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Limp - assessment of paediatric limp in the Emergency Department

Date last published:

Limp is a common reason for children to present to the Children's Emergency Department.

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Starship clinical guidelines

Introduction

Limp is a common reason for children to present to the Children's Emergency Department. Most limp is benign in aetiology and self-limiting in nature, however some conditions can be associated with significant morbidity and require prompt diagnosis and management.

Key points

  • Most limp is benign

  • Aetiology varies depending on age

  • In preverbal children localization of pain causing limp is difficult

  • The entire limb should be examined including lumbar spine

  • Red flags must be considered

  • Discuss cases with a senior doctor where uncertain

  • Failure of limp to resolve (> 3 days) must be investigated further

Differential diagnosis

Pre-School4-10 years> 10 years
● Transient Synovitis hip
● Non accidental injury (NAI)
● Developmental Dysplasia of Hip (DDH) 
● 'Toddler's Fracture'
● Kingella Kingae osteomyelitis
  (typically appears as less severe onset)		● Transient Synovitis hip
● NAI
● Perthes Disease
● Osteomyelitis
● Septic arthritis		● Slipped Upper Femoral Epiphysis (SUFE)
● Transient Synovitis hip
● Overuse syndromes
   (ie. Osgood-Schlatters or Severs disease)
● Osteomyelitis
● Septic arthritis

 All ages

  • Trauma

  • NAI

  • Infection (septic joint, osteomyelitis)

Less common

Assessment

All children require a thorough history and examination. 

The history should include:

  • Onset of symptoms, including:

    • Pattern of pain (worse in the morning suggests more rheumatological or at night suggests over-use or traumatic)

    • Relieving features (exacerbated or relieved with activity)

    • Impact on activity

    • Has pain woken the child overnight

  • Recent illness (all children with joint pain should be assessed for sore throat and Group A Strep infections)

  • Recent trauma -witnessed or not?

  • Complete inability to weight-bear or partial weight-bearing

  • Systemic symptoms - fever, rash, weight loss, lethargy, bruising

  • Focus of pain and transience if able to ascertain

  • Previous injuries - NAI alerts

An examination should include:

  • General appearance

  • Vital signs

  • Abdominal and neurological examination

  • Symmetry of limb including gluteal folds in the younger child

  • Gait or in the pre-verbal/toddling child, readiness to put foot to ground

  • Note the position of optimal comfort - is the affected limb internally rotated or externally rotated in the bed

  • Assess for swelling, erythema, bruising, and rashes both locally and systemically

  • Range of movement through the whole limb (above and below the level of pain) including rotationally, passively, actively and again while the child is distracted

  • Palpate both muscles and along the length of long bones for tenderness or masses

Red Flag symptoms to discuss with senior or the Orthopaedic service:

  • Fever

  • Weight loss

  • Night pain

  • Constant, severe or worsening pain

  • Complete refusal to weight-bear following analgesia

  • Older than 10 years of age

  • Obesity in the child over 8

  • History greater than 3 days

  • Bruising both unexplained and patterned

Septic Arthritis is an emergency. A child presenting with fever; limp and haemodynamic compromise is suspicious of septic arthritis and should be discussed with the orthopaedic service urgently

Investigations

Investigations are often not required for limp in the absence of red flags (See algorithm or discuss with SMO if uncertain.)

  • X-rays are usually unhelpful except in older, adolescent children (SUFE) or specific situations such as suspected fracture in 'toddlers fractures' in newly ambulating toddlers.

  • FBC, CRP and ESR may be required if red flags are present. Consider blood culture if infection is suspected.

  • Further imaging e.g. USS, CT or MRI, bone scan may be organized by the orthopaedic service.

Management

All children with limp require pain assessment and management - any indicator of pain should immediately be managed. Simple analgesia (paracetamol +/- ibuprofen) is usually adequate.

Children with "Red Flags" must be discussed with a senior doctor or the Orthopaedic service.

Specific management is dependent on diagnosis. Most children will improve with simple analgesia and if no red flags are found on history or examination they can be discharged as below.

limping child

 

Discharge

Discharge with return advice. This includes:

  • Rest and regular simple analgesia (NSAID's e.g. ibuprofen and/or paracetamol) for 48hrs.

  • GP/CED review if the limp persists longer than 3 days following discharge with no improvement.

  • Return to CED or GP if the child develops a fever, becomes unwell, if the pain migrates to other joints, or if the pain is worsening despite pain relief

  • Parents should be given the 'limping child' parent advice sheet

 

References

  • Bartoloni, A. et al. (2018). Imaging of the limping child. European Journal of Radiology, 109(2018), 155-170.

  • Davis, T., Lawton, B., Klein, K., Goldstein, H., Tagg, A. (2017). Walking in circles: The limping child, Emergency Medicine Australasia, 29(4), 380-382.

  • Payares-Lizano, M. (2020). The limping child, Pediatric Clinics of North America, 67(1), 119-138.

  • Sawyer, J., Kapoor, M. (2009). The limping child: A systemic approach to diagnosis, American Family Physician, 79(3), 215-224.

 

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Clinical Guideline
Starship Child Health
2 year(s)
Abby Baskett, Briege McAteer
Abby Baskett
Greg Williams

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