The Limping Child: Evaluation and Diagnosis

John M. Flynn, MD, and Roger F. Widmann, MD

Abstract

A limp is a common reason for a child to present to the orthopaedist. Because of cally between 12 and 16 months of
the long list of potential diagnoses, some of which demand urgent treatment, an age), they have a short stride
organized approach to evaluation is required. With an understanding of normal length, a relatively fast cadence
and abnormal gait, a directed history and physical examination, and the devel- and slow velocity, and a widened
opment of a differential diagnosis based on the type of limp, the patient’s age, base of support in double stance.
and the anatomic site that is most likely affected, the orthopaedist can take a Their hips, knees, and ankles move
selective approach to diagnostic testing. Laboratory tests are indicated when through a small arc of motion. 2
infection, inflammatory arthritis, or a malignant condition is in the differential Until 30 to 36 months of age, chil-
diagnosis. The C-reactive protein assay is the most sensitive early test for mus- dren have neither the balance nor
culoskeletal infections; an abnormal value rapidly returns to normal with effec- the abductor strength to maintain
tive treatment. Imaging should begin with plain radiography. Ultra- single-limb stance for very long.
sonography is particularly valuable in assessing the irritable hip and guiding By 7 years of age, children exhibit a
aspiration, if necessary. mature gait.2
J Am Acad Orthop Surg 2001;9:89-98 The mature gait cycle is com-
posed of the stance phase (initial
contact, loading response, mid-
stance, terminal stance, preswing)
A limp is a common reason for a child sient synovitis) to conditions in and the swing phase, during which
to present to the orthopaedist, often which early diagnosis may be life- the limb is advanced in space to
after first being seen by a primary- saving (e.g., acute leukemia).1 The position the foot for the next heel-
care physician or in an emergency long differential diagnosis (Tables 1 strike. The abductors stabilize the
department. Most parents are keen and 2) may seem daunting, particu- pelvis during stance phase, pre-
observers; they are quick to detect larly when the site of origin is un- venting significant side-to-side
even subtle gait abnormalities and known. However, after obtaining a motion as the opposite limb swings
generally will not wait long to have thorough history and performing a
a limp evaluated. The orthopaedist careful physical examination, the site
is expected to recognize the gait of origin can often be localized and
Dr. Flynn is Assistant Professor of Orthopaedic
abnormality, determine the proba- the differential diagnosis narrowed, Surgery, Unviersity of Pennsylvania School of
ble site of origin, and then develop a thus permitting a well-organized Medicine, Philadelphia; and Attending
good working diagnosis before approach to obtaining additional Surgeon, Division of Orthopaedic Surgery,
ordering selective diagnostic tests. data with selective diagnostic tests. Children’s Hospital of Philadelphia. Dr.
Widmann is Assistant Professor of Orthopaedic
These tests should provide the data Appropriate treatment can then be
Surgery, Weill Medical College of Cornell
for confirming the diagnosis and instituted. University, New York, NY; and Assistant
developing a treatment plan while Attending Surgeon, Hospital for Special
decreasing costs to the health-care Surgery, New York.
system, as well as minimizing pain Normal Gait
and anxiety for the child and parent. Reprint requests: Dr. Flynn, Division of
Orthopaedic Surgery, Children’s Hospital of
Pain, weakness, and mechanical Normal gait is a smooth, rhythmic,
Philadelphia, 34th and Civic Center Blvd,
factors are the primary causes of mechanical process that advances Philadelphia, PA 19104-4399.
limp in children. The etiology of a the center of gravity with a mini-
limp ranges from benign, self-limited mum expenditure of energy. Many Copyright 2001 by the American Academy of
conditions that call for only a diag- aspects of gait change with age. 2 Orthopaedic Surgeons.
nosis and reassurance (e.g., tran- When children begin to walk (typi-

