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66-558: A limp is a type of asymmetric abnormality of the gait. Limp or LIMP may also refer to: Limp A limp is a type of asymmetric abnormality of the gait . Limping may be caused by pain, weakness, neuromuscular imbalance, or a skeletal deformity. The most common underlying cause of a painful limp is physical trauma ; however, in the absence of trauma, other serious causes, such as septic arthritis or slipped capital femoral epiphysis , may be present. The diagnostic approach involves ruling out potentially serious causes via

132-430: A WBC count greater than 12×10 /l, fever greater than 38.5 °C (101.3 °F), ESR greater than 40 mm/h, CRP greater than 2.0 mg/dL, and refusal to walk. People with septic arthritis usually look clinically toxic or sick. Even in the absence of any of these factors, however, septic arthritis may be present. Joint aspiration is required to confirm the diagnosis. Other infections that classically lead to

198-660: A challenge and it is important to have a toolbox of skills, supports and strategies to draw upon to manage the ups and downs of having a chronic illness. There are many things that can help children with JIA to grow up to have full and active lives. Having good sleep habits and routines gives a child the best chance of having a refreshing night's sleep and preventing daytime fatigue. This in turn affects concentration, energy levels, memory and mood. Most children need between eight and twelve hours of sleep to feel refreshed, depending on age. Simple strategies like maintaining regular bedtimes, limiting screen time to two hours before bed, having

264-469: A child with JIA typically involves a team of medical professionals, which may include (but is not limited to) paediatric rheumatologists, paediatric rheumatology nurses, general paediatricians, general practitioners, adult rheumatologists, physical therapists (PTs), occupational therapists (OTs), podiatrists , psychologists, social workers, pharmacists, ophthalmologists and orthopaedic surgeons . The multi-disciplinary team (MDT) work in conjunction with

330-407: A child's confidence in their own body. They usually work with the child and family to develop a home exercise program which changes over time as the child makes progress. Arthritis in childhood can be associated with muscle weakness and wasting around the affected joints. It can also lead to low bone density , which may predispose to osteoporosis and fractures in adulthood. Getting regular exercise

396-406: A classic rash and may become quite ill. Late effects of arthritis can include joint contractures (stiff, bent joints with loss of movement) due to joint damage; limb length discrepancies and muscle wasting . Children with JIA vary in the degree to which they are affected by particular symptoms. Eye disease: JIA is associated with inflammation in the front of the eye (specifically iridocyclitis ,

462-474: A detrimental effect on JIA. In fact, there is evidence to show that both low and high-intensity exercise programs result in improved physical function and reduced pain in children with JIA. Guidelines indicate that children with JIA should be encouraged to be physically active and can safely participate in sports without disease exacerbation. Those with actively inflamed joints should limit activities within pain limits, then gradually return to full activity following

528-439: A disease flare. It may be necessary to use aids like splints or casts to correct biomechanics , but prolonged splinting and casting are now rarely indicated for children with JIA. Following joint injections, children are often advised to 'take it easy', often undertaking one to two days of low activity, although advice around this varies. When a joint (usually a knee) loses range of motion due to prolonged inflammation and pain,

594-469: A form of chronic anterior uveitis ), which affects about one in six children with JIA. Eye involvement occurs most commonly in girls, those with only a few joints involved ( oligoarthritis ), and those with a positive anti-nuclear antibody (ANA). It usually follows the onset of arthritis or may be detected at the same time as arthritis; occasionally it may occur before joint involvement. The factors linking eye and joint disease are not clearly understood, and

660-717: A large joint (such as the knee) is inflamed may have increased growth in the short term, leading to limb-length discrepancy (i.e. one arm or leg is slightly longer than the other). This is due to increased blood supply to the bony growth plates surrounding the inflamed joints. Bone density and bone strength may be reduced through a combination of inflammation, corticosteroid use and reduced physical activity levels. Other musculoskeletal complications may include joint contractures, muscle weakness or muscle wasting. Uveitis, if left untreated, can result in scarring, glaucoma , cataracts , and even blindness . Regular monitoring allows for early detection and treatment. Steroid eye drops are usually

726-407: A limp include Lyme disease (a bacterial infection spread by deer ticks ) and osteomyelitis (an infection of the bone). Accidental or deliberate physical trauma may result in either a fracture, muscle bruising, or a contusion. It is the leading cause of a limp. Deliberate abuse is important to consider. Slipped capital femoral epiphysis (SCFE) is a condition in which the growth plate of

