Pediatric emergency medicine trisk 0908 0908

periods of vigorous activity, usually worse at night, suggest benign hypermobility
syndrome or benign nocturnal limb pain of childhood (growing pains). A
painless, poorly localized limp may occur with metabolic bone disease (e.g.,
rickets).
Limping in the absence of localized limb findings may also suggest a nonlimb
source such as the spine or the abdomen. Spinal problems that can cause leg pain,
weakness, or limp include dysraphism, vertebral infection, spondylolisthesis, and
herniated disc. Spinal dysraphism refers to a spectrum of abnormalities in the
development of the spinal cord and vertebrae ranging from obvious
(myelomeningocele) to occult (tethered cord). Associated neurologic and
musculoskeletal findings, including pain, atrophy, high arches, and tight heel
cords, may develop in early childhood. Vertebral infection typically presents with
fever and back pain. Spondylolisthesis and herniated disc are rare in young
children but may be seen in adolescents who complain of back pain or radicular
pain. Limp may rarely present as an early symptom of a peripheral neuropathy,
either hereditary (e.g., Charcot–Marie–Tooth disease) or acquired (Guillain–Barré
syndrome, vitamin or medication related). Intra-abdominal pathology that can
result in limp includes appendicitis, ovarian cyst, inflammatory bowel disease,
pelvic or psoas abscess, and renal disease. Solid tumors, most commonly
neuroblastoma, can cause limp through retroperitoneal irritation or extension into
the spinal canal. Likewise, a sacral teratoma may affect the nerves of the cauda
equina or sacral plexus. Testicular pain may present with limping in a boy who is
reluctant or embarrassed to admit the true source of his discomfort.

EVALUATION AND DECISION
The conditions that lead to a presentation of limp range from mundane (poorly
fitting shoes) to life threatening (leukemia). The role of the pediatric acute care
clinician is to rule out the possibility of life- and limb-threatening pathologic
conditions. The serious conditions include bacterial infection of the bone or joint
space, malignancy, and disorders that threaten the blood supply to the bone, such
as avascular necrosis and SCFE. Often, a definitive diagnosis will not be reached

in the emergency department, and the patient will require follow-up with the
primary care physician or specialist. Figure 46.1 provides an algorithmic
approach to the child with a limp.

History
The history in a limping child should include information about the onset and
duration of the limp, the family’s perception of the origin of the problem, and
associated symptoms such as pain, fever, and systemic illness. When pain is