Vol 9, No 2, March/April 2001 89

The Limping Child

Table 1
Differential Diagnosis of Antalgic Gait

<4 yr 4 to 10 yr >10 yr

Toddler’s fracture (tibia or foot)
Osteomyelitis, septic arthritis,
diskitis
Arthritis (juvenile rheumatoid
arthritis, Lyme disease)
Discoid lateral meniscus
Foreign body in the foot
Benign or malignant tumor
Fracture (especially physeal)
Osteomyelitis, septic arthritis, diskitis
Legg-Calvé-Perthes disease
Transient synovitis
Osteochondritis dissecans (knee or ankle)
Discoid lateral meniscus
Sever’s apophysitis
Accessory tarsal navicular
Foreign body in the foot
Arthritis (juvenile rheumatoid arthritis,
Lyme disease)
Benign or malignant tumor
Stress fracture (femur, tibia, foot, pars
intra-articularis)
Osteomyelitis, septic arthritis, diskitis
Slipped capital femoral epiphysis
Osgood-Schlatter disease or Sindig-
Larsen-Johanssen syndrome
Osteochondritis dissecans (knee or
ankle)
Chondromalacia patellae
Arthritis (Lyme disease, gonococcal)
Accessory tarsal navicular
Tarsal coalition
Benign or malignant tumor

through. During normal walking Abnormal Gait lumbar spine, as demonstrated

motion, one foot is always on the
ground. The kinematics of normal
gait has been studied in detail,2,3
establishing normal ranges of joint
motion during different phases of
the gait cycle. The ankle dorsiflexes
at heel-strike, then plantar-flexes to
foot-flat, and then dorsiflexes again
as the tibia moves forward. The
knee is flexed at heel-strike, extends
until toe-off, and then flexes during
swing, allowing clearance of the
foot as it positions for the next heel-
strike. The hip follows a similar
pattern, with slight flexion at heel-
strike, extension through stance,
and then flexion in swing.
Normal gait can be altered by pain,
a mechanical problem, or a neuro-
muscular problem. A child will
adopt an antalgic gait in an effort to
prevent pain in the affected limb.
The single-limb-support phase of
stance is shortened on the painful
extremity, as is the stride length of
the normal opposite limb (to get
back to bearing weight on the well
leg as quickly as possible). A vari-
ant of the classic antalgic gait is the
“cautious” gait of a child with back
pain.4 For example, a child with
diskitis will lose the normal rhyth-
mic flexion and extension of the
when bending to pick up objects off
the floor.5 Another variant of the
antalgic gait is the complete refusal
to walk. This pattern is seen most
often in toddlers and may indicate
a condition causing pain that can-
not be avoided by any of the possi-
ble gait alterations.
Circumduction—excessive hip
abduction, pelvic rotation, and hik-
ing—functionally shortens a limb,
thus enhancing foot clearance dur-
ing swing when there is joint stiff-
ness, particularly in the ankle. 6
Children with a significant limb-
length inequality may “vault” with
the short leg (or toe-walk) to clear

Table 2
Differential Diagnosis of a Nonantalgic Limp

Circumduction Gait/
Equinus Gait (Toe-Walking) Trendelenburg Gait Vaulting Gait Steppage Gait

Idiopathic tight Achilles tendon
Clubfoot (residual or untreated)
Cerebral palsy
Limb-length discrepancy
Legg-Calvé-Perthes disease Limb-length discrepancy Cerebral palsy
Developmental dysplasia of the hip Cerebral palsy Myelodysplasia
Slipped capital femoral epiphysis Any cause of ankle or Charcot-Marie-Tooth
Muscular dystrophy knee stiffness disease
Hemiplegic cerebral palsy Friedreich’s ataxia

