The limping child
a popular one
Red flags
- Age <3y
- Unable to weight bear
- Systemically ill, fever → septic arthritis?
-
9y with pain/restricted movement
Normal motor milestones
Ddx
at any age
- constant, localising, reproducible pain:
- infection - osteomyelitis, septic arthritis, psoas abscess
- trauma (bony vs soft tissue injury) - pelvis MSK injuries in children
- malignancy
- Ewing sarcoma
- Leukemia! → metaphyseal bands, sclerotic/lytic lesions on XR
- metabolic disease
- rash/bruising → inflammatory joint disease, non-accidental injury
- muscle weakness → neuromuscular disease e.g. spina bifida; Guillain Barre
by age
| Age | Ddx |
|---|---|
| < 3y | Toddler's fracture developmental dysplasia of the hip |
| 3-10y | Transient synovitis Perthé's disease |
| 10-18y | Slipped upper femoral epiphysis Malignancy Perthé's disease Osteochondritis dissecans Osgood-Schlatter disease Chondromalacia patellae |
misc:
- sever's disease = heel pain, most often in boys age 10-12
investigations
Local limping child pathway says get X-rays and bloods on everyone
- As a suggested starting set: FBC, U+E, CRP, ESR
Pelvic XR should have AP and frog-leg view
sources/links
https://dontforgetthebubbles.com/the-child-with-a-limp/
https://www.rcemlearning.co.uk/modules/the-limping-teenager/
https://www.rcemlearning.co.uk/foamed/the-limping-child/ → see guidelines
https://dontforgetthebubbles.com/osteochondrosis/
https://dontforgetthebubbles.com/the-child-with-a-limp/
https://pemplaybook.org/podcast/please-just-stop-limping/
https://cks.nice.org.uk/topics/acute-childhood-limp/diagnosis/assessment/
https://bestpractice.bmj.com/topics/en-gb/709
https://doclibrary-rcht.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/Clinical/Paediatrics/Orthopaedic/AcuteAtraumaticLimpInChildrenClinicalGuideline.pdf