Limping Child Guideline

(with thanks to Dr Rajashree Ravindran)

Children who have hip pathology may present with a variety of non-specific symptoms. They may present with pain, refusal to bear weight, limp, or decreased movement of the lower extremity. If pain is present it is important to determine where it is coming from, as pelvis and low back pathology may refer pain to the hip region and hip pathology commonly presents with referred thigh or knee pain.[1]

The history should include

1. pain characteristics
2. trauma (recent/remote)
3. mechanical symptoms (catching, clicking, snapping, worse during or after activity)
4. systemic symptoms (fever, irritability, weight loss, anorexia)
5. inflammatory symptoms (morning stiffness)
6. neurological symptoms (weakness, altered sensation)
7. gait (limp or not weight bearing)
8. effects of previous treatments (including antibiotics, analgesics, anti-inflammatory drugs, physiotherapy)
9. The current level of function of the child and development

Examination:

1. Temperature and vital signs.
2. Musculoskeletal exam including gait assessment: Look, Feel, Move approach to joint examination can be used. It should be noted that it is exceptionally rare to appreciate swelling of the hip on physical exam as it is a deep joint.
3. A CNS examination is also vital to exclude any neurological pathology.
4. Look for abdominal masses(Neoplasias in children can present with a simple limp)
5. Examine the genitalia(testicular torsion may present simply as a limp[2]) and perform an ENT examination
6. Look for rashes, bruises in unusual areas and remember the possibility of a non accidental injury.

Common differential diagnosis of limp by age:[2] 

Investigations:

Limp due to trauma: If a traumatic fracture is suspected perform an x ray of the affected site and involve the orthopaedic team as appropriate. Always consider the possibility of non accidental injury in a younger child presenting with fracture.

Atraumatic limp: The algorithm as below can be used for guidance.  You may wish to give the parent information leaflet out as part of your “safety netting” as it reminds the family to seek further help if the limp is still present 1 or 2 weeks later.

Algorithm for Child presenting with an atraumatic limp

Parent information leaflet

REFERENCES

1.            Frick, S.L., Evaluation of the child who has hip pain. Orthop Clin North Am, 2006. 37(2): p. 133-40, v.

2.            Perry, D.C. and C. Bruce, Evaluating the child who presents with an acute limp. BMJ, 2010. 341: p. c4250.

3.            Kocher, M.S., D. Zurakowski, and J.R. Kasser, Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am, 1999. 81(12): p. 1662-70.

4.            Caird, M.S., et al., Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am, 2006. 88(6): p. 1251-7.

5.            Howard, A. and M. Wilson, Septic arthritis in children. BMJ, 2010. 341: p. c4407.

6.            Kang, S.N., et al., The management of septic arthritis in children: systematic review of the English language literature. J Bone Joint Surg Br, 2009. 91(9): p. 1127-33.

7.            Kocher, M.S., et al., Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am, 2004. 86-A(8): p. 1629-35.

8.            Padman, M. and B.W. Scott, (i) Irritable hip and septic arthritis of the hip. 2009. 23(3): p. 153-157.