Pediatric emergency medicine trisk 0909 0909

present, the physician should inquire about the location and severity. A history of
trauma should be addressed, keeping in mind the inherent difficulty in obtaining
an accurate trauma history in very young children. Conversely, obvious trauma in
the absence of a consistent history raises the question of inflicted injury. In more
chronic presentations, any cyclical or recurrent patterns should be noted. Stiffness
and limp primarily in the morning suggest rheumatic disease, whereas evening
symptoms suggest weakness or overuse injury. A history of joint or limb swelling
should be investigated, with attention to the degree of swelling and any migratory
or recurrent patterns.
The medical history should include birth and developmental history. Breech
position is associated with developmental dysplasia of the hip, and mild cerebral
palsy may present in childhood with abnormal gait. History of viral infections,
streptococcal pharyngitis, medication use, and immunizations may provide clues
to the cause of limping. A family history of rheumatic or autoimmune disease,
neurologic disease, inflammatory bowel disease, hemoglobinopathy, or other
bleeding disorders may help facilitate diagnosis. Finally, the review of systems
should include questions about past trauma, infections, neoplasia, endocrine
disease, metabolic disease, and congenital anomalies.

Physical Examination
The physical examination in a limping child should begin with observation of the
child’s gait. Ideally, the child should be observed walking in bare feet and
wearing minimal clothing, preferably in a long hallway. The physician should
attempt to observe the child unobtrusively to avoid gait changes caused by selfconsciousness. The observer should note the symmetry of stride length, the
proportion of the gait cycle spent in stance phase, hip abductor muscle strength
(with weakness manifested by Trendelenburg or waddling gait), in-toeing or outtoeing, and joint flexibility. Muscle strength may be tested by asking the child to
run, hop, and walk on toes and heels.
After observing the child in action, the physician should perform a complete
examination with attention to the musculoskeletal and neurologic systems. The
musculoskeletal examination begins with inspection of the limbs and feet for
swelling or deformity. Supine positioning with the leg slightly flexed, abducted,

and externally rotated at the hip is suggestive of fluid in the joint capsule. The
spine should be inspected for curvature, both standing and bending forward, and
the soles of feet and toes should be checked for foreign bodies and calluses. The
bones, muscles, and joints should be palpated for areas of tenderness; range of
motion of all joints should be checked; and limb lengths (from anterior-superior
iliac spine to medial malleolus), as well as thigh and calf circumferences, should