers with painless limp or leg length discrepancy.

• Legg-Calvé-Perthes disease – avascular necrosis of the femoral head, typically in boys aged 4–8 years.

• Slipped capital femoral epiphysis (SCFE) – affects adolescents, especially obese boys; causes hip/knee pain and limp.

• Clubfoot, flatfoot, or limb length discrepancy – mechanical causes of abnormal gait.

5. Neoplastic

• Leukemia – bone pain may cause intermittent limping.

• Bone tumors (e.g., osteosarcoma, Ewing sarcoma).

6. Neurological

• Cerebral palsy – spasticity and muscle imbalance affect gait.

• Peripheral neuropathy or muscle disorders (e.g., muscular dystrophy).

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Evaluation

History

• Onset: sudden vs gradual.

• Duration: acute, subacute, or chronic.

• Associated symptoms: fever, night pain, weight loss, joint swelling, morning stiffness.

• Trauma history.

• Developmental milestones.

• Family history of musculoskeletal or neurological disorders.

Physical Examination

• Gait assessment: antalgic gait, Trendelenburg gait, toe-walking.

• Joint examination: swelling, warmth, tenderness, range of motion.

• Limb length measurement.

• Neurological exam: reflexes, tone, strength.

Investigations (if needed)

• Blood tests: CBC, ESR, CRP (infections, leukemia, inflammation).

• Imaging:

  • X-ray of affected joint/limb.

  • Ultrasound of hip (for effusion).

  • MRI (for bone tumors, Perthes disease, osteomyelitis).

• Joint aspiration – if septic arthritis suspected (urgent).

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Management

1. Supportive and Conservative

• Minor injuries or transient synovitis – rest, analgesics (paracetamol, ibuprofen), gradual return to activity.

• Viral myositis – resolves with hydration and rest.

2. Infection

• Septic arthritis/osteomyelitis – urgent hospitalization, IV antibiotics (e.g., ceftriaxone, flucloxacillin), surgical drainage if required.

3. Inflammatory

• Juvenile idiopathic arthritis – managed with NSAIDs (ibuprofen, naproxen), disease-modifying antirheumatic drugs (methotrexate), corticosteroids if needed.

4. Orthopedic Conditions

• DDH – bracing (Pavlik harness) in infants; surgery in older children.

• Legg-Calvé-Perthes disease – activity restriction, physiotherapy, surgical intervention if severe.

• SCFE – surgical pinning of femoral head to prevent progression.

5. Neoplastic

• Leukemia or tumors – referral to oncology for chemotherapy, surgery, or radiotherapy as indicated.

6. Neurological

• Cerebral palsy – physiotherapy, orthotics, muscle relaxants (baclofen), possible surgery.

• Muscular dystrophy – supportive care, steroids (prednisone, deflazacort), physiotherapy.

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Red Flags (Require Urgent Referral)

• Inability to bear weight.

• High fever with limp (possible septic arthritis).

• Night pain waking child from sleep.

• Progressive worsening limp.

• Systemic symptoms (weight loss, night sweats, lethargy).

• Asymmetry or deformity in lower limbs.

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Medications (Generic Names and Usual Pediatric Doses)

• Paracetamol (Acetaminophen): 10–15 mg/kg every 4–6 hours (max 60 mg/kg/day).

• Ibuprofen: 5–10 mg/kg every 6–8 hours (max 40 mg/kg/day).

• Antibiotics (for infections):

  • Ceftriaxone: 50–75 mg/kg IV daily.

  • Flucloxacillin: 25–50 mg/kg IV every 6 hours.

• Methotrexate (for JIA): 10–15 mg/m² once weekly.

• Corticosteroids (for inflammation): Prednisolone 1–2 mg/kg/day (short course).