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Limp

Medicine > Neurosciences

Epidemiology

Epidemiology

  • Limping is a common presentation in both children and adults, often indicating an underlying musculoskeletal, neurological, or systemic condition.
  • In children, transient synovitis is the most common cause of acute limping, particularly in those aged 3-8 years.
  • Developmental dysplasia of the hip (DDH) and Perthes disease are also significant causes in pediatric populations.
  • In adults, limping is frequently associated with osteoarthritis, particularly of the hip or knee.
  • Trauma is a leading cause of limping across all age groups, necessitating careful evaluation for fractures or soft tissue injuries.
  • The prevalence of limping increases with age due to degenerative joint diseases and neurological conditions like stroke.
  • Epidemiology varies globally, with higher rates of infectious causes like septic arthritis in regions with limited access to healthcare.

Differential Diagnosis Schema 🧠

Musculoskeletal Causes

  • Osteoarthritis: Common in older adults, causing pain and stiffness in the hip or knee, leading to a limp.
  • Transient Synovitis: Most common cause of acute limp in children, usually self-limiting and follows a viral infection.
  • Developmental Dysplasia of the Hip (DDH): Presents in infants and young children with leg length discrepancy or abnormal gait.
  • Perthes Disease: Avascular necrosis of the femoral head, typically affecting boys aged 4-10 years, presenting with a painless limp.
  • Slipped Capital Femoral Epiphysis (SCFE): Affects adolescents, particularly those who are overweight, causing hip pain and a limp.
  • Trauma: Fractures, sprains, or muscle strains are common causes of acute limping in all age groups.
  • Septic Arthritis: Acute onset of joint pain, fever, and limp, often requiring urgent intervention.
  • Juvenile Idiopathic Arthritis (JIA): Chronic inflammatory condition causing joint pain, swelling, and limp in children.
  • Achilles Tendinopathy: Causes pain and difficulty walking, leading to a limp, particularly after physical activity.
  • Plantar Fasciitis: Heel pain leading to limping, often worse in the morning or after prolonged standing.

Neurological Causes

  • Cerebral Palsy: A common cause of limping in children, often presenting with spasticity and asymmetric gait.
  • Stroke: Can lead to hemiplegia or hemiparesis, resulting in a limp due to weakness or spasticity in one leg.
  • Peripheral Neuropathy: Causes distal weakness and sensory loss, leading to an abnormal gait and limping.
  • Lumbar Radiculopathy: Compression of spinal nerves can cause radicular pain and limping due to weakness or discomfort.
  • Multiple Sclerosis: Can present with limb weakness or spasticity, resulting in an abnormal gait or limp.
  • Spinal Cord Compression: Causes weakness, sensory loss, and spasticity, leading to a limp.
  • Parkinson’s Disease: Characterized by bradykinesia and rigidity, leading to a shuffling gait or limping.
  • Myopathies: Muscle diseases such as muscular dystrophy can cause weakness and a characteristic waddling gait.

Systemic and Other Causes

  • Rheumatoid Arthritis: A systemic inflammatory disease that can affect any joint, leading to pain and limping.
  • Osteomyelitis: Infection of the bone causing pain, fever, and limping, often requiring urgent treatment.
  • Sickle Cell Disease: Can cause painful vaso-occlusive crises leading to acute onset of limp due to bone infarction.
  • Leukemia: Can present with bone pain and limping in children, sometimes without other systemic symptoms.
  • Leg Length Discrepancy: Can cause limping due to unequal limb lengths, often noticed in childhood or adolescence.
  • Hip Dysplasia: Can be congenital or acquired, leading to an abnormal gait and limping.
  • Gout: Acute onset of severe joint pain, often in the foot, leading to a limp.
  • Paget’s Disease: A chronic bone disorder that can cause deformities and limping in older adults.
  • Malignancy: Bone tumors or metastases can cause pain and pathological fractures, leading to a limp.
  • Inflammatory Bowel Disease: Can be associated with enteropathic arthritis, causing joint pain and limping.

Key Points in History 🥼

Background

  • Onset and Duration: Determine if the limp is acute, subacute, or chronic in onset.
  • Pain: Assess whether the limp is associated with pain and, if so, the nature, location, and severity of the pain.
  • Progression: Explore whether the limp is getting better, worse, or staying the same over time.
  • Associated Symptoms: Inquire about fever, weight loss, night sweats, or systemic symptoms that may suggest infection or malignancy.
  • Recent Trauma: Ask about any recent injuries, falls, or physical activities that could have caused trauma.
  • Developmental History: In children, assess milestones and any history of developmental delay or congenital abnormalities.
  • Past Medical History: Include any history of musculoskeletal, neurological, or systemic diseases.
  • Medication History: Note any medications, especially corticosteroids or chemotherapeutic agents that can affect bone health.
  • Family History: Explore any family history of musculoskeletal disorders, neurological conditions, or congenital abnormalities.
  • Social History: Consider the impact of limping on daily activities, school, or work, and assess for any psychosocial factors.
  • Functional Impact: Determine how the limp affects mobility, balance, and independence in daily activities.
  • Review of Systems: Conduct a thorough review to uncover any underlying systemic causes, including weight loss, malaise, or gastrointestinal symptoms.

Possible Investigations 🌡️

Clinical Examination

  • Gait Analysis: Observe the patient’s gait to assess the nature of the limp, whether it is antalgic (painful), Trendelenburg (weakness of hip abductors), or another type.
  • Joint Examination: Examine all relevant joints for swelling, tenderness, range of motion, and deformities.
  • Neurological Examination: Assess muscle strength, tone, reflexes, and coordination to rule out neurological causes.
  • Leg Length Measurement: Assess for any leg length discrepancy, which may contribute to the limp.
  • Palpation: Palpate the bones and soft tissues for signs of tenderness, masses, or abnormalities.
  • Spinal Examination: Consider in cases of suspected radiculopathy or other spinal causes of limping.
  • Skin Examination: Look for rashes, ulcers, or other skin changes that might indicate systemic disease.

Imaging

  • X-ray: First-line imaging to evaluate for fractures, joint abnormalities, or bone lesions.
  • Ultrasound: Useful for detecting effusions, soft tissue masses, or developmental dysplasia of the hip (DDH).
  • MRI: Indicated in cases of suspected soft tissue injuries, osteomyelitis, or when x-rays are inconclusive.
  • CT Scan: Provides detailed images of bone structures, useful in complex fractures or when MRI is contraindicated.
  • Bone Scan: Consider in cases of suspected osteomyelitis, bone tumors, or metastatic disease.
  • Joint Aspiration: Diagnostic and therapeutic, particularly in suspected septic arthritis or inflammatory arthritis.
  • Leg Length X-ray: Specifically for assessing leg length discrepancies.
  • Electromyography (EMG): To assess for neuromuscular causes of limping, such as peripheral neuropathy or radiculopathy.

Laboratory Tests

  • Full Blood Count (FBC): To check for infection, anemia, or hematologic malignancies.
  • C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR): To assess for inflammation or infection.
  • Blood Cultures: Indicated if septic arthritis or osteomyelitis is suspected.
  • Uric Acid Levels: Consider in suspected gout.
  • Rheumatoid Factor (RF) and Anti-CCP: To evaluate for rheumatoid arthritis in the appropriate clinical context.
  • Antinuclear Antibodies (ANA): Useful in diagnosing systemic lupus erythematosus (SLE) or other connective tissue diseases.
  • Bone Biopsy: Consider in cases of suspected osteomyelitis or bone tumors when other tests are inconclusive.

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Neurosciences