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792-407: A range of devices including computers, laptops, personal digital assistants, multimedia-players, and wearable accelerometers synchronised to smart phone. This allows access to these interventions from home. Early usability studies have been gaining positive feedback by children and adolescents. They are familiar with this type of technology and report liking these interventions. However further research

858-491: A refusal to walk. Hip deformities with associated muscular weakness, on the other hand, may be present with a Trendelenburg gait , with the body shifted over the affected hip. The causes of limping are many and can be either serious or non-serious. It usually results from pain, weakness, neuromuscular imbalance, or a skeletal deformity. In 30% of cases, the underlying cause remains unknown after appropriate investigations. The most common underlying cause of limping in children

924-427: A series of plaster casts may be used to gradually extend shortened muscles and restore range. These serial casts are usually applied over days to weeks. Active strengthening and lengthening is used in conjunction with serial casting for optimal results. Some children may benefit from foot orthotics to support and correct body position and function. Orthotics maintain biomechanical alignment and may reduce discomfort in

990-577: A sleep ritual, avoiding napping during the day, avoiding sugary and caffeinated drinks, having a healthy well-balanced diet, regular exercise and using relaxation techniques can assist in having good night's sleep. Relaxation techniques can also help to reduce stress, physical tension and be a useful pain management technique. There are a variety of mindfulness strategies which include things like deep breathing, guided-imagery or progressive muscle relaxation. All techniques need to be practiced over time, and it may be necessary to try different combinations to find

1056-408: Is a degenerative disease of the head of the femur which results in bone loss and deformity. It usually presents as a chronic condition. Cancers including acute lymphocytic leukemia , osteosarcoma , and Ewing’s sarcoma may result in a gradual onset of limping in children. It is often associated with night sweating, easy bruising, weight loss, and pain most prominent at night. The diagnosis of

1122-449: Is a predictor of psycho-social well-being. Several studies has also shown that pain at debut is a strong predictor of persistent pain. Pain has been found to negatively impact all aspects of quality of life and is associated with a reduction in physical, social and emotional functioning. Children who have higher levels of pain tend to have reduced levels of socialization, school attendance and participation in activities. Increased pain

1188-495: Is also correlated with poor sleep and higher fatigue in children with JIA. The causation of pain in JIA is multifactorial. There are disease-related factors, which relate to the inflammatory process, and anatomical or biomechanical changes that are associated with joint swelling and joint disease. There are psychological factors around dealing with stress, coping with a chronic illness and managing anxiety or depression which can influence

1254-481: Is an important part of the management of JIA to promote bone and muscle health. There is variation in the exact exercise prescription which best promotes musculoskeletal health whilst reducing fatigue, pain and swelling. Consensus is that children with JIA should be following national public health standards of physical activity and participating in moderate fitness, flexibility, and strengthening exercises, compatible with their abilities and disease restrictions. It

1320-509: Is characterised by chronic joint inflammation. JIA is a subset of childhood arthritis, but unlike other, more transient forms of childhood arthritis, JIA persists for at least six weeks, and in some children is a lifelong condition. It differs significantly from forms of arthritis commonly seen in adults ( osteoarthritis , rheumatoid arthritis ), in terms of cause, disease associations, and prognosis. The prognosis for children with JIA has improved dramatically over recent decades, particularly with

1386-482: Is currently underway, with the goal of forming more personalized treatment plans, reducing medication side effects and improving remission rates. Current areas of investigation include clinical, protein, genetic and radiological markers, amongst others. Children with JIA demonstrate similar levels of depression and anxiety to children with other chronic diseases; however, causality has not been established. The unpredictable and undulating course of JIA disease activity and

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1452-659: Is important that – across the week – the exercise is a combination of moderate to vigorous cardiovascular activity (e.g. walking to school, scooting, bike-riding, playing tag, dancing, doing physical education, sports such as basketball or football) and strengthening exercises. Bone strengthening activities build up muscles; by having the muscles push and pull against the bone, the bones themselves get stronger. This can include things like playing on climbing equipment, swinging on monkey-bars, using weights, carrying groceries, skipping or running. A Cochrane meta-analysis looking at existing RCTs showed in all studies that exercise does not have