90 Journal of the American Academy of Orthopaedic Surgeons


the long leg, rather than circumduct
it. An equinus gait (toe-walking)
occurs when ankle dorsiflexion is
limited. This may result from gas-
trocnemius-soleus spasticity, short-
ening of the Achilles tendon, or
both. Thus, stance phase will be
initiated with toe-strike rather than
heel-strike.
Several abnormal gait patterns
result from muscle weakness or a
neurologic abnormality. A Trendel-
enburg gait results from altered
hip mechanics, particularly abduc-
tor weakness. During stance on the
involved side, the contralateral side
of the pelvis drops. To preserve
balance, the child may lean the
trunk toward the affected side. A
variation of the Trendelenburg gait
is the waddling gait of a child with
bilateral hip dislocation. A “step-
page gait” develops when the ankle
dorsiflexors are weak (e.g., as in
Charcot-Marie-Tooth disease). To
compensate for the weakness, the
child increases knee flexion in the
swing phase to clear the foot. The
foot will slap to the ground because
the ankle dorsiflexors are unable to
decelerate the foot between heel-
strike and foot-flat. An unsteady
gait may result from conditions that
affect balance, such as Friedreich’s
ataxia. Careful initial analysis of
the gait can enhance the specificity
of the remainder of the physical
examination and facilitate localiza-
tion of the origin of the limp.
History
An accurate history may be difficult
to obtain from a young child, and
some or all of the history must be ob-
tained from the parents or primary
caregivers. A brief discussion with
the child, followed by a parental
description of pain complaints and
changes in gait pattern, is invalu-
able in guiding the subsequent
physician-directed evaluation. In
certain circumstances, adolescents
Vol 9, No 2, March/April 2001
John M. Flynn, MD, and Roger F. Widmann, MD
and some children should be ques-
tioned privately, as they may pro-
vide important details regarding
exposure to sexually transmitted
diseases, such as gonococcal infec-
tion, which may not be obtained in
the presence of parents.7 Once the
parent and patient have had an
opportunity to describe the pain
and/or limp in their own terms, the
physician is best prepared to com-
plete the history.
The history should focus on the
character of the limp: the presence
or absence of pain or other localiz-
ing symptoms, the frequency and
duration of symptoms, and the
mechanism of injury, when appro-
priate. A history of ceasing athletic
participation or social play with
friends should raise concern.4 The
absence of pain suggests either neu-
romuscular or metabolic disease or
a congenital or developmental ab-
normality, such as hip dysplasia or
limb-length discrepancy. In a tod-
dler, the absence of pain complaints
may not be particularly helpful,
and the physical examination takes
on greater importance.
The pattern, onset, and duration
of pain may suggest the origin. 4
Acute onset of severe pain over a
few days focuses the evaluation on
trauma, infection, or malignancy,
whereas gradual worsening over
months suggests inflammatory or
mechanical symptoms.8 It is helpful
to characterize the quality of the
pain as constant, intermittent, or
transient. Constant pain is of partic-
ular concern, suggesting an intra-
medullary process, such as expand-
ing tumor or infection. A history of
trauma is readily established in most
circumstances, with some notable
exceptions: pathologic fracture and
child abuse.
It is important to characterize the
timing of pain (e.g., morning pain,
pain after activity, or pain that wakes
the child from sleep). Morning pain
or pain and stiffness after inactivity
are more characteristic of inflamma-
tory joint disorders.8 Pain after activ-
ity may suggest an overuse injury,
such as a stress fracture, or an inter-
nal articular derangement, such as
an osteochondral lesion, a meniscal
tear, or an anterior cruciate ligament
tear. Night pain that wakes a child
from sleep may represent benign
“growing pains,” but the concern is
that it may derive from osteoid oste-
oma or a malignant condition.
Pain relief with nonsteroidal anti-
inflammatory medications may be
characteristic of osteoid osteoma but
is not diagnostic. Referred pain must
also be considered, particularly thigh
or medial knee pain referred from
painful conditions of the hip (e.g.,
slipped capital femoral epiphysis).
Buttock or lateral thigh pain may be
referred from the back. Pain in multi-
ple joints suggests an arthritic process.
A past medical history including
recent trauma or exposure to infec-
tious diseases and use of antibiotics
is helpful in diagnosis. Recent vari-
cella infection may lower systemic
immunity, rendering the child sus-
ceptible to opportunistic bone or
joint infections.9 Failure to achieve
appropriate developmental mile-
stones or, more ominously, deterio-
ration of motor ability warrants fur-
ther neuromuscular or metabolic
evaluation. The review of systems
should seek a history of recent fever,
weight loss, or malaise suggestive of
infection or malignancy. A history
of prior medical evaluation for the
same problem should be sought, and
the pertinent records should be ob-
tained when possible. A complete
history should include questioning
about the family history of neuro-
muscular disease, metabolic disease,
inflammatory arthritis, or infectious
disease exposure.
Physical Examination
The physical examination of the
limping child has three essential
components: the gait exam, the
91
The Limping Child
standing/floor exam, and the table-
