Limping child

Differential diagnosis

  • Septic arthritis – fever, red, swollen, warm joint
  • DDH
  • Toddle fracture – sudden twist or unwitnessed fall, tender over tibial shaft
  • Non-accidental injury
  • Transient synovitis – usually 4-8yo, may follow viral infection
  • Perthes’ disease – usually 4-8yo, similar to synovitis but symptoms do not settle
  • SUFE – usually >10yo, obese, boys, can be bilateral
  • Referred pain

 

Data gathering

  • Red flags – fever, systemically unwell
  • Others – trauma, DDH risk factors, other joint problems
  • Examine – temp, pGALS – Gait (+tiptoes and heels), Legs (hip, knee), Spine

 

Clinical management

  • Investigations
    • X-ray
      • consider even for trivial trauma as children are more prone to subluxation or fracture
    • USS / Bloods
      • refer if considering
  • Treatment
    • Suspected transient synovitis
      • If 3-9 years old, well, afebrile, mobile and limping less than 48hr
        • Reassess after 48hr – if symptoms resolving, likely transient synovitis
        • If symptoms fail to resolve after 7 days, consider referral
    • Other causes
      • Require secondary care input
  • Followup / Safety-net
    • Refer
      • Child < 3 years old – transient synovitis is rare and septic arthritis/NAI more common
      • Child > 9 years old with pain or restricted hip movement – to rule out SUFE
      • Fever
      • Systemically unwell