1518-456: Is joint swelling which is sometimes – but not always – associated with pain. The presence of joint stiffness is another typical feature, particularly when present in the morning and improving with activity. No single test can confirm a diagnosis of JIA: a combination of presenting signs and symptoms, blood tests , and if necessary medical imaging, is used to make the diagnosis. The blood tests may measure levels of inflammatory markers, as well as

1584-432: Is mainly because JIA is an umbrella term for several subtypes of JIA, which differ according to the number of affected joints, severity of disease and presence or absence of inflammation in other parts of the body. The key clinical feature in JIA is persistent swelling of the affected joints. Any joint can be affected, but large joints such as the knee and ankle are most commonly involved. Involvement of small joints of

1650-455: Is minor physical trauma . In those with no history of trauma, 40% are due to transient synovitis and 2% are from Legg–Calvé–Perthes syndrome . Other important causes are infectious arthritis, osteomyelitis, and slipped capital femoral epiphysis in children. Septic arthritis can be difficult to separate from less serious conditions such as transient synovitis . Factors that can help indicate septic arthritis rather than synovitis include

1716-492: Is most common in Caucasians. The cause of JIA, as the word " idiopathic " suggests, is unknown and an area of active research. Current understanding of JIA suggests that it arises in a genetically susceptible individual due to environmental factors. The diagnosis of JIA can be difficult, in part because joint pain in children is so common and may be from many causes other than JIA. The characteristic feature of arthritis

1782-458: Is still needed to understand their full potential in supporting children and adolescents living with complex needs. At the time of receiving a JIA diagnosis, children and their families often have many questions regarding prognosis . Recent therapeutic advances in the management of JIA have made inactive disease and clinical remission achievable goals for the majority of children with access to modern treatments. Clinical remission can be defined as

1848-812: Is the knee, but other affected joints may include the ankles, wrists, elbows and others. The anti-nuclear antigen (ANA) is positive in up to 80% of patients with oligoarthritis and is associated with a higher risk of associated eye disease (uveitis), particularly in younger patients. The prefixes oligo- and pauci- mean 'few'. There are several other disorders and diseases that present with symptoms like JIA. These causes include, but are not limited to, infectious (for example septic arthritis or osteomyelitis ) and post-infectious conditions ( reactive arthritis , acute rheumatic fever , and in some geographic areas Lyme disease ); hematologic and neoplastic diseases such as leukemia or bony tumors; and other connective tissue diseases (such as systemic lupus erythematosus ). For

1914-465: The Systemic JIA subtype often experience extra-articular manifestations including fever, rash, enlarged lymph nodes, enlarged liver or spleen, serositis and anaemia. JIA is a chronic disorder, which if neglected, can lead to serious complications. However, with regular follow-up and modern treatments, complications have reduced and outcomes improved. If inflammation is not treated, it can damage

1980-618: The absence of signs and symptoms of inflammatory disease activity, including extra-articular manifestations of the disease. Differentiating subtypes of JIA helps to target treatment and leads to more positive outcomes, however subtype is not the only predictor of JIA outcome. Poor prognostic factors include arthritis of the hip, cervical spine, ankles or wrists; prolonged elevation of inflammatory markers; and radiographic evidence of joint damage including erosions or joint space narrowing. Patients with RF-positive polyarthritis often have worse outcomes associated with more aggressive disease. Despite this,

2046-431: The affected joints, for example a knee held bent causing a limp, or being unable to make a full fist. Limited movement may reduce a child's ability to fully participate in activities and undertake usual tasks such as those used for self-care. In some JIA subtypes, more non-specific symptoms of being unwell may be present, such as lethargy , fatigue and poor appetite. Children with systemic JIA usually present with fever and

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2112-844: The case of unexpected events or medication administration during school hours. Importantly, JIA can be disruptive not just to the academic aspects of school. It is equally important to optimise school attendance so that the child can maintain friendships and keep up with opportunities to socialize with peers. As adolescents progress through high school, they may need to factor their current medical status and functional abilities into decisions around their future education and employment plans. Most children with JIA will not be restricted in their study goals or professional aspirations. Students with JIA can usually apply for special arrangements during assessment periods, such as additional time to allow for rest/stretch periods and use of adaptive equipment in some situations. These applications often need to be supported by

