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Pediatric presentation

Limp in children

The hip diagnoses are stacked by age, and the child who will not weight-bear with a fever is septic until proven otherwise.

  1. What are you worried about?

    • Septic arthritis and osteomyelitis
    • Slipped upper femoral epiphysis in the adolescent
    • Leukemia or bone tumour presenting as limp
    • Non-accidental injury in the non-ambulatory infant

  2. Differential, by age

    Infant 1 to 12 months

    1. Developmental dysplasia of the hip
    2. Septic arthritis or osteomyelitis
    3. Non-accidental injury
    4. Neuromuscular disease

    Toddler 1 to 3 years

    1. Toddler's fracture
    2. Transient synovitis
    3. Septic arthritis
    4. Developmental dysplasia presenting at walking age
    5. Non-accidental injury

    Preschool 3 to 5 years

    1. Transient synovitis
    2. Septic arthritis
    3. Perthes disease
    4. Juvenile idiopathic arthritis
    5. Leukemia

    School age 6 to 11 years

    1. Perthes disease
    2. Transient synovitis
    3. Juvenile idiopathic arthritis
    4. Osteomyelitis
    5. Bone tumour
    6. Overuse injury

    Adolescent 12 to 17 years

    1. Slipped upper femoral epiphysis
    2. Traction apophysitis
    3. Sports injury
    4. Osteosarcoma or Ewing sarcoma
    5. Septic arthritis

  3. Key history

    • Onset, trauma, a preceding viral illness, fever
    • Pain location (hip pain is felt in the groin, thigh or knee), night pain, morning stiffness
    • Weight-bearing: none, partial, painful
    • Systemic features: weight loss, pallor, bruising, fatigue
    • The developmental and birth history (breech, family history of hip dysplasia)

  4. Key examination

    • Watch the child walk, or refuse to
    • Examine every joint from the spine to the toes, and the feet and shoes
    • Hip range of motion, especially internal rotation and abduction; a log-roll test
    • Temperature, the skin over the bone, effusions
    • Pallor, lymph nodes, hepatosplenomegaly, bruising

  5. Red flags

    • Fever with refusal to weight-bear
    • Night pain, weight loss, pallor, bruising
    • A limp lasting more than a week, or worsening
    • Limited hip internal rotation in an adolescent
    • An injury that does not fit the developmental stage

  6. Initial investigations

    • Blood count, C-reactive protein, erythrocyte sedimentation rate when infection, inflammation or malignancy is possible
    • Hip ultrasound for an effusion; aspiration is the only way to tell septic from transient
    • Plain X-ray of the hip, both sides, with a frog-leg lateral, for Perthes disease and slipped epiphysis; the tibia for a toddler's fracture
    • Blood culture before antibiotics when septic arthritis or osteomyelitis is suspected; MRI for osteomyelitis

  7. How to interpret them

    • The Kocher criteria (fever, non-weight-bearing, raised erythrocyte sedimentation rate, raised white count) shift the probability of a septic hip but never exclude it
    • A normal X-ray in the first week does not exclude osteomyelitis or early Perthes disease
    • A blood film is the test for the limp that comes with pallor

  8. When the child is deteriorating

    • Suspected septic arthritis: urgent orthopedic review, aspiration, then antibiotics
    • Slipped epiphysis: non-weight-bearing and urgent orthopedics; do not send home walking

  9. Cases and practice

    Refusing to walk since breakfast4 years old · A 4-year-old woke up limping and now will not put his right foot down. He had a cold last week. His mother thinks he hurt himself in the garden.
    Practice drillsAcute pediatrics

Conditions under this presentation

The presentation of leukemiaJuvenile idiopathic arthritisIgA vasculitis (Henoch-Schonlein purpura)Septic arthritis versus transient synovitisSickle cell disease on the ward
Perthes disease and the slipped epiphysis on filmThe septic hip and the slipped epiphysis in theatre

The adult frame, for contrast

FluidThe hot joint, tappedApproachThe adult joint pain frame