Pediatric Leg Disorder

See Limping Child for acute painful gait
This Pediatric Leg Disorder topic addresses the more chronic, progressive pediatric leg abnormalities

Distinguish between 2 types of Gait Abnormality (critical first step)
1. Acute, Antalgic Gait (painful) resulting in Limping Child (urgent evaluation)
  1. See Limping Child
2. Chronic, progressive, nonantalgic gait or other leg abnormality
  1. Described here
Past medical history and growth and development
1. Prenatal and birth history
2. Developmental Milestones

Growth
1. Height and weight with growth percentiles
2. Normal growth decreases likelihood of underlying systemic condition (e.g. Rickets, metabolic bone disease)
Facial Appearance
1. Abnormal facies may suggest genetic disorder
Neurologic
1. See Developmental Delay
2. See Muscle Weakness in Children
Skin
1. Ecchymosis
  1. Nonaccidental Trauma
2. Midline spinal skin changes (e.g. dermal sinus, midline Lipoma, sacral dimple)
  1. See Cutaneous Signs of Dysraphism
3. Neurocutaneous Syndrome (e.g. Cafe-Au-Lait Macule)
  1. See Neurofibromatosis

See Gait Evaluation in Children
Distinguish between painful (antalgic) and non-painful (nonantalgic) Abnormal Gait
Antalgic Gait
1. Stance phase on unaffected limb is shortened due to pain
2. Refusal to bear weight especially with limited range of motion, systemic symptoms, fever
  1. Septic Arthritis
Nonantalgic gait
1. See Abnormal Gait
2. Includes Steppage Gait, Trendelenburg Gait, Circumduction Gait, Equinus Gait

Joint Inflammation (Joint Swelling, warmth, and painful range of motion)
1. Inflammatory Arthritis
2. Septic Arthritis (non-weight bearing)
3. Reactive Arthritis
Muscle
1. Muscular atrophy: Disuse atrophy or neurologic disorder
2. Calf hypertrophy: Muscular Dystrophy
Ligaments
1. Joint Laxity
Bone Tenderness
1. Fracture or bone Contusion
2. Bone Tumor (may present with palpable bone mass)
3. Osteomyelitis
Spine
1. Evaluate spinal flexion and extension
2. Evaluate for Scoliosis, lumbar lordosis, thoracic kyphosis

See Hip Exam
See Hip Rotation Evaluation in Children
See Hip Range of Motion
Gluteal or thigh skin fold asymmetry
1. Congenital Hip Dysplasia
Galeazzi Sign
1. Limb Length Discrepancy
FABER Test or Pelvic Compression Test positive
1. Sacroiliac Joint Disorder
Trandelenburg Test positive
1. Congenital Hip Dysplasia, weak hip adductors
W-Sitting Position
1. Associated with Femoral Anteversion
2. Patient sits on floor with each heel adjacent to the ipsilateral hip
  1. Hips flexed and externally rotated
  2. Knees maximally flexed
Hip resting position flexed and externally rotated
1. Slipped Capital Femoral Epiphysis
  1. Hip unable to be abducted or internally rotated
2. Hip Joint effusion
  1. Hip abducted
Hip internal rotation lost
1. Aseptic Necrosis of the Femoral Head
2. Slipped Capital Femoral Epiphysis
3. Intraarticular hip disorder
Pelvic compression resulting in pain
1. Sacroiliac joint disorder
2. Pelvis Trauma

Foot Deformity
1. See Pediatric Foot Evaluation
2. See Gait Evaluation in Children
3. See Foot Anatomy
4. Consider common foot disorders
  1. Clubfoot (tiptoe walking, fixed equinus position)
  2. Metatarsus Adductus (foot cause of In-Toeing)
  3. Calcaneovalgus Deformity (Out-toeing)
Rotational Deformity
1. Torsional Profile (Leg Rotation Evaluation in Children)
2. Foot Progression Angle (In-Toeing, Out-toeing)
3. Thigh-Foot Angle (tibial torsion)
4. Hip Rotation Evaluation in Children (Femoral Anteversion)
Angular Deformity
1. Nearly all newborns start with Genu Varum
  1. Neutral position by age 2 years
  2. Genu Valgum by age 3-6 years
  3. Returns to neutral or slightly valgus position (esp girls), by age 7-11 years old
2. Evaluate standing knee alignment
  1. Intercondylar distance
  2. Intermalleolar distance
  3. Tibiofemoral angle
3. Disorders
  1. Genu Varum (bow leg)
  2. Genu Valgum (knock knee)