top exam. The child should be
dressed in as little clothing as is prac-
tical; gym shorts and bare feet are
ideal. Much can be missed watching
a small child walk in an oversized
gown that extends to the floor.
Gait Examination
The examination area should
offer sufficient space to see multiple
gait cycles. It is important not to be
fooled by an artificial “doctor walk”;
the best chance to see the true limp
is by observing gait when the child
does not know she is being watched,
such as when the child is walking to
the examination room.10 Running
may accentuate the limp or abnor-
mal gait. Subtle weakness or the
upper-extremity posturing of cere-
bral palsy might not be seen until
the child runs. Shoes may provide
valuable clues to gait problems; for
example, a child having trouble
clearing his foot in swing phase may
have excessive toe wear.
It is best to adopt a systematic
approach to the gait examination,
working from the ground up and
watching each limb segment and
joint through several gait cycles.
Trying to simultaneously analyze
every facet of gait is difficult for
even the most experienced clinician,
considering that a typical toddler
takes 180 steps per minute. Note
how the foot strikes the floor—is
there heel-strike, foot-flat, or toe-
strike? A child may walk on the
medial or lateral border of the foot
to protect a sore bone or the site of a
puncture wound or foreign body.
Abnormal limb rotation may be
observed. Metatarsus adductus,
internal tibial torsion, or femoral
anteversion will result in an internal
foot-progression angle. An adoles-
cent with a slipped capital femoral
epiphysis or a young child with an
occult fracture may walk with an
external foot-progression angle.
The next feature to consider is
the symmetry of the stance phase.
92
A unilateral shortened stance phase
is characteristic of an antalgic gait.
The range of motion of each joint
should also be evaluated. Limited
ankle dorsiflexion is seen in chil-
dren with a short Achilles tendon
or a spastic gastrocnemius-soleus.
At the knee, motion should be ob-
served through several gait cycles.
Contracture or spasticity in the
quadriceps or hamstrings or intra-
articular derangement will limit
knee motion. Any frontal-plane ab-
normalities should be noted as well
(e.g., a varus thrust of the proximal
tibia in Blount’s disease). Hip mo-
tion may be abnormal, exhibiting
circumduction, persistent flexion,
or excessive pelvic or trunk motion.
Upper-extremity posturing as well
as difficulty with balance and coor-
dination may suggest a neurovas-
cular origin of the limp.
Standing/Floor Examination
After the history and vital signs
have been taken and the physician
has thoroughly studied the child’s
gait, there are several tests to con-
sider before the tabletop examina-
tion. The spine should be examined
with the child standing, taking care
to note balance in the coronal and
sagittal planes, scoliosis, lumbo-
sacral step-off, pelvic obliquity, and
any cutaneous findings (e.g., café-
au-lait spots, hairy patches, or sacral
dimples). On the forward bend, the
examiner should note a thoracic or
lumbar prominence due to scoliosis.
The Trendelenburg test is per-
formed by having the child stand
on the affected leg with the knee
flexed and the hip extended. The
child may need to rest his hands
against the wall for balance. If the
Trendelenburg test is performed
with hip flexion, the hip flexors can
elevate the pelvis and mask a mild
deficiency of the gluteus medius.4
It may take 20 seconds or more of
continuous testing on the affected
limb before abductor weakness
causes the opposite pelvis to drop.
Journal of the American Academy of Orthopaedic Surgeons
If muscular dystrophy is a possi-
bility, a Gower test is performed by
having the child sit on the floor and
then rise quickly, observing to see if
he uses his hands to substitute for
weak hip extensor muscles. Repeti-
tive single-leg heel raises and toe
raises can be utilized to accentuate
subtle weakness in the foot plantar-
flexors or dorsiflexors.
Tabletop Examination
With the child on the examining
table, one should thoroughly in-
spect for asymmetry, deformity,
erythema, rashes, and swelling.
Puncture wounds or foreign bodies
should be sought on the plantar
surface of the foot in walkers and
on the anterior aspect of the knee in
crawlers. The resting position of
the limb should be noted; for exam-
ple, a child with septic arthritis of
the hip will hold the hip flexed and
externally rotated. Note also any
muscle hypertrophy (e.g., calf hy-
pertrophy in muscular dystrophy)
or atrophy (e.g., global unilateral
atrophy in hemiplegia or quadri-
ceps atrophy in a child with a pain-
ful hip or knee).
Palpation of the lower extremity
to find the point of maximum ten-
derness is often the most valuable
part of the physical examination of a
limping child. Knowing the exact
site of pain dramatically limits the
differential diagnosis and may elim-
inate the need for a bone scan or
other diagnostic test (Fig. 1). Every
joint of the lower extremity should
be taken through its range of mo-
tion, noting pain, contractures, or
muscle spasticity. The patellofemo-
ral joint, a common source of pain
in adolescents, should be tested for
signs of apprehension or pain with
patellar compression during flexion
and extension. The sacroiliac joint is
tested by direct percussion posteri-
orly and by stressing the joint with
the hip positioned in flexion, abduc-
tion, and external rotation (FABER
test). The rotational profile should
 John M. Flynn, MD, and Roger F. Widmann, MD