2178-438: The cause of a limp is often made based on history, physical exam findings, laboratory tests, and radiological examination. If a limp is associated with pain it should be urgently investigated, while non-painful limps can be approached and investigated more gradually. Young children have difficulty determining the location of leg pain, thus in this population, knee pain equals hip pain . SCFE can usually be excluded by an x-ray of

2244-594: The child and their family to develop strategies to help with these issues. Many JIA support organisations run camps and activities for children with JIA and their families. Surgery is only used to treat the most severe cases of JIA and is now rarely required. Maintaining physical activity is important in all children, but especially for children with JIA. The physical therapist has a role in guiding physical rehabilitation (muscle stretching and strengthening, enhancing joint range of movement, improving balance, etc.); optimising physical functioning; goal-setting; and improving

2310-641: The child and their family with support and education about JIA, strategies to promote age-appropriate self-sufficiency and help the child to adapt and adjust to any challenges they face. There are many ways to make daily tasks easier or more manageable. One of the key ways the multidisciplinary team helps children with JIA is to involve them, and their families, in the decision-making process regarding their treatment and rehabilitation. In young children with JIA, symptoms may result in either delay or regression in developmental milestones such as walking, running or climbing. Upper limb function may also be affected. Members of

2376-474: The child and their parents, the local health service and medical team, the child's school and teachers, community leaders and sports coaches to best support the child and their family. Together, the team help children to participate as fully and independently as possible in their daily activities by maximising quality of life, maximising function and minimising disruption to the life of the child or young person. The multidisciplinary team work together to provide

2442-660: The child or young person and their family. Optimal management of JIA requires a multidisciplinary team working to address the needs of an individual patient. Optimising physical and social functioning is accomplished via a two-pronged approach: non-pharmacological strategies such as physical therapies, pain management strategies, and social supports; and the swift use of medication to control inflammation and extra-articular symptoms. Early diagnosis and treatment are imperative in helping reduce joint damage and other symptoms, which will help reduce levels of permanent damage leading to long term disability. The optimal approach to treating

2508-447: The diagnosis. Rarely, metabolic diseases, such as Farber disease may also mimic JIA. Patients with Farber disease typically have subcutaneous nodules and a hoarse or weak voice due to growth of nodules on the larynx. The major emphasis of the treatment of JIA is helping the child or young person regain normal levels of physical and social functioning by controlling inflammation and extra-articular symptoms. Clinical remission should be

2574-504: The disorder is autoimmune — meaning that the body's own immune system starts to attack and destroy cells and tissues (particularly in the joints) for no apparent reason. The immune system is thought to be provoked by changes in the environment , in combination with mutations in many associated genes and/or other causes of differential expression of genes. Experimental studies have shown that certain mutated viruses may be able to trigger JIA. The disease appears to be more common in girls, and

2640-439: The family, the school and the health care team. Prolonged or repeated school absences can have academic, social and emotional implications; except in rare circumstances they are rarely necessary (other than absences for medical or therapy appointments). These adaptations may include requiring extra time to get between classes or during examinations, using specialised pens or switching to typing rather than handwriting, or minimising

2706-457: The first line treatment for anterior uveitis. However, other treatments – many of which also treat arthritis (e.g. methotrexate , biologics ) – may be required to keep the inflammation under control, and to minimise steroid use over the longer term. Long term steroid use can cause contribute to the development of cataracts. Macrophage activation syndrome (MAS) is a severe, potentially life-threatening complication that can occur in patients with

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2772-538: The first sign of arthritis may be limping, especially in the morning. Young children are often very good at changing how they move when they have joint pain: they learn to move so that it does not hurt. For example, a child will not push up using an inflamed wrist when climbing, instead putting their weight through the forearm. Morning stiffness that improves later in the day is a common feature (this implies inflammatory-type joint pain versus mechanical-type joint pain). Swelling and pain usually result in limited movement of

2838-439: The first six months of disease. Two subtypes of oligoarticular arthritis exist: persistent oligoarthritis, where no more than four joints are affected throughout the whole disease course; and extended oligoarthritis, where more than four joints are affected after the first six months of disease. Patients in this subtype are often young, typically aged two to three years and with a female preponderance. The most commonly involved joint

