Updating systematic reviews

For a limping child with focal findings on physical examination, initial imaging includes anteroposterior and lateral radiography of the involved site.

If there are no focal findings on physical examination, radiography of both lower extremities should be performed.

Causes of chronic limp include rheumatic disease, dermatomyositis, acute rheumatic fever, inflammatory bowel disease, and systemic lupus erythematosus.

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(CBC = complete blood count; CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; MRI = magnetic resonance imaging; WBC = white blood cell.)A history should be obtained from the child and ideally both parents.

If possible, separate interviews should be performed when physical abuse is suspected.12The initial interview can provide valuable clues .

Several different types of limps are associated with nonantalgic gait, and most do not require urgent evaluation and treatment.

There are a variety of etiologies for limping in a child Print Figure 1.

Toxic synovitis also may present with an associated viral illness and fever.

Rheumatic disease and leukemia are rare causes of fever and limp.

Hip joint effusion (the joint has maximal intracapsular space when flexed, abducted, and externally rotated; a child with hip effusion attempts to keep the hip in this position to maximize joint volume and minimize pain); septic arthritis Hip joint effusion (the joint has maximal intracapsular space when flexed, abducted, and externally rotated; a child with hip effusion attempts to keep the hip in this position to maximize joint volume and minimize pain); septic arthritis Gait is best examined by having the child walk and run while distracted.

Each limb segment should be observed systematically through several gait cycles.

The stance phase is further divided into initial double-limb support (20%) followed by single-limb stance (60%) and another period of double-limb support (20%).3With increasing age, the duration of single-limb stance, walking velocity, and step length increase, whereas the number of steps taken per minute decreases.

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