tional oblique views may reveal

more subtle osseous changes, such
as a minimally displaced tibial frac-
ture (toddler’s fracture) or the peri-
osteal elevation of a stress fracture.
In children who present with a limp
or refusal to bear weight but are too
young to localize pain, plain radio-
graphs of the entire lower extremity
should be obtained (Fig. 2).
Plain radiographs are not particu-
larly helpful in identifying early
bone or joint infections. The early ra-
diographic findings of acute hema-
togenous osteomyelitis include a nor-
mal osseous appearance with subtle
displacement and swelling of the soft
tissues.13 Comparison views may
depict subtle soft-tissue swelling, but
radiographic sensitivity for the early
changes of osteomyelitis is less than
50%.14 The radiographic appearance
of early soft-tissue changes due to
septic arthritis is difficult to interpret
A B and unreliable.15 Early bone or joint
Figure 1 A, A healthy limping toddler presented with reproducible tenderness to palpa-
changes are not typically seen radio-
tion over the midportion of the tibia. Rotational stress to the tibia was also painful. graphically until 10 to 12 days after
Although the radiographs were read as normal, an occult fracture was suspected. B, At 4 the onset of bone or joint infection,13
weeks, radiographs showed periosteal elevation along the medial cortex of the tibia
(arrows), confirming the clinical suspicion of a toddler’s fracture. The child’s symptoms
and the presence of these changes
resolved after 4 weeks in a cast. suggests a significant delay in diag-
nosis.
The triphasic technetium-99m
bone scan is an excellent test for
be documented in children with in- limp, plain radiography should evaluating a limping child when
toeing or out-toeing.11 Appropriate always be performed first, because the history and physical examina-
neurologic testing should also be radiographs are inexpensive, can be tion fail to localize the anatomic site
performed. easily obtained at any hour, and are of pathologic changes (Fig. 3). Bone
Limb lengths should be assessed. both sensitive and specific for a scanning has been demonstrated to
If an inequality is noted, the differ- wide variety of disorders.12 In chil- be superior to the other standard
ence is most accurately determined dren who can localize tenderness, screening tests for infection (tem-
by leveling the pelvis with blocks initial plain radiographs should perature, white blood cell [WBC]
under the short leg. Although a sig- include orthogonal images of the count, erythrocyte sedimentation
nificant limb-length inequality may affected limb that visualize the joint rate [ESR], and plain radiography)
itself alter gait, it also suggests other both above and below the point of in the limping toddler.14 The tech-
potential causes of limping, such as maximum tenderness. A third ob- netium accumulates at the site of in-
hemiplegia and developmental dis- lique view is included when imag- creased blood flow and osteoblastic
location of the hip. ing the ankle or foot if an area of activity in osteomyelitis, stress frac-
suspected pathologic change may tures, occult fractures, neoplasm,
be obscured by bone overlap, mini- and metastases. In suspected early
Radiographic Evaluation mal displacement of fracture frag- bone infection, bone scans have high
ments, or minimal physeal widen- sensitivity (84% to 100%) and speci-
Although the various imaging ing. 12 If the patient can localize ficity (70% to 96%).12,14,16
modalities may each have a role in pain but the initial radiographs of Although the diagnosis of many
the assessment of the child with a the long bones are negative, addi- long-bone infections can be made

Vol 9, No 2, March/April 2001 93

The Limping Child

in clinical practice.17 Other advan-

tages of bone scanning over cross-
sectional imaging modalities include
decreased expense, less need for se-
dation, and the ability to image the
whole body.
Limitations of bone scintigraphy
include difficulty in distinguishing
between bone infarct and osteomy-
elitis in hemoglobinopathies and the
occurrence of false-negative bone
scans in cases of Langerhans cell his-
tiocytosis and some other aggressive
tumors in children.17 Bone scanning
has low sensitivity for septic arthri-
tis, especially when there is adjacent
osteomyelitis, and is therefore not
indicated in this circumstance.
Leukemia may result in increased,
decreased, or no change in tech-
A B netium uptake.14 A “cold” scan (i.e.,
one showing low uptake) in the set-
Figure 2 A, Anteroposterior (AP) radiograph of the hips and pelvis of a 2-year-old girl
with a 2-week history of limping, fever, malaise, and difficulty sleeping through the night.
ting of suspected osteomyelitis is
Periosteal changes (arrow) were noted in the right femur. B, A full-length AP radiograph not necessarily negative; instead, it
of the femur demonstrates the extent of periosteal elevation and geographic medullary may represent bone rendered avas-
canal erosion of the lesion, which on biopsy proved to be eosinophilic granuloma.
cular due to a subperiosteal or end-
osteal abscess. A study of cold bone
scans in pediatric patients with
without scintigraphy, bone scans Prior bone drilling and periosteal osteomyelitis revealed that they had
are particularly helpful in localiz- elevation have been demonstrated more severe bone infections requir-
ing sepsis around the pelvis and experimentally to have no effect on ing more aggressive medical and
the spine—areas that are difficult a subsequent bone scan performed surgical treatment compared with
to examine and where soft-tissue within 24 hours,18 and prior aspira- control children with “hot” bone
changes are difficult to identify.17 tion has not interfered with results scans and osteomyelitis.19