2904-468: The first six months: Each subtype has a specific pattern of features as outlined in the table and descriptions below. (The seventh category, not included in the table, is 'Undifferentiated' and includes any patient with JIA who does not meet criteria for other subtypes, or who meets criteria for two or more subtypes). skeleton Oligoarticular (or pauciarticular ) JIA is the most common JIA subtype, and occurs when there are up to four joints involved during

2970-507: The hands and feet is more likely when many joints are affected (' polyarthritis '). Swollen joints may also feel warmer to touch. Swelling may be difficult to detect clinically, especially for joints such as those of the spine, sacroiliac joints , shoulder, hip, and jaw; imaging techniques such as ultrasound or MRI can be very useful to identify the inflammation. Joint pain is an important symptom, although some children experience minimal or no pain with their arthritis. In these children,

3036-642: The head of the femur may occur. A non-painful limp may be due to a number of mechanical conditions including hip dysplasia and leg length differences. Transient synovitis is a reactive arthritis of the hip of unknown cause. People are usually able to walk and may have a low grade fever. They usually look clinically nontoxic or otherwise healthy. It may only be diagnosed once all other potential serious causes are excluded. With symptomatic care it usually resolves over one week. Juvenile rheumatoid arthritis presents gradually with early morning stiffness, fatigue, and weight loss. Legg–Calvé–Perthes syndrome

3102-422: The head of the femur slips over the underlying bone. It most commonly presents with hip pain in males during puberty and is associated with obesity . The majority of people affected have a painful limp and in half of cases both hips are affected. Nearly a quarter of people present with only knee pain. Treatment involves non-weight-bearing movement and surgery. If not identified early, osteonecrosis or death of

3168-433: The hips. An ultrasound or x-ray guided aspiration of the hip joint maybe required to rule out an infectious process within the hip. A limp at one hospital emergency department was the presenting complaint in 4% of children. It occurs twice as commonly in boys as in girls. Juvenile rheumatoid arthritis JIA is an autoimmune, noninfective, inflammatory joint disease, the cause of which remains poorly understood. It

3234-429: The introduction of biological therapies and a shift towards more aggressive treatment strategies. JIA treatment aims for normal physical and psychosocial functioning, which is an achievable goal for some children with this condition. Arthritis means inflammation within the joint, and is usually recognised by swelling, pain, stiffness and restricted joint movement. Symptoms of JIA vary from individual to individual. This

3300-537: The joint pain and swelling is not from a fracture , cancer , infection , or congenital abnormality. In some cases, fluid from the joint can be aspirated and analysed to assist in making a diagnosis. This test can assist by ruling out other causes of arthritis such as infection. The current classification system by the International League of Associations for Rheumatology (ILAR) recognizes seven distinct subtypes of JIA, based on their presentation within

3366-414: The joint, the cartilage and the bone. With the advent of modern therapies, these complications of JIA have become much less common. Children with JIA may have a reduced overall rate of growth, especially if the disease involves many joints or other body systems. This may be due to a combination of the disease itself, as well as its treatments, particularly corticosteroid use. Paradoxically, limbs where

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3432-401: The legs and back when children participate in physical activities such as sports. Pain is the most common and often the most distressing symptom of JIA (although some children with JIA do have joint inflammation without any pain at all). Pain can occur even when children are receiving effective doses of therapies which are managing their underlying disease. A multinational study showed that pain

3498-461: The load of heavy books or equipment to be carried in a child's school bag. The exact requirements will vary from child-to-child and will depend on the joints affected. In many instances, the child's treating team will be able to provide specific advice and information for teachers and coaches to smooth the transition back to school. This may take the form of an individualized plan outlining any extra measures that need to be taken at school, what to do in

3564-440: The method that works best for each individual. These techniques are readily available online, in books, recordings, apps or by seeing a trained professional such as a psychologist. Most children with JIA will be able to consistently attend school, without too many disruptions, even during a disease flare. However, they may require extra help or adaptations in order to do so. Maximising school attendance involves collaboration between

3630-425: The multidisciplinary team can perform developmental assessments to identify deficits and guide treatments. The information gathered can be shared with schools and child care facilities. One of the key ways occupational or physical therapists help young children with JIA is by developing a home therapy program based around play. Exercises are prescribed by both physical therapists and occupational therapists to increase

