The limping child

Dr Tom Leach

6 years ago

Contents

Introduction
Differentials
History
Examination
Investigation
Management
Summary of disorders
References
Related Articles

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

Differentials

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

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 – 8	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 – 12 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 ↑BMI 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’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