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The limping child

The limping child- a summary of main causes and assessment in general practice.

Causes can be divided based on age, anatomy or pathology.

Infants < 1 year –Trauma including NAI Septic arthritis / osteomyelitis Developmental dysplasia of hip.Young children 1-4 yrs –Transient synovitis Trauma including NAI and toddler’s fracture Septic arthritis / osteomyelitis Developmental dysplasia of hips (DDH ) Perthe’s disease.School aged children-Trauma Transient synovitis Septic arthritis / osteomyelitis Perthe’s disease Psychogenic pain -less common. Older children/ adolescents -Trauma Septic arthritis / osteomyelitis SUFE Inflammatory arthritis Chondromalacia Psychogenic pain. All age groups-Septic arthritis Osteomyelitis Juvenile idiopathic arthritis Reactive arthritis Non-malignanyt haematological disease e.g haemophilia , sickle cell Metabolic disease e.g rickets Neuromuscular disease e.g cerebral palsy , spina bifida Malignancy Non-accidental injury

septic arthritis –
Septic arthritis ( SA ) / Osteomyelitis
 ( OM )
○ acute onset of joint pain
○ fever
○ inability to weight bear
○ unwell appearing child Can be difficult to differentiate from transient synovitis ( Kochers criteria can be used to differentiate ) In SA hip- hip held flexed and abducted Orthopaedic emergency Complications include
○ sepsis
○ cartilage destruction
○ growth plate damage
○ avascular necrosis of the femoral head


Transient synovitis –Commonest cause of non-traumatic acute hip pain in children Onset following a viral infection – cause is unclear but many experts have proposed a viral agent More common in boys aged 4-8 yrs Recurrence rate of 3 % throughout childhood Diagnosis by exclusion Resolves without any sequeale in 1-2 weeks Treatment 
○ reassurance
○ bed rest
○ simple analgesia

Perthes disease –Legg-Calve-Perthes disease Idiopathic avascular necrosis of the femoral head Common age 4-8 yrs
M >F 5:1 , B/L in 20 % Presents as subacute limp – pain may sometimes be referred to the groin , thigh or knee Can co-exist with other pathologies e.g JIA Diagnostic difficulties
○ discomfort & limp may fluctuate
○ initial X Rays can be normal Management
○ conservative – bed rest, analgesia and physio
○ surgical in severe cases

Slipped upper femoral epiphysis –Also known as Slipped Capital Femoral Epiphysis ( SCFE ) Most common hip disorder in adolescents Biggest risk factor is weight > 90th percentile
 ( ie overweight ) M >F , B/L in 25 % Proximal femoral epiphysis becomes displaced relative to the metaphysis Some times more common in children endocrine disorders / disturbances Presentation may be with
○ pain, limp and ↓↓ ed hip ROM
○ absent hip pain ( in up to 50 % of children )
○ pain may be localised to knee or distal thigh
○ only knee pain and no hip pain An Orthopaedic emergency ( risk of further slip and avascular necrosis , chondrolysis ) Delay in diagnosis , misdiagnosis is common

Developmental dysplasia of hips –Known earlier as congenital dislocation of the hip Male/ Female ratio 1:4 Risk factors include
○ 1st child
○ female
○ family h/o DDH
○ breech presentation
○ high birth weight
○ oligohydraminos May present later with asymmetrical gluteal and thigh skin folds and Trendelenberg gait If not picked up early it may present later with limp , hip pain, and /or osteoarthritis in older children

History-Painless or painful Constant pain or intermittent Onset – acute or gradual Uni or bilateral Duration – getting worse or better Does it interfere with normal activities Time of the day when it is worse Is it waking the child from sleep H/O fever/ toxicity Any swelling , redness , weakness or stiffness h/o trauma ( common ) Family h/o rheumatological or neuromuscular disorders

Examination –Ensure proper exposure Can the child weight bear Gait – can the child run , stand on one foot , hop, walk on heels and toes , squat Vital signs examine for pallor , bruising , lymph nodes , rashes

pGALS approach can be used here
 limb length discrepancy check spine In lower extremities -all joints – look , feel , move , function, range of motion 
checking for effusion , ROM , tenderness , swelling , warmth complete hip examination neurological exam of lower extremities compare with the well leg abdomen ( inflamed appendix can cause hip pain )
hernia orifice , testes

red flags –fever >= 38.5 inability to weight bear or severe , localized joint pain redness , swelling , stiffness of the joint or limb pain on moving joint ( passive ) systemic symptoms such as weight loss , night sweats or fatigue possible unwitnessed trauma / NAI / incongruent history / pattern of injury refractory or unremitting pain / persistent night waking

References

  1. Helen Foster The limping child A free online interactive information resource for clinicians https://madeinheene.hee.nhs.uk/Portals/16/Child%20with%20limp%20handout%2014%20March%202018.pdf Newcastle University and Northumbria University 2014
  2. The Limping Child : A Systematic Approach to Diagnosis Jeffrey R Sawyer, MD American Family Physician 2009
  3. Limp-in children: Differentiating benign from dire causes Destin Hill MD et al JPONLINE.com Vol 60 , No4 , April 2011, The Journal of Family Practice
  4. CKS NHS Acute Limp in a child Last revised August 2015 https://cks.nice.org.uk/acute-childhood-limp
  5. Limp- Emergency management in children Statewise Paediatric Guideline Children’s Health Queensland Hospital and Health Service
  6. The Limping Child Faculty of Paediatrics RCPIreland https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/paediatrics-the-limping-child.pdf
  7. Slipped upper femoral epiphysis Samuel J Parsons et al Current Orthopaedics ( 2007 ) 21,215-228
  8. Evaluating a Child Who Has a Limp Gillette children’s Specialty Healthcare Volume 22, Number 3 2013 https://www.gillettechildrens.org/assets/uploads/for-medical-professionals/A_Pediatric_Perspective_2013_Limping_Child.pdf

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