3696-590: The perception of pain and the degree of functional impairment. There are also social factors, which relate to family and peer relationships, parental distress and social and financial supports. Given the waxing and waning nature of JIA, children's physical abilities, pain and mood can change during periods of flare or remission. Coping with chronic illness during childhood and adolescence is associated with significant stress that can put children at risk for emotional or behavioural distress and can interfere with compliance and adherence to treatment regimes. Managing JIA can be

3762-447: The presence of specific immune markers which may include anti-nuclear antibody, HLA-B27 , rheumatoid factor and anti–citrullinated protein antibody . These serological markers may be negative in children with JIA, and are often present in healthy children; as such they should not be interpreted in isolation but in the context of the clinical presentation. Many children with JIA have normal blood work. X-rays may be required to ensure that

3828-436: The primary target for all patients and treatment should be adjusted until this is achieved. Prompt recognition and management is important as early initiation of therapy increases the likelihood of a response to first-line treatments and of achieving drug-free remission later in life. While overarching consensus treatment guidelines exist, all treatments should be specifically tailored to the individual's needs in discussion with

3894-434: The probability of this subgroup achieving inactive disease at least once within five years was shown to be 90% in a large Canadian study. Research is currently being undertaken into clinical prediction models to allow earlier identification of children who are likely to have a worse prognosis. Compliance with therapy, especially medication, has a positive correlation with disease outcome. Research into specific JIA biomarkers

3960-592: The range a child can move a joint, to strengthen the muscles around a joint, to decrease pain and stiffness and to prevent further limitations in their joint movements. OTs and PTs can provide children with age-appropriate games and activities to allow the children to practice their exercises while playing and socializing with friends. Examples are crafts, swimming, and sports. Children with JIA may experience challenges with low mood, social interaction, reduced self-confidence and negative self-image. Psychologists, OTs, nurses, social workers and other team members can work with

4026-490: The systemic subtype of JIA. MAS involves uncontrolled activation of the immune system, sometimes referred to as a 'cytokine storm', which can present with a sepsis -like picture of fever, rash, enlarged liver and spleen, enlarged lymph nodes and cardiorespiratory compromise. It is recognised by a series of characteristic changes in laboratory parameters, including a high ferritin and a paradoxically low erythrocyte sedimentation rate . The cause of JIA remains unknown. However,

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4092-574: The systemic-onset form of JIA, the differential diagnosis also includes Kawasaki disease and periodic fever syndromes. Some genetic skeletal dysplasias as forms of mucopolysaccharidosis especially type1 Scheie syndrome , progressive pseudorheumatoid dysplasia and multicentric osteolysis, nodulosis, and arthropathy syndrome may also mimic JIA, as they may present with joint swelling, joint restriction, stiffness, and pain. The clinical and radiologic overlap between genetic skeletal dysplasias and JIA can be great that molecular analysis may be need to confirm

4158-549: The transition process from paediatric to adult services. A new emerging area of support for disease management is through digital technology using eHealth and mobile health (mHealth) interventions. These interventions have to potential to support the development of self-management skills, or assist the healthcare team to monitor symptoms. For JIA, current studies have focused on the health issues pain, health related quality of life, physical activity and disease management. Children and adolescents have used these interventions through

4224-503: The treating medical team. The treating team can assist adolescents in finding ways to tell their employers about their condition in a positive way. OTs and social workers can also help teenagers understand their rights as an employee with a chronic illness. It is important that adolescents with JIA understand how to take care of themselves and manage their disease when working full-time or attending higher education. The team will also support those patients who still require medical input through

4290-527: The two do not necessarily follow the same course. This complication is usually asymptomatic (without symptoms) and can occur when the joints are not active. It can be detected by an experienced optometrist or ophthalmologist using a slit lamp to look for inflammatory cells in the fluid inside the eye. Most children with JIA will require referral for regular slit lamp screening examinations. Poorly controlled chronic anterior uveitis may result in permanent eye damage, including blindness. Systemic JIA: children with

4356-447: The use of X-rays , blood tests , and sometimes joint aspiration . Initial treatment involves pain management . A limp is the presenting problem in about 4% of children who visit hospital emergency departments. A limp is a type of asymmetric abnormality of the gait . When due to pain it is referred to as an antalgic gait , in which the foot is in contact with the ground for a shorter duration than usual; in severe cases there may be

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