The limping or non-weight bearing child is a common general practice and emergency department presentation, that can cause a lot of stress for parents.
There are also a wide range of differentials, although most of these can easily be narrowed down by age. Thankfully, most of the differentials are not emergencies, but there are some serious things not to be missed.
The majority of cases will likely be transient synovitis (or no cause identified). This is a benign disorder
- Non-accidental injury – NAI
- Developmental dysplasia of the hip – DDH
- Transient synovitis
- Perthes disease
- Slipped capital femoral epiphysis (SCFE)
- Septic arthritis
- Viral myositis
- Toddler’s fracture
- Reactive arthritis or other rheumatological disorder
- Duration of symptoms
- Speed of onset
- Limp or complete refusal to weight bear?
- History of trauma?
- There may often be a history of (typically mild) trauma that is incidental
- Preceding illness?
- Recent viral infection? (Transient synovitis or reactive arthritis)
- Any fever?
- Location of pain
- Often difficult to localise, especially in children <5 years
- Morning stiffness? (Rheumatological disorder)
- Any previous injuries or other child protection concerns?
- General appearance
- Neurological examination
- Excessive or not in keeping with accidental injury
- Check for tenderness, including inguinal area (masses)
- In boys – if any abdominal pr inguinal pain – check the scrotum!
- Lower limb
- Bony tenderness
- Assess hip, knee and ankle
- Hip pathology suggested by restricted internal rotation and abduction
- Check lumbar spine and sacrum
- If limp <3 days duration, no history of trauma and afebrile, investigation is not typically required
- If septic arthritis suspected (fever, often severely restricted movement), then consider:
- CRP / ESR
- Blood cultures
- USS – can show effusion in septic arthritis of hip joint
- If limp >3 days duration, or history of trauma, consider imaging:
- X-ray, typically of hip and knee, “frog leg lateral view” is good for spotting SCFE
- Bone scan can spot areas of increased bone turnover, and as such may help to identify:
- Perthe’s disease
- Occult fracture
- Depends on the underlying disorder
- See individual topic articles
In the case of transient synovitis, or no cause identified:
In my experience, many non-specific cases in otherwise well toddlers improve dramatically with NSAIDs and a short wait (an hour or so) and can be safely discharged from the Emergency Department or GP surgery. In cases with a fever, give NSAIDs whilst the results of FBC and CRP are awaited, and if normal this is typically enough to exclude septic arthritis if the child’s walking improves, and I would discharge these patients home with NSAIDs and close FU (e.g. advise review with the GP the following day). The cases of septic arthritis I have seen tend to be pretty obvious – with a clearly distressed child refusing to move the limb at all, but be wary that early septic arthritis may not be so severe – Dr Tom Leach
Summary of disorders
|Developmental dysplasia of the hip (DDH)
Most by <3 months
Inflammation of synovial of hip
Age 3 – 8
|Be confident it is not septic arthritis first!
Avascular necrosis of the femoral head
Age: 2 – 12
|Chronic and insidious onset
Hip pain (may radiate down leg or present as knee pain) and limp
Restricted ROM hip
Antalgic or trendelenburg gait
In severe cases can cause leg length discrepancy
Aim to restore ROM and prevent disability
Surgical management indicated in severe cases or in children > 8 years
Most cases resolve with time (2-5 years), but patients can be left with an aspherical femoral head, pre-disposing to OA and need for joint replacement in middle age or younger
|Slipped capital femoral epiphysis
Age 10+ until fusion of growth plate (late teenage years)
An undisplayed fracture of the dial shaft of the tibia
Age 9 months to 3 years
School age children
|Reactive arthritis / rheumatological disorders
- Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
- Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
- Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy
- Child with limp - RCH