Antalgic Gait in Children (Limping in Children)

What is Antalgic Gait in Children (Limping in Children)?

An antalgic gait, or a limp, is often seen in children and can be a sign of many different health conditions. These conditions can range from harmless to severe. By asking detailed questions about the child’s medical and personal history, performing a physical examination, and using tests or medical images wisely, doctors can usually determine the cause of the limp in children.

What Causes Antalgic Gait in Children (Limping in Children)?

An antalgic gait, or a walking style that aims to avoid pain, can be caused by either traumatic or non-traumatic issues. Traumatic issues normally involve things like bruises, muscle strains, and overuse injuries. Non-traumatic issues, on the other hand, can include infections, cancer, and bone disorders.

Traumatic issues often have a history of injury causing symptoms that make parents or caregivers seek medical help. For example, older infants and young children may get something called a toddler’s fracture, which is a specific type of lower leg fracture that can occur even with minimal trauma. These children often refuse to put weight on the leg. X-rays may help confirm the fracture, but in around 40% of cases, the X-ray may appear normal. In these situations, a visit to a pediatric orthopedist, a doctor who specialises in treating children’s bones, may be needed.

Healthcare providers should always consider the possibility of non-accidental trauma in children, particularly in infants or kids who can’t walk yet. Signs of this can be injuries that don’t align with the child’s developmental level or the provided explanation. Several red flags include, delayed care seeking, unusual bruising, and fractures at different healing stages. If child abuse is suspected, a thorough evaluation and notification of child protective services are mandatory.

Non-traumatic issues can often be infectious. If a child has a fever and an antalgic gait, it may be due to an infection caused by a virus or bacteria like Staphylococcus aureus or Streptococcus pyogenes. The infection might be in an extremity, the spinal bones, or discs of the spine. Children may also present with conditions such as Transient Synovitis, Osteomyelitis, or Myositis, which can affect gait and cause pain.

Some bone abnormalities can also cause an antalgic gait. Conditions like slipped capital femoral epiphysis (a condition where the ball at the head of the thigh bone slips backwards) and Legg-Calvé-Perthes disease (a condition that disrupts blood flow to the hip) are common causes in the pediatric population.

Cancer can also cause issues with walking in children. This can vary from a benign tumor which causes pain at night relieved by anti-inflammatory medications, to more serious conditions like Osteosarcoma, Ewing sarcoma, and Leukemia characterized by progressively worsening pain.

Rarely, disorders like juvenile rheumatoid arthritis (JRA) and lupus can also be the cause. In rare cases, conditions like appendicitis or testicular torsion could also be the reason behind a child’s antalgic gait. Therefore, it’s important that a complete physical examination, including the abdomen and genital areas, is performed to rule out these conditions.

Risk Factors and Frequency for Antalgic Gait in Children (Limping in Children)

An antalgic gait is a type of limp that kids can sometimes have. Different things can cause it at different ages. For adolescents and teenagers, the common causes include conditions like SCFE and osteoid osteoma. Younger children might get this limp from LCP or transient synovitis.

Signs and Symptoms of Antalgic Gait in Children (Limping in Children)

When a child is walking differently to avoid pain (known as an “antalgic gait”), a detailed medical history and physical check-up are necessary. It’s important to ask if the child has reached certain development phases, like pulling themselves up and moving along furniture for infants and toddlers, or being able to climb for older toddlers and school-age children. This step is key if the child’s pain is a result of a fracture. Some health conditions like osteogenesis imperfecta, a condition that weakens bones, can cause serious injuries from what seems like a minor trauma. Therefore, it should always be taken into account when examining these children.

A child’s physical examination must be suitable for their development stage. As a child’s vitals can vary with their age. It can be helpful to watch the child interact with their caregiver before beginning the examination. Start by examining the unaffected limb, then slowly move towards the area causing discomfort. This helps to make the child less anxious. During the examination, look for signs of swelling (edema), redness (erythema), abnormal shape (deformity), or reduced movement range. Special attention should be given to the hips, especially in infants, to examine the range of movement and look for signs of discomfort. If the child is old enough, having them try to walk towards their parents can help identify where the pain is by observing their walking pattern.

