Clinical The Limping Child IN THE URGENT CARE CENTER Urgent message: The ability to evaluate children presenting with a limp—and to recognize red flags that help distinguish those to treat from those requiring immediate referral—should be within the purview of the urgent care clinician. Raymond W. Liu, MD, Hadeel Abaza, MD, and Allison Gilmore, MD Introduction limping child without a clear traumatic history or diagnosis is a common presentation to an urgent care center. The broad differential diagnosis can be daunting, with causes that range from relatively benign conditions or injuries to those requiring emergent care. A careful history and physical exam, in conjunc- tion with an understanding of the age relationship of many diagnoses, can narrow the differential dramatically and inform the decision to treat or refer as needed. This article will provide a framework for evaluating limping children in the urgent care center, with an em- phasis on preventing potentially catastrophic outcomes. Types of Gait While determining type of gait is ideal, this is probably beyond the scope of training of the typical urgent care practitioner. Therefore, recent changes in gait should be determined whenever possible, whether identified by di- w w w. j u c m . c o m © Photoresearchers (X-Ray) and Corbis (People). Digital Composite: Tom DePrenda A rect questioning of the pa- tient or reported by the care- giver. Antalgic gait is the most common gait type seen, re- sulting from pain in any part of the lower extremity or the back. It is characterized by a shortened stance phase on the affected side, with a re- sultant increase in the swing phase. In more severe cases, the child refuses any weight bearing. Differential diagno- sis of antalgic gait may be categorized according to the patient’s age (Table 1). Other, less common, gaits categorized as nonantalgic are beyond the scope of this article. Patient History Typically, the history taken from a child is incomplete and supplementation from the caregivers can be helpful. Any associated trauma should be delineated. If pain is present, it is important to document its location, fre- quency, duration, and timing. Acute pain suggests trauma, infection, or malignancy, JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | D e c e m b e r 2 0 0 7 11