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Child Health Guideline Identifier

Limp - assessment of paediatric limp in the Emergency Department

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Introduction

Limp is a common reason for children to present to the Children's Emergency Department. Most limp is benign in aetiology, 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
  • 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-School 4-10 years > 10 years
Transient Synovitis hip
Non accidental injury (NAI)
Developmental Dysplasia of Hip (DDH) 
Transient synovitis hip
Perthes Disease
NAI
Slipped Upper Femoral Epiphysis (SUFE)
Transient Synovitis hip
Overuse syndromes (ie. Osgood-Schlatters disease)

 All ages

  • Trauma
  • NAI
  • Infection

Less common

  • Vasculitis - Henoch scholein purpura (HSP)
  • Systemic - Rheumatic fever
  • Malignancy - ALL, Bone tumours
  • Rheumatological
  • Intra-abdominal - appendicitis
  • Inguinoscrotal - testicular torsion

Assessment

All children require a thorough history and examination. 

The history should include:

  • Onset of symptoms
  • Recent illness, recent trauma -witnessed or not?
  • Weight bearing or not
  • Systemic symptoms - fever, rash, weight loss, lethargy
  • Previous injuries - NAI alerts

An examination should include:

  • General appearance
  • Vital signs
  • Rashes
  • Abdominal and neurological examination
  • Gait.

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.
  • 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. 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.

Discharge

Discharge with follow up. If transient synovitis is suspected, the child appears well and the pain resolves or improves significantly with analgesia, then the child can be discharged home with specific 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.
  • Earlier review 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 Irritable Hip parent advice sheet if transient synovitis is suspected.

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Document Control

  • Date last published: 31 July 2018
  • Document type: Clinical Guideline
  • Services responsible: Children’s Emergency Department
  • Owner: Abby Baskett
  • Editor: Greg Williams
  • Review frequency: 2 years

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