Limping child

There is a wide ranging clinical concern in children presenting with a limp from benign to sinister causes as follows:

History:

– Onset and duration of symptoms 

– Presence of Fever?

– recent illness (e.g. URTI), Rash

– Any known trauma?

– Is child able to localise site of pain?

– Any joint swollen, red or warm?

– Pallor, tiredness, weightless?

– Any joint pain in upper limb, backache?

– Any known illness in child  / family? 

– Possibility of NAI

 

Examination:

– Febrile / afebrile? Systemically unwell?

– Any bruising, pallor? Lethargic?

– Rash (e.g. HSP)

 

– P-GALS assessment*

– Weight-bearing possible?

– Observe gait and balance

    able to run, walk on tiptoes, hop?

– Joint exam– any swelling, redness, warmth

– Joint movements–

    full range, pain free & symmetrical?

– Hips – including int/ ext rotation

– Examine spine, knees and small joints in hands/ feet

 

– Tone, Power, tendon reflexes, plantars?

– Lymphadenopathy? Hepatospleenomegaly?

– Groin swelling? Testicular swelling in boys?

Red Flags in a Limping Child:

– Fever

– Young child with suspected NAI

– Limping for over 2 weeks

– Pallor, bruising tiredness

– Backache, night sweats

– Lymphadenopathy, 

  Hepatospleenomegaly

– Focal neurological abnormality

– Known Sickle cell dis, 

  immunocompromise

– More than 1 joint affected

 

Investigations:

None if suspecting irritable hip

(see management prompts)

– Safety net advice & review in 72 hours

 

Febrile/ red flags/ systemically unwell:

– FBC, U&E, CRP, Bld culture

– Xray Pelvis 

   (AP if <8y; AP & Frog leg if >8y)

– Xray of another joint if affected

 

– Orthopaedic referral for urgent 

   joint aspiration before antibiotics

Targeted tests for other causes

– USS abdomen & Pelvis

– MRI of joint/ abdomen/ pelvis

Management:

Depends on likely cause

 

Transient synovitis in 3 – 8y age:

– Post viral, short duration limp <3d

– systemically well, no red flags

– pain localised to hip, rarely knee

– May have mild effusion in joint

– resolves in 10 – 14 days

– Offer pain relief & review in 3d

 

Septic arthritis:

– Can be a subtle presentation

– Can rapidly destroy a joint

– Urgent joint aspiration before antibiotics

 

 

 

Perthes disease:

– Avascular necrosis of femoral head

– Age 4 – 10 years

– Xray shows flat irregular femoral head with increased joint space

 

SUFE:

– Obese (boys>girls)

– Peripubertal age

– Affected leg externally rotated

– Xray Frog-Lateral view

  femoral epiphysis slipped

 

Other potentially serious diagnosis