A B

Figure 3 A, AP radiograph of an 8-year-old girl who presented with a limp and the sudden, nontraumatic onset of severe left groin and
thigh pain. The film was read as normal. B, The history, physical examination, and plain radiographs did not allow precise localization of
the process. A bone scan showed decreased uptake in the left femoral head, suggesting Legg-Calvé-Perthes disease.

94 Journal of the American Academy of Orthopaedic Surgeons


Ultrasonography is a valuable
diagnostic tool in the evaluation of
a limping child with an irritable hip
(Fig. 4). Ultrasonography is nonin-
vasive, requires no sedation, and is
typically more accessible and less
expensive than other secondary
radiologic tests. 20 However, if
infection is highly probable, ultra-
sonography should not delay urgent
operative irrigation and debride-
ment. If a hip effusion is noted, the
ultrasonographer can assist with a
guided aspiration and can docu-
ment the intra-articular positioning
of the needle. If ultrasonography is
not available, a possibly infected
hip can be aspirated with fluoro-
scopic guidance.
In one series of 44 patients with
a limp or hip pain and negative
plain radiographs, ultrasonog-
raphy was 100% accurate in pre-
dicting the presence of aspiration-
documented hip effusion.21 Another
larger prospective study of 111 chil-
dren with irritable hips confirmed
that the plain radiograph was of lit-
tle value in the detection of early
hip effusion; in that study, there
was radiographic evidence of effu-
sion in 15% of hips, compared with
sonographic evidence of effusion in
71% of hips.15 Furthermore, Zawin
et al 22 showed that ultrasound-
guided hip aspiration in the radiol-
ogy suite decreased the subsequent
operative time for septic hips by
50%. However, a large prospective
study of 500 painful hips in chil-
dren demonstrated that ultrasound
cannot effectively differentiate
among sterile, purulent, and hem-
orrhagic effusions.23 The authors of
that study concluded that ultra-
sonography of the hip should be
reserved for select cases in which
sepsis is suspected.
Ultrasound evaluation of the irri-
table hip is performed with the
transducer oriented in an oblique
sagittal plane parallel to the long
axis of the femoral neck with the hip
in extension.12 An effusion causes
Vol 9, No 2, March/April 2001
John M. Flynn, MD, and Roger F. Widmann, MD
Femoral
head
Hip capsule
Effusion
A B
Figure 4 A, A 12-year-old girl presented with an antalgic limp on the right and thigh
pain. She had pain with internal rotation of the hip, suggesting an effusion. The plain radio-
graph was normal. B, Sonogram of the right hip shows an effusion. Ultrasound-guided
aspiration yielded purulent fluid. Drainage of the septic hip was performed immediately.
bulging of the iliofemoral ligament, proved to be the most effective im-
so that the joint capsule appears aging modality for bone marrow,
convex; the normal opposite capsule joints, cartilage, and soft tissues
will be concave.22 (Fig. 6, C). It is extremely useful in
Ultrasonography can help con- cases of suspected tumor and stress
firm the diagnosis of osteomyelitis fractures.
on the basis of characteristic early
and late ultrasonographic clinical
features.24 Early changes, such as Laboratory Testing
deep soft-tissue swelling, are fol-
lowed by periosteal thickening. Infection, inflammatory disease, and
Subperiosteal fluid or abscess is seen malignancy all demand rapid diag-
as a later finding 1 to 2 weeks after nosis and treatment, and laboratory
the onset of symptoms. The main testing may assist both in making
value of ultrasound imaging of the the appropriate diagnosis and in
extremity in cases of suspected in- monitoring the efficacy of treatment.
fection is to rule out subperiosteal Laboratory testing is indicated when
abscess.20 a child presents with an acute non-
Cross-sectional imaging, includ- traumatic limp and signs and symp-
ing computed tomography (CT) and toms of fever, malaise, night pain, or
magnetic resonance (MR) imaging, localized complaints. Appropriate
is rarely necessary as an initial tests include a complete blood cell
study in the evaluation of a limping count with differential and determi-
child. Computed tomography is in- nation of the ESR, the C-reactive
dicated specifically for imaging of protein (CRP) and antinuclear anti-
suspected localized abnormalities of body levels, and the rheumatoid fac-
cortical bone (Fig. 5). It may also tor and Lyme titers.
confirm the presence of either a cen- In the setting of bone or joint
tral nidus in cases of osteoid osteoma infection, the WBC count is neither
or the occurrence of a tarsal coalition. sensitive nor specific. Although the