Testing for Antalgic Gait in Children (Limping in Children)

A child’s health history and physical exam will guide the decision on whether further tests and scans are needed. Most children may not need these additional steps. But, indicators such as fever, long-lasting symptoms, looking unwell, or concerning symptoms like weight loss, easy bruising, or joint pain may require further investigation.

Lab Tests

When an infection or cancer is suspected, certain blood tests can be helpful. These tests could include a Complete Blood Count (CBC), checks for inflammation (like Erythrocyte Sedimentation Rate or C-Reactive Protein), and a blood culture. Some other tests that analyze the chemistry of the child’s blood, including their liver function, can be beneficial to check if other organs might be involved, which could happen in cases of children with infections or cancers. If cancer is suspected, additional tests to check levels of certain chemicals in the blood, such as Lactate Dehydrogenase and Uric Acid, could be used. Some guidelines can help doctors differentiate between temporary joint inflammation and bone infection based on the clinical exam and lab test results.

Imaging

Exposure to radiation is a significant concern when scanning children, and various international guidelines and expert opinions back the concept of keeping radiation exposure “as low as reasonably achievable.” Several typical imaging methods can be used.

Plain Radiography: Readily available with low radiation exposure, this is the first choice for imaging in children with a painful and limping walk. The picture should focus on the specific part of the body causing the issue. X-rays are useful for detecting trauma, certain hip conditions, or suspected bone infections or joint infections, primarily to rule out other diseases. The imaging technique should be correctly done to effectively identify fractures, which can be subtle in children. Distinctive patterns on the x-ray may hint towards specific types of bone cancer.

CT Scan: A CT scan can capture subtle fractures that may not be detected through x-ray, making it useful in cases of trauma. However, it’s not that helpful for identifying infections. Although a CT scan is available in most hospitals, it does use ionizing radiation. In trauma settings, a contrast dye is generally not used.

MRI: The MRI scan’s advantages include no radiation exposure and superior image detail. This method is excellent for checking for infections or potential cancer cases. The images are typically taken with and without a contrast dye. However, the disadvantages of MRI include higher costs and longer scanning times, often necessitating sedation in younger children.

Ultrasound: This method can detect fractures and is readily available, does not expose the child to radiation, and does not need a contrast dye. However, it can’t differentiate the causes of hip fluid buildup and might give misleading results if not done correctly or on time.

Treatment Options for Antalgic Gait in Children (Limping in Children)

Broken bones in children are often managed with a splint, followed by the application of a cast for a few weeks. This treatment usually applies to simple fractures that haven’t moved out of place. However, the extent of the fracture and the age of the child determine if a surgical treatment is necessary. Open fractures, in which the bone is exposed, typically require cleaning and irrigation in the operating room. This process is followed by realignment of the bone, if needed, and casting. It’s advisable to consult with a children’s orthopedic specialist, especially if there’s uncertainty about the proper treatment.

For children with conditions like slipped capital femoral epiphysis (SCFE) or Legg-Calve-Perthes (LCP) disease, immediate consultation with a pediatric orthopedic specialist is necessary. Children diagnosed with SCFE generally need surgical repair. Notably, this isn’t always the case if the slip is minor. Still, these children must avoid putting weight on the affected leg and follow-up frequently with a medical professional. Usually, a preventative measure, like inserting a pin, is taken to prevent any further slippage. The management of LCP disease varies from patient to patient, depending on their symptoms and results from imaging tests, and could range from immobilization of the joint to surgery.

Children with bone infections, muscle inflammation, or disc inflammation are usually hospitalized for treatment and given intravenous antibiotics. It’s recommended to consult a pediatric infectious disease specialist or pediatric orthopedic surgeon before beginning antibiotic treatment. If an abscess, or a pus-filled sac, is present, surgical removal is necessary.

