Limp

Definition: abnormal gait that minimizes weight bearing on the affected leg to reduce pain and instablitlity

Epidimiology:

• Any limp is considered abnormal
• Limping is due to one of more of three causes
• Pain
• Weakness
• Structural abnormalities of the spine, pelvis or lower extremities
• pain originating in the leg or referred pain form the abdomen or spine
• Normal gait has two phases
• Stance
• When foot in contact with the floor and bears all the body weight
• Begins when the heel strikes the ground and ends when toes push off the ground
• Swing
• When the foot is not in contact with the ground
• Begins with toe off and ends with heel-strike
• Types of abnormal gait
• Antalgic
• Etiology is normal pain
• Shortened stance phase on affected limp is characteristic
• Trendelenburg
• Pelvis dips toward the painful/weak extremity producing a side-lurching gait
• Often seen in pts with congenital hip dislocation, Legg-Calves-Perthes disease or slipped capital femoral epiphysis (SCFE)
• Differential Diagnosis
• Birth to 2 years
• Septic arthritis
• Osteomyelitis
• Congenital Hip dislocation
• Child abuse
• 2 – 10 yrs
• Septic arthritis
• Osteomyelitis
• Legg-Calves-Perthes
• Juvenile Rheumatoid Arthritis
• Transient synovitis of the hip
• Leukemia
• Sickle Cell Pain crisis
• Fractures
• 10 – 18 yrs
• Fractures
• SCFE
• Tumors
• Osteomyelitis
• Osgood-Schlatters syndrome
• Scoliois
• Specific conditions
• Septic arthritis
• Medical emergency that requires early diagnosis and surgical intervention
• Microbial invasion of synovial space occurs by hematogenous spread, local spread or traumatic/surgical infection of the joint space
• If untreated, accumulation of fluid and pus raises the intra-articualr pressure and permanently injures vessels and articular cartilage
• Knee is most commonly affected joint
• Most common organisms are S. aureus, Group A Strep, S. pneumoniae
• N. gonorrhea in sexually active adolescents and Salmonella in SCD pts
• Labs: CBC, ESR, Bld Cx, Plain films
• Tx: Surgical drainage and IV Abx
• Legg-Calves-Perthes disease
• A.k.a. idiopathic juvenile avascular necrosis of the femoral head
• Characterized by ischemic necrosis, collapse and subsequent repair of the femoral head
• Peak incidence between 4 and 9 years
• M > F (4-5 : 1)
• Bilateral involvement seen in 10%
• Pts typically present with cc of limping
• Early phase: radiodense femoral head, widened joint space
• Late phase: normal bone density, abnormal shape of femoral head
• Disease is self-limiting but immediate orthopedic referral is necessary
• Tx: corrective braces or surgery
• Slipped capital femoral epiphysis (SCFE)
• Misnomer: epiphysis remains in normal position in the acetabulum; proximal femur mataphysis displaces anterolaterally and superiorly; giving the appearance of a posteriorly and inferiorly displaced epiphysis.
• Risk factors: Male, obese
• Bilateral in 20-25%
• Pts usually present with c/o nonradiating, dull, aching pain in the thigh, groin, hip or occasionally the knee
• Usually patients have antalgic, Trendelenburg gait pattern
• Pain is often worse with activity
• Labs: CBC, ESR, AP hip, frog leg lateral view
• Failure to Dx increases risk of avascular necrosis
• Tx: Bedrest, traction and surgical fixation of femoral head onto the neck
• Post-op complications: chondrolysis of femoral head and acetabulum, fx at sit of pin placement
• Potential of further slipping remains until growth plate closes