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Introduction
A child who presents to a physician with a limp always requires careful evaluation, since the limp may arise from one of many different potentially serious causes. When the child in question is a toddler with a limited vocabulary, additional problems may arise due to the patient's inability to adequately verbalize his or her problems.
Case 1
A 3-year, 10-month-old Hispanic female with Down's syndrome was brought to the emergency room with a 5week history of intermittent left knee pain associated with an intermittent limp. There was no history of trauma. The physical examination revealed no edema, tenderness, nor warmth in the left lower extremity. There was full range of motion at all joints. X-rays of the knee and foot were felt to be unremarkable. The child was afebrile with normal labs and an erythrocyte sedimentation rate (ESR) of 41. No treatment was prescribed, but the mother was asked to bring the patient to the orthopedic clinic for follow up and further evaluation. The child was subsequently seen at the clinic one week later and was at that time walking with less of a limp. She was afebrile with an ESR of 30 and normal lab values. It was felt that the child's undiagnosed condition was improving, thus, no treatment was prescribed. However, the family was called by a resident every other day as follow up, and the mother was instructed to call should there be any sudden change in the child's condition.
The mother called one week later stating that the limp had worsened. The child was refusing to walk and was constantly pointing to her knee. The patient was brought back to the hospital for repeat examination.
On physical exam, the only positive finding was a prominent antalgic gait with a slight gluteal lurch. Repeat x-rays of the knee were negative. However, AP pelvis films...