A little too much swagger:

Limp in pediatrics

The Story

11 y/o F with right knee pain for the past 3

weeks which started to get worse over the
past 1-2 days. There was a concern that her
knee was becoming warm to the touch,
increasing pain the night prior to presentation
that woke her from sleep.
No recent sore throat or URI, no diarrhea, no
rash or swollen joints, no recent trauma and
she had a tactile fever for the past 2 nights.
She was initially taken to an InstaCare, then
referred to OSH and ultimately sent to PCH.

Story continued

PMH: hypothyroidism
PSH: no surgeries
FHx: No autoimmune disorders, no one
sick at home
Medications: Levothyroxine
Social: Father died suddenly 2 weeks ago
and family moved to Utah 1 week ago to
be closer to extended family. She is in
the 6th grade and is a good student.

Physical Exam
VS: T- 38.4 HR-88 RR- 20 BP- 123/70 O2- 95%
Weight- 71.7 kg Height-160 cm BMI: 27.8
GEN: Overweight, NAD, comfortable, smiling
HEENT: No conjunctival injection, PERRL, TM clear b/l, MMM, tonsils 1+
without erythema or exudate
Neck: No LAD
CV: RRR with S1/S2, no murmurs or gallops. Pulses 2+ upper and lower
extremities, CRT <3 seconds
Lungs: CTAB, good air flow
Abdomen: Obese, +BS, soft, non-tender, no HSM
MSK: FROM left hip and left knee, no tenderness to palpation along
left leg, no erythema of joints, no effusions appreciated.
Strength 5/5 left hip, left thigh, left leg and left foot.
Right hip has pain with internal>external rotation, rotation limited
by pain, no erythema or effusions right hip. Tenderness with
deep palpation right hip. FROM right knee, no erythema or
effusions right knee, tenderness to palpation at distal femur 2/5
strength right hip and thigh (tought to be 2/2 pain), 5/5 strength
right leg and right foot
NEURO: sensation intact and symmetric lower extremities, patellar reflexes
2+ symmetric, Achilles reflexes 2+ bilaterally

The patient

11 y/o with 1 week right knee pain,

fever.

Differential

Traumatic/overuse

Stress fractures
Osgood-Schlatter
Sever disease
Occult fracture

Infectious
Septic arthritis (S. aureus, GAS, S. pneumoniae, K. kingae, N. gonorrhea, N. meningitidis, Salmonella, H. flu)
Toxic/Transient synovitis
Osteomyelitis
Myositis

Rheumatologic
Juvenile idiopathic arthritis
Acute rheumatic fever

Oncologic
Osteosarcoma
Ewings sarcoma
Osteochondroma
Osteoid osteoma
Lymphoma/leukemia
Neuroblastoma

Other
Slipped capital femoral epiphysis
Legg-Calve-Perthes disease
Osteochondritis dissecans

Studies

BMP: 143|3.8|103|26|11|0.64|83 Ca-9.8

CBC: 12.2|11.9|36.7|458 N-60 L-24
ESR: 60
CRP: 5
Blood cultures were not drawn
XR Knee: nml
XR Hip: nml, asymmetric positioning of
patient difficult to determine effusion

MRI

Diagnosis

Ewings sarcoma

Approach to patient with a

Limp

What type of limp?

Antalgic limp: shortened stance phase on

the affected side

https://www.youtube.com/watch?v=W-S8P
k63YRE
Circumduction limp: (
https://www.youtube.com/watch?v=t5VJd
RUS4X0
)
Toe walking

Approach contiued

History
Duration of limp, onset (insidious vs.

acute), weight bearing

Sports, activities, trauma, recent illnesses,
fever
Underlying medical conditions (sickle cell),
immunization status (H. influenzae)

Exam

Examine skin and back (paraspinus

muscles and spinal processes)
Unaffected limb first!

Hip Exam

Internal rotation
Flex to 90 place hand 1 knee and 1 on foot/ankle move knee out

(nml 20-30)

External rotation
Flex to 90 place 1 hand on knee and 1 on foot/ankle move the

knee in and ankle/foot out (nml 40)

Forward flexion
Have patient flex hip with both hands (nml 120-135)

Abduction
Leg out flat, 1 hand on opposite hip, hand under ankle and move

leg out (nml >30-45)

Adduction
Leg out flat, 1 hand on opposite hip, hand under ankle and move

leg across body (nml >20)

Knee Exam

Palpation: tibiofemoral joint medial

compartment (medial femoral condyle)
lateral compartment
patellofemoral compartment

Knee ROM

McMurray Test
Menisci test, grab heel and flex the knee, cup hand

over knee join rotate lower leg internally and

externally

Abduction
Supine patient move thigh 30 laterally, flex knee

slightly, place 1 hand lateral knee other medial

ankle push medially against knee and laterally at
ankle

Adduction
1 hand medial knee and 1 hand lateral ankle push

medially against knee and laterally against ankle

Ankle

Palpate joint Achilles tendon

palpate heel and plantar fascia
metatarsophalangeal joints

Ankle ROM

Ankle flexion
Toes toward the floor

Ankle extension
Toes toward the ceiling

Inversion
Heel bends inward

Eversion
Heel bends outward

References

Herman, M. The Limping Child. Peds in

Review. Vol 36(5). May 2015
Bickley, L. Bates Guide to Physical
Examination and History Taking. 2009.
www.youtube.com
www.uptodate.com