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The child with a limp: a symptom and not a diagnosis
  1. Eve Smith1,
  2. Mark Anderson2,
  3. Helen Foster1,3
  1. 1Department of Paediatric Rheumatology, Great North Children's Hospital, Newcastle Upon Tyne, UK
  2. 2Department of Paediatric Medicine, Great North Children's Hospital, Newcastle Upon Tyne, UK
  3. 3Newcastle Musculoskeletal Research Group, Institute Cellular Medicine, The Medical School, Newcastle Upon Tyne, UK
  1. Correspondence to Dr Eve Smith, Department of Paediatric Rheumatology, Great North Children's Hospital, Richardson Road, Newcastle Upon Tyne NE1 4LP, UK; evemdsmith{at}yahoo.co.uk

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Introduction

The limping child frequently poses a diagnostic challenge and clinical assessment may not be easy. Epidemiological studies are sparse; in one study1 children with an acute limp accounted for <2% of all paediatric emergency department (ED) attendances although the frequency may well be different in the primary care setting.

Trauma is the commonest cause of limping and many cases of atraumatic limp will resolve spontaneously. However, limp is not a diagnosis and it is important to assess limping children carefully as rarer, but serious, causes can be associated with significant morbidity, and even mortality, if there is a delay in diagnosis.

Children warranting urgent investigation are the very young (<3 years of age), the ill and febrile, the non-weight bearing and those with painful restricted hip movements. Teaching on the limping child correctly focuses on the hip, where significant pathology often occurs. However, limp may be due to extra-articular causes or joint problems other than those affecting the hip; these can be easily missed without careful assessment.

What is meant by the term ‘limping’?

In most cases, acute limping describes an antalgic (painful) gait, that is, minimising weight bearing on a sore limb, with a shortened stance phase and increased swing phase of the gait cycle. Acute refers to duration of 1–2 days in contrast to a chronic limp (>6 weeks) and subacute (2 days and up to 6 weeks). Subtle limping may be accentuated by asking the child to run: listening for an asymmetric cadence can be helpful. Limping is also used to describe other abnormal gait patterns, often due to a spectrum of causes that are not acute in origin (eg, cerebral palsy) and not covered in detail in this article.

The age of the child is helpful in establishing a differential diagnosis (table 1)2 ,3 which will be aided by careful initial assessment, judicious use …

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