Magnetic resonance imaging has WBC count is elevated in 25% to
95
The Limping Child
A B
Figure 5 A, A 10-year-old soccer player presented with a limp and thigh pain of 4 weeks’
duration. AP radiograph shows a radiodense area in the medial subtrochanteric region.
B, CT scan obtained to better characterize the sclerotic area shows a pattern typical of a
femoral-neck stress fracture. A biopsy was avoided. The pain and limp resolved after 2
months of protected weight bearing.
31% of children with osteomyeli-
tis, 25 normal values for the WBC
count are seen frequently in osteo-
myelitis.26 The differential is more
sensitive and may be abnormal in as
many as 65% of children with osteo-
myelitis and 70% with septic arthri-
tis. The complete blood cell count
may reveal moderate to severe ane-
mia in cases of systemic juvenile
rheumatoid arthritis (JRA), as well
as leukocytosis with active disease.8
Patients with systemic-onset JRA
may present with WBC counts in the
range of 30,000 to 50,000/mm3. The
platelet count may rise considerably
as well.
The ESR is a sensitive indicator
of inflammation and is most helpful
in the diagnosis and follow-up of
bone or joint infection. The ESR
reflects changes in the concentration
of fibrinogen synthesized by the
liver, which increases after 24 to 48
hours and may not return to normal
for 3 weeks with appropriate treat-
ment.27 In one study of previously
well children with new-onset limp,
an ESR elevated to over 50 mm/hr
was associated with a clinically im-
portant diagnosis in 77% of cases.28
The ESR is also a sensitive indicator
96
of infection and is elevated in 90%
of patients with osteomyelitis.16,25
However, early in the course of in-
fection, the ESR may be normal. Ex-
treme elevation of ESR in what ap-
pears to be isolated osteomyelitis
should raise the question of associ-
ated septic arthritis.
C-reactive protein is an acute-
phase protein synthesized by the
liver in response to inflammation.
Unlike the ESR, the CRP level rises
within 6 hours of onset of symp-
toms and returns to normal within 6
to 10 days with appropriate treat-
ment. The CRP level is more sensi-
tive than the WBC count or the ESR
in assessing the effectiveness of
therapy and predicting recovery
from osteomyelitis and septic arthri-
tis.27,29 The CRP value is not influ-
enced by prior aspiration or drilling
of the cortex, and a secondary rise
suggests relapse.29 The CRP level
should be determined on the initial
screening examination if musculo-
skeletal infection is in the differen-
tial diagnosis.
Aspiration and evaluation of joint
fluid should be performed when
joint sepsis is considered in the dif-
ferential diagnosis. Of the large
Journal of the American Academy of Orthopaedic Surgeons
joints, the hip is the most technically
difficult to aspirate. Sedation and
local anesthesia are helpful, and
aspiration under fluoroscopic guid-
ance with arthrography at the com-
pletion of the procedure is recom-
mended to confirm appropriate
spinal needle placement within the
joint.30 Ultrasound-guided aspira-
tion provides similar confirmation of
needle placement. Culture and cell
counts should be obtained in all
cases. A WBC count greater than
80,000/mm3 with a percentage of
polymorphonuclear cells greater
than 75% is highly suggestive of
joint sepsis, although early sepsis
may present with a much lower cell
count.30
The rheumatoid factor and anti-
nuclear antibody levels are deter-
mined when inflammatory arthritis
is a possibility. In practice, JRA is
the most frequently diagnosed pedi-
atric arthritis.31 It must be noted
that the rheumatoid factor test is
positive in only 15% to 20% of chil-
dren with JRA, and is more fre-
quently positive in older children
and children in a poor functional
class. 8 The finding of a positive
antinuclear antibody test is impor-
tant in the identification of children
most at risk for the development of
chronic uveitis, which may result in
blindness if untreated.
Testing for Lyme disease should
be performed on any patient who
presents with acute arthritis and
who lives in or has recently traveled
to an endemic area.32 The presenta-
tion of acute Lyme arthritis may
have considerable overlap with that
of septic arthritis, including fever,
local swelling, pain with range of
joint motion, and an elevated WBC
count in joint aspirate. Serologic
confirmation of Lyme disease is
based on a two-test approach con-
sisting of a preliminary enzyme-
linked immunosorbent assay and a
confirmatory Western immunoblot
assay, which specifically examines
the reactivity of antibodies.32
 John M. Flynn, MD, and Roger F. Widmann, MD

