This referral guide is intended to cover new presentations of limp in children without a clear history of trauma. Limp is a clinical presentation, not a diagnosis. This guide considers the possible diagnoses and important things to cover during clinical assessment.
When assessing a child with atraumatic limp, age is important as well as nature and duration of the limp. Different diagnoses are more common at different ages. The table below shows the most common differential diagnoses by age.
| Toddler (1-4 years) | Child (4-10 years) | Adolescent (> 10 years) |
| Developmental dysplasia of the hip (DDH) | Transient Synovitis of the hip (Irritable hip) | Perthes Disease (avascular necrosis of the femoral head) |
| Osteomyelitis or Septic Arthritis | Perthes Disease (avascular necrosis of the femoral head) | Slipped upper femoral epiphysis (SUFE) |
| Transient Synovitis of the hip (Irritable hip) Less likely in children < 2 years | Osteomyelitis or Septic Arthritis | Overuse syndromes/stress fractures |
| Toddlers Fracture | Viral myositis (usually bilateral) | |
| At all ages, consider oncological diagnoses eg: ALL or primary bone tumours | ||
| At all ages, consider abdominal pathology eg: testicular torsion, appendicitis, constipation |
Always consider safeguarding especially if the history is inconsistent or presentation is delayed. Oncological diagnoses (ALL, bone tumours) can present at any age.
Abdominal pathology can present as a limp (appendicitis, constipation, testicular torsion) so all children need abdominal systems examination as below.
History:
Important questions to ask in a comprehensive history are:
Examination:
Recent height and weight in red book/ centile chart
The following are considered ‘Red Flags’ and necessitate prompt referral via the Paediatric Assessment Unit (PAU).
Children with any ‘Red Flags’ will be seen in the Paediatric Assessment Unit and any required investigations will be arranged there.
If considering a diagnosis of Perthes or SUFE, an AP film of both hips (plus frog leg view in possible SUFE) is useful. This is usually done as part of a Paediatric/Orthopaedic assessment.
Please remember that a ‘normal’ x ray does not exclude osteomyelitis as changes are often seen 7-10 days after symptoms first appear. Please refer to Paediatrics and do not be reassured by a normal x ray report.
If the working diagnosis is simple transient synovitis with a short history (< 24 hours) and the child is well, with no ‘Red Flags’, the child can be managed at home. The parents should be given advice to give regular analgesia, including NSAIDs (unless contra indicated) and given safety netting advice. If the child worsens, or develops systemic symptoms, they should return urgently either to GP or A&E.
If the child remains well, they should be reviewed in 48 hours. If the limp has completely resolved and they are otherwise well, no further investigations are needed.
In all other scenarios, the child will need Paediatric (and possibly Orthopaedic) review. Please see below for referral information.
Please refer same day for any children with ‘Red Flags’. They will be directed to our Paediatric Assessment Unit and may need investigations including blood tests (for FBC, ESR, CRP, blood culture if pyrexial), and x rays. They may also be seen by the Orthopaedic Team depending on the working diagnosis. Urgent (same day) referrals should be discussed with PAU using the PAU phone (via switchboard) or the registrar bleep (out of hours, also via switchboard).
If there are no ‘Red flags’ but limp is persistent, the child may be suitable for review in one of our Rapid Access Clinics. Currently, children are referred via email: Khft.paediatric-rapidaccessreferrals@nhs.net which is checked daily.
If you are unsure or would like to discuss the referral, please contact us via Kinesis for non-urgent advice.
Here is the NHS page for parents on a limp in children:
