Clinical Notes : Orthopedics

52. Limp in a Child

Summary points

  • Atraumatic limps are a source of concern to both the family doctor and emergency practitioner

  • Age is the key factor in forming a list of differential diagnoses

  • The hip is the most common source of pathology, and pain is often referred to the knee

  • A delay in the diagnosis of a slipped upper femoral epiphysis may worsen the outcome

  • Transient synovitis and septic arthritis may be difficult to differentiate so any clinical concern warrants urgent investigation

 

It is essential not to miss the following diagnoses :

 

Septic arthritis

  • Any age (peak 0-6 years)

  • Male = Female

  • Child usually unwell

    • Fever, pain, limp/ refuse to stand

    • If infant, poor feeding/ unsettled

  • Hip usually flexed and abducted

  • Urgent referral essential for USS and bloods to prevent destruction of the joint.

 

Transient synovitis

  • Age 3-8 typically

  • Male: Female 2:1

    • Usually follows URTI (up to 50%)

    • Child is usually well with no or a low grade fever only

  • Bilateral pain in 5% of cases

    • Reassure, analgesia

    • Usually resolves in 1-2 days

  • Small joint effusion on USS confirms diagnosis. CRP/ FBC normal

  • 1-2% progress to Perthes’ disease

 

Perthes’ disease

  • Avascular necrosis of femoral head

  • Age 4-12. (peak 5-7)

  • Male: female 4:1

  • 15% bilateral

  • Increased with low birth weight, low socioeconomic class, white ethnicity

  • Urgent Referral for early diagnosis essential to prevent destruction of the femoral head / OA requiring early hip replacement

    • Insidious painless limp followed by hip, knee, lateral thigh pain

    • Decreased abduction and internal rotation

    • Leg length discrepancy

 

Slipped upper femoral epiphysis (SUFE)

  • Fracture of the growth plate with posterior slipping of femoral epiphysis off the neck

  • Young adolescent (10-15)

    • 12 yrs female, 13.5 years male average

    • Male: Female 1.5:1

  • Increased risk if obese or hypothyroidism

  • 20-40% bilateral

  • Present with hip or knee pain

    • Hold leg still often externally rotated resisting internal rotation on examination

  • Urgent referral

 
 
 
 
 
 

In the OOH setting it is important to document the following data :

 

History

  • History

    • fever

    • Recent viral illness (URTI commonly with transient synovitis)

    • trauma

  • Onset of pain

    • Acute more indicative of trauma or infection,

    • Insidious, think Perthes’

  • Family history of hip problems or systemic illness in the child

  • Pain in knee

    • More likely SUFE or Perthes’

 

Examination

  • Observe gait

  • Measure leg length to rule out discrepancy

    • If found consider Perthes’

  • Assess for muscle loss/ atrophy

  • Examine the joint

    • Is there point tenderness to indicate trauma?

    • Passive and active movements

      • TIP: Lie the child prone and bend the knees. Int/ ext rotation is much easier to assess in this position.

      • SUFE resist internal rotation

      • Perthes’ reduced abduction and internal rotation

  • Examine knees and back to rule out other pathology

 
 

Evaluating the child who presents with an acute limp

BMJ 2010;341:c4250

(Published 20 August 2010)

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Limp in children: Differentiating benign from dire causes

J Fam Pract. 2011 April;60(4):193-197

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Assessment of gait disorders in children

BMJ Best Practice

Last reviewed: February 2019

Last updated: June  2018

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