Antalgic gait is a limp that develops in response to pain, often in the foot, knee, or hip. It is the most common type of limp people can have. Causes of antalgic gait range from minor injuries that heal on their own to painful infections and tumors in the bone or soft tissue that need specialist treatment. All of these conditions result in a person taking uneven strides in response to the pain in areas of their lower body, including their hips, legs, and feet. Minor injury is the most common cause of limping in children, followed by infection and inflammation. A person affected by an antalgic limp may lift and lower their foot with their ankle fixed in one position.
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NCBI Bookshelf. Robert Vezzetti ; Bruno Bordoni. Authors Robert Vezzetti 1 ; Bruno Bordoni 2. Antalgic gait is a common symptom in the pediatric patient. The differential diagnosis is broad and includes both benign and serious etiologies. The etiology of antalgic gait can be divided into traumatic and non-traumatic categories.
Traumatic etiologies are typically contusions, strains, and overuse injuries, while non-traumatic etiologies include infectious, oncologic, and bone processes. Most times there is a history of trauma resulting in symptoms that prompt a caregiver to seek evaluation by a healthcare provider. Management of these children depends on the physical examination and imaging findings. These are spiral fractures of the tibia that may follow minimal trauma and sometimes there may be no trauma history.
The most common finding in these children is a refusal to bear weight; the physical examination may be normal or there may be pain elicited over the distal tibia when palpated. There is a low threshold for a thorough evaluation of non-accidental trauma if any of these are present. Additional "red flags" include a delay in seeking care, other signs of injury such as patterned bruising or bruising in unusual locations, such as behind the ears or on the back, and other fractures, particularly fractures in various stages of healing.
Fractures that require a significant amount of force, such as scapular fractures, or unique fracture types, such as corner fractures and bucket-handle fractures, should raise suspicion for non-accidental trauma. If available, the practitioner should also consult with a child abuse pediatrician. The American Academy of Pediatrics has published guidelines on the radiographic evaluation of a child with suspected non-accidental trauma.
This includes a proper skeletal survey in children younger than 2 years of age this imaging test should be performed on children ages 2 to 5 years on a case-specific basis with a repeat survey done in 10 days to evaluate for healing occult fractures that may not be evident on the initial surgery. In children older than 5 years of age, skeletal surveys are of limited value.
The presence of fever and antalgic gait should raise suspicion for an infectious cause. Viral and bacterial agents can produce symptoms. The most frequent bacterial agents are Staphylococcus aureus and Streptococcus progenies. Involved locations may be in the bones of an extremity, the vertebrae, or discs of the spine.
Infections can follow trivial trauma, puncture wounds, or animal bites. Transient Synovitis: Commonly seen in the young school-age children, this condition mimics osteomyelitis or septic arthritis, producing pain and sometimes a refusal to ambulate. Fever may or may to be present. It is self-limited. Infants with osteomyelitis may present with fever and fussiness or pain may be elicited with a movement of the involved extremity. Older children will present with fever and painful gait.
There may be reproducible pain to palpation or pain with a range of motion of the involved extremity. Young children have a predisposition to have concomitant septic arthritis with osteomyelitis due to boney vascular anatomy; this becomes less common as children age. While S. Myositis: Viral myositis is a common cause of antalgic gait in pediatric patients. Influenza is the most predominant virus in these children and is often bilateral.
While any gram-positive bacterial species can case pyomyositis, staphylococcal species predominate. This is often focal and may have associated osteomyelitis. Older children may localize pain to the back especially the lumbar area and infants may become irritable when placed in a sitting position and may prefer to be prone. SCFE: This condition, in which the capital femoral epiphysis is displaced from the femoral neck through the epiphysis, is most often encountered in adolescent patients, particularly those who are obese.
The most frequent presenting symptoms are progressively worsening hip pain and difficulty ambulating without fever. Physical examination of these patients reveals an afebrile child limited range of motion of the hip and tenderness. Symptoms include gradual onset of hip pain and difficulty ambulating. This condition can be preceded by trauma often trivial or associated with chronic steroid use.
Physical examination uncovers a limited range of motion of the hip, but pain may not be a prominent symptom. Osteosarcoma and Ewing sarcoma: - These are the2o most common malignant bone lesions in the pediatric population.
They most often are found in the distal tibia. Progressively worsening pain is the usual symptom and may not respond to anti-inflammatory medications. Often the child will have an existing diagnosis of a rheumatologic disease, but the clinician should keep this possibility in mind, especially in older children, for example teenagers. Children with appendicitis or testicular torsion may present with an antalgic gait.
It is essential to perform a thorough physical examination, including the abdomen and genital areas, to exclude these processes. Several factors should be considered regarding pediatric bone anatomy and physiology. Pediatric bones are unlike adult bones. During development, the epiphysis is weaker than surrounding ligaments, which results in vulnerability to fracture. The porous nature of pediatric bones allows for unique fracture patterns, such as Greenstick fractures and buckle or torus fractures, and bowing deformities in response to injury.
