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Introduction

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

Age of presentation of various childhood lower limb disorders

Age of presentation of various childhood lower limb disorders

Differentials

History

  • 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?

Examination

  • General appearance
  • Temperature
  • Gait
  • Neurological examination
    • Weakness
  • Bruising
    • Excessive or not in keeping with accidental injury
  • Abdomen
    • 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

Investigation

  • 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:
    • FBC
    • 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:
      • Osteomyelitis
      • Discitis
      • Perthe’s disease
      • Occult fracture

Management

  • 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

Disorder Presentation Investigation Management
Developmental dysplasia of the hip (DDH)

Most by <3 months

  • On screening examination for DDH
  • Late cases – gait abnormalities as a toddler
  • USS if <3 months
  • X-ray if >3 months
  • Pavlik harness for 6-12 weeks in <3 months at time of diagnosis
  • Older children may require surgery
Non-accidental injury

Any age

  • Variable
  • Look for skin bruising
  • Suggested mechanism of injury out of line with signs and findings
  • History from parent often vague and varies with repeated recounts
  • Often x-rays for bony damage
  • As per the specific injury
Transient synovitis

Inflammation of synovial of hip

Age 3 Р8

  • Limp or refusal to weight bear
  • Acute onset
  • Typically 1-2 weeks after viral URTI
  • Typically afebrile and systemically well (may have fever from concurrent URTI)
  • Pain often worse in the morning and improves during day
  • Child may hold leg in position of hip flexion, abduction and external rotation
  • Pain often responds well to NSAIDs
X-ray

  • Usually normal
  • May show joint space widening

Bloods

  • Often performed to rule out septic arthritis
  • FBC, CRP / ESR
Be confident it is not septic arthritis first!

  • NSAIDs – e.g. ibuprofen 10mg/Kg TDS
  • Symptoms usually resolve in <7 days
  • Arrange next-day FU if there is any doubt as to the diagnosis
Perthe’s disease

Avascular necrosis of the femoral head

Age: 2 Р12

Typically: 4-8

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

X-ray

  • Joint space widening
  • Irregular femoral head
  • Crescent sign

Bone scan

  • Often diagnostic

MRI

  • More sensitive than x-ray
Usually non-operative

  • NSAIDs
  • Traction
  • Crutches
  • Physio

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)

 

  • Often vague and insidious – pain in hip / thigh / groin / knee
  • About 10% of cases are acute onset
  • ‚ÜĎBMI
  • Bilateral in up to 50% of cases
  • Antalgic gait
  • Externally rotated hip – “out-toeing”
X-ray

  • “Frog-leg lateral view” – usually diagnostic

Bloods

  • Unremarkable
  • Surgical management is always required
  • Advise – non-weight bearing until assessed by orthopaedics
  • Screws are applied to the femoral neck and head to prevent further slipping
Septic arthritis

Any age

  • Hot, red painful joint
  • Severe pain on moving joint
  • Limping or often refuse to weight bear
  • May be systemically unwell – fevers, rigors, hypotensive
  • Bloods – FBC and CRP typically raised
  • Joint aspiration send for MC+S can confirm the infection and characterise the organism
  • IV antibiotics (flucloxacillin, or clindamycin if allergic) – often for several weeks, with oral antibiotics for several weeks after that
  • Many cases also require surgical “washout”
Toddler’s fracture

An undisplayed fracture of the dial shaft of the tibia

Age 9 months to 3 years

  • Ambulatory child, now refusing to weight bear or walking with a limp
  • May resulting form a fall – injury is often fairly innocuous or insignificant and may not be remember (toddlers fall a lot!)
  • Warm be some tenderness, swelling and warmth over the fracture site
  • Typically the result of a twisting injury
  • X-ray – often normal, but may show spiral or oblique fracture of the distal shaft of tibia
  • May see new bone formation 7-10 days after the fracture
  • Backslab – typically an above knee cast
  • Will heal in 8-12 weeks
Viral myositis

School age children

  • Recent viral infection (usually influenza)
  • Calf pain
  • Tip-toe walking and/or refusal to weight bear, often with crawling on all 4s
  • Diagnosis is clinical
  • Bloods may show raised CK
  • Benign
  • Reassure parents that it should resolve in 3-4 days
  • Simple analgesia
  • Safetynet for dark urine (rhabdomyolysis)
Reactive arthritis / rheumatological disorders

Any age

  • Preceding history of (usually viral) infection
  • Often multiple joints affected
  • May cause limp or refusal to weight bear
  • No specific diagnostic test
  • Inflammatory markers normal
  • Simple analgesia
  • Reassure parents
  • Can take several weeks or months to resolve

References

  • Murtagh‚Äôs 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

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