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.
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:
Pain
Site, severity,
duration, exacerbating and relieving factors
Ability to weight
bear
Possibility of
referred pain (from testes, abdomen, back)
Timing of pain
(night pain waking from sleep more likely to be neoplastic)
Improves or
worsens with activity
Limp
Duration
Unilateral vs
bilateral (bilateral more likely to be myositis)
Precipitating
factors – history of precipitating viral illness: sore throat, URTI, diarrhoeal
illness, chicken pox
Systemic symptoms
Fever/sweats
Loss of appetite/fatigue
Weight loss
Recent
antibiotics use (may make osteomyelitis or septic arthritis harder to diagnose)
Family history of rheumatological, neuromuscular
disease or haemoglobinopathies
Examination:
Is the child
generally well or unwell? General examination including temperature and heart
rate.
Is there fever
(usually associated with increased risk of infection/sepsis)
Unusual bruising
may indicate the possibility of child maltreatment or an underlying malignancy
Generalised
lymphadenopathy or rash may indicate infection, inflammatory joint or
haematological disease
Observe gait –
can the child weight bear?
Focussed neuro
examination
Observe, palpate
and move all bones and joints (look for
heat, erythema, swelling, restriction of movement)
Observe back –
palpate for tenderness
Abdominal
examination (check testes in boys)
Recent height and weight in red book/ centile
chart
Red Flags
The following are considered ‘Red Flags’ and necessitate
prompt referral via the Paediatric Assessment Unit (PAU).
Not weight
bearing
Systemic upset,
including fever (>38.5oC), malaise, weight loss, sweats
Red, hot joint
Pain waking child
at night
Unexplained rash/
unusual pattern or quantity of bruising
Neurological
deficit
Very young
children (< 2years of age)
Safeguarding
concerns (inconsistent history, delayed presentation, incongruent pattern of
injury, vulnerable child – due to social or medical reasons)
Any child with a
known immunodeficiency (asplenia, chromosomal abnormality, inherited
immunodeficiency)
Children with a diagnosis of Sickle Cell Disease need
urgent review and should have ‘Direct Access’ to PAU.
Investigations
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.
Management
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.
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.
Supporting Information
Here
is the NHS page for parents on a limp in children:
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