In cases where the pain may be due to cancer, the child is typically admitted to the hospital for further testing and treatment. This process is managed under the guidance of a pediatric oncologist, and the extent of the disease is determined.

For children presenting with pain due to rheumatic diseases, treatment really depends on how severe their pain is and how well it responds to pain relievers. Consulting with a specialist in pediatric rheumatology is typically recommended to guide the treatment process.

What else can Antalgic Gait in Children (Limping in Children) be?

If a child is observed to have a limping or uneven gait, there could be several reasons behind it. These could be due to an injury, infection, disease related to the immune system, or even cancer. In order to determine the exact cause, a detailed understanding of the child’s history, an extensive physical examination, and accurate laboratory tests and imaging are crucial.

The possible conditions that might cause this include:

• Appendicitis
• Bruises
• Discitis (an inflammation of the intervertebral disc space)
• Ewing sarcoma (a type of cancer that occurs in bones or soft tissue)
• Fractures
• Juvenile rheumatoid arthritis (a long-term disease causing stiffness and inflammation in the joints)
• LCP disease (a hip disorder)
• Leukemia (a type of cancer of the blood and bone marrow)
• Myositis (inflammation of the muscles)
• Non-accidental trauma (abuse or maltreatment)
• Osteomyelitis (a bone infection)
• Osteosarcoma (a type of bone cancer)
• SCFE (a hip condition in teens)
• Septic arthritis (joint inflammation due to bacterial or fungal infection)
• Septic joint (infection in a joint)
• Transient synovitis (temporary inflammation of the hip)

What to expect with Antalgic Gait in Children (Limping in Children)

Most children with broken bones usually recover well after receiving suitable treatment. Similarly, children who experience pain due to an infection also do well after appropriate care. However, in cases where the pain is caused by cancer, the child’s prognosis largely depends on the type and stage of the cancer, which will influence the treatment options selected.

For kids with a rheumatologic cause for their pain – meaning, the pain is caused by conditions related to inflammation or degeneration of muscles, joints, or fibrous tissue – they are typically kept on suitable medications based on their specific diagnosis. This could be juvenile rheumatoid arthritis or lupus, for instance.

Possible Complications When Diagnosed with Antalgic Gait in Children (Limping in Children)

The health complications and risk of death in a child largely depend on what’s causing their symptoms. Providing the right treatment at the right time can greatly reduce the chances of complications coming up. If a child has osteomyelitis (a bone infection), there’s a risk it could lead to a bone abscess (a pocket of pus), sepsis (a reaction to severe infection) or even death. Children who have septic joints (infected joints) might end up with permanent walking problems that could affect their quality of life.

When it comes to cancer-related issues, treatment usually involves chemotherapy drugs, surgery, or both. This can mean many hospital stays for the child, and the chemotherapy can make them more likely to get severe bacterial and viral infections. Children with rheumatological conditions (diseases affecting the joints, muscles, and ligaments) can also find their daily activities seriously affected. The treatments for these conditions could also increase their risk of severe infections.

Key risks to children’s health:

• Bone abscesses due to osteomyelitis
• Sepsis
• Death from severe infection
• Permanent walking problems due to septic joints
• Higher risk of severe infections due to cancer treatments
• Impact on daily activities from rheumatological conditions
• Increased risk of severe infections from treatments for rheumatological conditions

Preventing Antalgic Gait in Children (Limping in Children)

If a child is released from the emergency room walking in a way that suggests they’re trying to avoid pain, caregivers should be briefed on when to bring the child back for a check-up and make sure a follow-up is scheduled soon. They shouldn’t start an antibiotics course. If the child continues to have a high temperature, the pain doesn’t reduce or gets worse, they refuse to walk, or they seem unusually grouchy, it could be a sign that a return to the emergency room is necessary. Depending on the case, the child may need a follow-up appointment with a children’s bone specialist.