A thorough history and physical examination are an essential first step in evaluating a child with an antalgic gait. The clinician must ask if a child has reached specific developmental milestones, particularly, motor milestones such as crawling or cruising in infants and toddlers or the ability to climb in toddlers and school-age children.
Underlying medical conditions such as osteogenesis imperfect can result in significant injuries even in the setting of apparently trivial trauma and must be taken into account in approaching these children. The physical examination of the child needs to be developmentally appropriate. Pediatric vital signs vary with age. Often it is helpful to simply observe the child as they interact with their caregiver before performing a physical examination.
Examining the non-affected extremity first, followed by gradually examining the area in question is a useful technique to ease stranger anxiety. Note for any signs of edema, erythema, deformity, or diminished range of motion. Pay close attention to the hips particularly in infants and perform a thorough range of motion examination, looking for any signs of distress.
History and physical examination will dictate whether laboratory studies, imaging, or both are indicated. Most children do not warrant testing. The presence of fever, prolonged symptoms, toxic appearance, or concerning symptoms such as weight loss, easy bruising, joint pain are reasons to initiate a workup. When an infectious or oncologic source is suspected, there are basic hematologic tests that can be useful. If an oncologic process is suspected, then lactate dehydrogenase and uric acid tests may be helpful.
There are published risk stratification guidelines that help a clinician differentiate between transient synovitis and osteomyelitis based on clinical examination and laboratory results.
Exposure to ionizing radiation is always a concern in the pediatric population. There are several common imaging modalities can that be employed. Selected imaging of the involved extremity is recommended. The tibia is cited as the bone that is most likely to have pathology on plain imaging.
A proper imaging technique is essential to maximize the effectiveness of the modality as pediatric fractures can be subtle. This includes at least 2 views of an involved extremity or a full pelvis view in evaluating hip pain, not a hemi-pelvis view. Both lesions may show poorly defined margins.
Computed Tomography CT : This modality can be useful in detecting subtle fractures when plain radiography is indeterminate, making it useful in the setting of trauma. CT is not useful for the evaluation of infectious processes. While widely available in most clinical settings, CT scanning does employ ionizing radiation.
Contrast is not employed in trauma settings. This modality is excellent for the evaluation of infectious or oncologic processes. Images are usually obtained with and without contrast. There are several disadvantages of MRI, including lack of availability, cost, and the time required to obtain a study, which often requires sedation in younger children.
However, US cannot distinguish then causes of hip effusion and can be misleading if not performed adequately or performed in an untimely manner.
Open fractures are often managed in the operating room with vigorous irrigation, cleaning, and exploration, followed by reduction if indicated and casting. Management for children with LCP Disease ranges from immobilization to operative intervention. If there is an associated abscess, the operative management is required. Consultation with pediatric rheumatology is recommended. The differential diagnosis of the child with an antalgic gait is broad. Consideration must be given to traumatic, infectious, rheumatologic, and oncologic etiologies.
The prognosis of children with an oncologic etiology depends on the type and stage of the malignancy, which will impact management choices. Appropriate and timely care will significantly impact the development of complications.
Osteomyelitis can progress to bone abscess formation, sepsis, and even result in death. Children with septic joints can develop gait disturbances that are permanent, impacting the quality of life.
Oncologic processes necessitate treatment with chemotherapeutic agents, surgical procedures, or both. This process involves multiple hospitalizations, and children receiving such agents are at risk for significant bacterial and viral infections. Rheumatologic etiologies can produce a significant impact on activities of daily living; the treatment agents used for these children also may place them at risk for significant infections.
Simple fractures of the femur, tibia, fibula, and foot require splinting with cast application within 1 week by a pediatric orthopedic surgeon. If any lesions are encountered on imaging that suggests malignancy, both pediatric oncology and pediatric orthopedics should be promptly consulted before the disposition of the child.
Caregivers of children who are discharged from the emergency department with antalgic gait should be given appropriate return precautions and timely followup arranged. Antibiotics should not be initiated.
NCBI Bookshelf. Robert Vezzetti ; Bruno Bordoni. Authors Robert Vezzetti 1 ; Bruno Bordoni 2. Antalgic gait is a common symptom in the pediatric patient. The differential diagnosis is broad and includes both benign and serious etiologies.
That often results in limping. The root of walking with an antalgic gait is pain. That pain can come from a number of causes including:. The treatment of antalgic gait starts with the identification and treatment of the underlying pain. Once the cause has been pinpointed, your doctor may prescribe specific treatment, such as:.
It is a form of gait abnormality where the stance phase of gait is abnormally shortened relative to the swing phase. It is a good indication of weight-bearing pain. From Wikipedia, the free encyclopedia. Journal of Bone and Joint Surgery.