Typical clinical presentations of the limping child
| Diagnosis | Clinical features |
|---|---|
| Septic arthritis | Classically the child is unwell, febrile and often inconsolable, unable to weight bear with the joint being hot, red, swollen and tender (at the hip restricted movement may be sole finding). High WCC, ESR and CRP. Classical features may be ‘masked’ if the child is immunosuppressed or has had recent antibiotics (partially treated septic arthritis). |
| Osteomyelitis | Usually unwell, febrile child and reluctant to weight bear. Limb may be swollen, warm, held flexed with bone tenderness. High WCC, ESR and CRP. Radiographs may be normal initially. |
| Transient synovitis of the hip | Typically boys (4–8 years), with preceding upper respiratory tract or gastrointestinal infection (7–10 days before), systemically well with acute onset, limited hip movement, reluctance to weight bear. WCC and ESR usually normal (or slightly elevated), diagnosis of exclusion. |
| Perthes’ disease | Typically boys (4–8 years), with insidious onset painless limp or activity related leg pain (may be referred to thigh or knee). Can be bilateral. FBC and ESR/CRP normal. Initial radiographs often normal but progress to avascular necrosis of the developing femoral head. |
| Juvenile idiopathic arthritis | Young children may not verbalise pain but present with observed limp, often intermittent, stiffness or gelling in mornings or after inactivity, change in mood or regression of motor milestones. Joint swelling can be subtle. Child may seem otherwise well, blood tests may be normal. Hip monoarthritis is a very uncommon initial feature. Late presentation is suggested by leg length discrepancy and muscle wasting. Risk of potentially blinding uveitis. |
| Malignancy (eg, leukaemia, neuroblastoma, bone tumours) | Can be systemically well initially but often presents with ‘red flags’ (systemic upset, fever, unremitting pain (with night waking), bone pain and tenderness, soft tissue or joint swelling or pathological fractures). Benign bone tumours, for example, osteoid osteoma, may present with night waking and pain which often respond to NSAIDS. |
| Developmental hip dysplasia | Painless limp observed since onset of walking; unilateral dislocations: Trendelenburg gait; bilateral dislocations: waddling gait. May have leg shortening, abnormal skin creases in legs and limited hip abduction. Abnormal radiograph. |
| Slipped upper femoral epiphysis | Typically overweight gonadally immature and hypothyroid children (boys > girls and over 10 years). Acute slip—sudden onset hip or knee pain (referred) with difficulty weight bearing and restriction of hip internal rotation (or abduction). Chronic slip more common. Trendelenburg gait may be apparent. Bilateral involvement (25%–40%). |
| Non-accidental injury | Suggested by the pattern of injury, delay in seeking medical attention, changeable or implausible history or mechanism of injury inconsistent with findings. Prior history of injuries or neglect. |
| Discitis | Usually affects toddlers. Can limp or refuse to weight bear. Tender spine. Adopt posture involving extension of the lumbar spine for comfort. Diagnosis may require bone scan as radiographs may be normal. |
| Lyme arthritis | Recent travel to an endemic area although a history of erythema migrans or a tick bite may be absent. May have neurological presentations (eg, Bells palsy or meningitis). |
| Abdominal pathology | Urine infection, testicular torsion, appendicitis. May present with non-weight bearing or limp, with or without abdominal pain, bowel or urinary symptoms. |
| Toddler fracture | Subtle undisplaced spiral fracture of the tibia caused by sudden twist often after an unwitnessed fall. Preschool children. Localised tenderness over tibial shaft may be present. Initial radiographs may be normal. Non-accidental injury must be considered. |
| Rickets | May have failure to thrive, poor growth with generalised bone pain, bone tenderness, skeletal deformities such as genu varum/valgum, muscle weakness, wrist swelling and even pathological fractures. Radiographs may be normal. Diagnosis requires bone biochemistry. |
CRP, C reactive protein; ESR, erythrocyte sedimentation rate; FBC, full blood count; NSAID, non-steroidal anti-inflammatory drug; WCC, white cell count.