General approach to the child with a limp

General approach to the child with a limp.

A conservative approach indicated, since very few children without systemic symptoms or true arthritis have any significant disorder. If pain persists or you suspect an acute arthritis, diagnostic evaluations can include a CBC, with differential ESR, anti-streptolysin O titer, rheumatoid factor, throat and urine cultures, ultrasonography for joint effusion, and radiographic studies of the hips. A joint tap should be done when there is clinical suspicion of a septic joint and an effusion by U/S.
Differential Diagnosis and Approach

Transient tenosynovitis (irritable hip).
Most common cause of limp (well over 90% in some series).
Frequently follows URI or streptococcal infection.
May have joint effusion but not true arthritis.
Generally resolves within 24 to 48 hours with rest and ibuprofen-acetaminophen.

Septic hip joint. A true emergency
Generally febrile with elevated ESR, WBC >18,000/mm3, but lab values may be normal and may overlap with those of other illnesses.
Will generally look sick and hold hip in flexion and external rotation.
Effusion present on ultrasonography but may also have effusion with transient tenosynovitis (71%). Tap is diagnostic.
Relatively sudden onset and rapid course.
Treat with antistaphylococcal antibiotics. Requires orthopedic consultation and surgical intervention.

Legg-Calv-Perthes disease (aseptic necrosis of the femoral capital head).
Most common between 5 and 10 years of age.
Slow insidious onset of limp and hip pain, which is progressive. Have limitation of motion of the hip.
Diagnosis by radiography of affected hip (see lucency of femoral head and eventually sclerosis and destruction of femoral head). Bone scan may reveal abnormalities earlier than radiograph would show.
Treatment requires consultation with orthopedics staff and includes rest, anti-inflammatories, and casting for more severe cases.

Slipped femoral epiphysis.
Generally seen in overweight teenagers, especially boys.
May have insidious onset of pain but can also follow acute trauma.
May be pain with passive motion.
Diagnosis by frog-legged radiographs of both hips.
Treatment is by orthopedic referral and surgical fixation.

Osgood-Schlatter disease.
Characterized by pain over the tibial tubercle, which is usually unilateral.
Usually occurs in active children between 10 and 15 years of age.
Treatment is rest and NSAIDs.

Diskitis.
An inflammatory process of the disk or disks (usually L3 to L5), which may be infectious in cause (staphylococcal primarily).
Presents with refusal to walk or limp, low-grade fever, and 'tripod posturing' - leaning back with back extended onto outstretched arms when sitting.
Generally have pain over involved disk area but may also have pain on straight-leg raising, hip motion.
Sedimentation rate almost always elevated, but CBC may be normal. Disk space may be narrowed on radiograph. Bone scan will show inflammatory focus.
Treatment is generally supportive with anti-inflammatories but may need antibiotics. Orthopedic consultation recommended.

Juvenile rheumatoid arthritis.
Defined as presentation of rheumatoid arthritis before 16 years of age.
20% have 'Still's disease,' which is JRA plus fever, thrombocytopenia, splenomegaly, generalized adenopathy.
40% have onset in one or a few joints.
40% have polyarticular onset similar to adult onset.
75% have complete remissions.

Jaundice is visible when a baby has a serum bilirubin level that exceeds 5 mg/dl. Generally jaundice is visible first on the head and progresses to the feet. It resolves with the opposite pattern, the feet clearing first.