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Limping Child

History​

  • Trauma
  • Precipitating events: viral infection preceding transient synovitis or reactive arthritis
  • Associated muscle weakness? neuromuscular disease
  • Birth and Developmental History: breech, family history of hip dysplasia, walking history, delay in motor milestones, regression

Examination​

Gait

  • Antalgic
  • High-stepping - neurological conditions
  • Tiptoe - limb length discrepancy or congenital talipes
  • Trendelenburg gait - developmental dysplasia of the hip
  • Circumduction - limb length discrepancy

FABER (Flexion, Abduction, and External Rotation) test: groin pain indicates a hip problem, pain in the SI area suggests sacroiliac joint disease

Red Flags​

  • Pain waking the child at night - Malignancy
  • Signs of redness, swelling, or stiffness of the joint or limb - Infection or inflammatory joint disease
  • Weight loss, anorexia, fever, night sweats, or fatigue - Malignancy, infection, or inflammation
  • Unexplained rash or bruising - Haematological or inflammatory joint disease, or non-accidental injury
  • Limp and stiffness worse in the morning - Inflammatory joint disease
  • Severe pain, anxiety, and agitation after a traumatic injury - An evolving compartment syndrome

Differential​

All ages

  • Fracture/soft-tissue injury
  • Cellulitis
  • Non-accidental injury (NAI)
  • Neoplasm
  • Septic arthritis
  • Neuromuscular
  • Osteomyelitis

Age 1–3 years

  • Septic hip
  • Developmental dysplasia of the hip (DDH)
  • Toddler’s fracture

Age 4–10 years

  • Perthes’ disease
  • Transient synovitis

Age 11–16 years

  • Slipped capital femoral epiphysis (SCFE)
  • Juvenile rheumatoid arthritis
  • Osteochondritis dissecans
  • Osgood–Schlatter disease

Developmental Dysplasia of the Hip (DDH)​

Congenital condition of abnormal hip joint development

Occurs more commonly in firstborn children, in those with a family hostory, breech presentation

Examination findings: asymmetric skin folds, limb shortening, and reduced hip abduction

If untreated can develop to osteoarthritis

Sources​

  • RCGP EKUL: The limping child: when to worry and when to refer
  • The limping child — when to worry and when to refer: a GP’s guide; Hassan Raja, Shehzaad A Khan and Abdul Waheed; British Journal of General Practice 2020; 70 (698): 467. DOI: https://doi.org/10.3399/bjgp20X712565