A B C

Figure 6 An 11-year-old girl sustained a suspected distal fibular physeal fracture. AP (A) and lateral (B) plain radiographs of the ankle
taken 10 days after the injury. C, Because of persistent pain and an ESR of 35 mm/hr, an MR imaging study of the distal portion of the leg
was obtained. The appearance of this transverse section at the distal fibula is consistent with fibular osteomyelitis and soft-tissue swelling
with an abscess, which were successfully treated with surgical drainage and antibiotic therapy. Cultures grew Staphylococcus aureus.

Making the Diagnosis
When a limping child is brought for
musculoskeletal evaluation, some
potential diagnoses require urgent
treatment to ensure the best possible
outcome. Some conditions affect all
age groups, but many conditions
have a peak age of onset. Although
there is increasing interest in prac-
tice standardization with use of
algorithms for many musculoskele-
tal conditions, there are so many
exceptions in the evaluation of the
limping child that any single algo-
rithm will be unreliable for all pre-
sentations. Despite this complexity,
there are five essential questions
that the orthopaedist must answer
to direct the evaluation of a limping
child: (1) Is the limp due to pain?
(2) Did the limp develop suddenly
or gradually, or has it always been
there? (3) Is the child systemically
ill? (4) What type of limp does the
child exhibit? (5) Can the problem
be localized (specifically, is there a
point of maximum tenderness)?
The answers to these questions will
narrow the differential diagnosis
and establish the pace of evalua-
tion. 33 Determining whether the
gait is antalgic is the first step in
developing a differential diagnosis
(Tables 1 and 2).
The answers to these five essen-
tial questions direct the evaluation
of different clinical scenarios. For
example, a healthy 4-year-old pre-
sents with the gradual onset of a
painless Trendelenburg gait. Exami-
nation shows that there is unilateral
limitation of hip motion. The work-
up of this limp requires only a plain
radiograph to establish the diagnosis
of Legg-Calvé-Perthes disease or de-
velopmental dysplasia of the hip.
In a very different scenario, an ill
child presents with the sudden
onset of an antalgic gait. Samples
for screening laboratory studies
should be drawn, and plain radio-
graphs should be obtained for ana-
tomic localization. If the site cannot
be localized, a bone scan is valu-
able. An MR imaging study may
add important information, espe-
cially if a malignant condition is
suspected. If septic arthritis of the
hip is a possibility, ultrasound-
guided aspiration may be indicated.
Unfortunately, the presentations
are usually not this straightforward.
The most common challenge is de-
termining whether an acute limp is
due to trauma. A typical case is illus-
trated in Figure 6. The 11-year-old
patient had ankle pain after falling.
Her pain persisted after casting of a
suspected fibular physeal fracture.
The plain-radiographic appearance
remained normal. Her limp was
clearly due to pain, which was wors-
ening with time. Because this was un-
characteristic for trauma, laboratory
tests were obtained, which revealed
an ESR of 35 mm/hr. Because the
process could be localized by pain
and swelling around the distal fibula,
a bone scan was not needed. An MR
imaging study obtained to simultane-
ously evaluate the soft tissues, the
bone, and the ankle joint revealed
osteomyelitis with a soft-tissue ab-
scess. The patient was successfully
treated with surgical drainage and
antibiotics.

Vol 9, No 2, March/April 2001 97

The Limping Child
Summary
Limping children commonly present
to the orthopaedic surgeon, who is
expected to recognize the gait abnor-
mality, determine the probable
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