Limping in children is fairly common. A range of benign to lifethretening causes  are in the list. Understading of normal and abnormal gait is critical. It required a care ful history and examination.

The onset, duration, severity, and location of the pain, associated systemic symptoms, past medical history, family history, and social history are all those are necessary.

Acute onset of hip pain is potential to infectious processes (eg, septic arthritis, bacterial osteomyelitis), transient synovitis (TS) and major trauma.

Some of the causes for insidious onset of hip pain are slipped capital femoral epiphysis (SCFE), Legg-Calvé-Perthes disease, or spondyloarthritis. Severe pain may be due to acute infections, malignancy or trauma.

Past history of Juenile chronic arthritis transient sinusitis, viral illness  or long term treatment with steroid gives clue to the diagnosis.

 

the inability to bear weight is a sign of serious pathology until proven otherwise. Clinical evaluation focuses differentiating inflammatory from noninflammatory disease.  Anemia, leukopenia, or thrombocytopenia may may be correlated with this limp, underlying chronic illness, including malignancy as well.

Toddler (1-4 years) Child (4-10 years) Adolescent (>10 years)
·         Developmental dysplasia of the hip (DDH)

·          Toddlers fracture

·         Transient synovitis of the hip (Irritable hip)

·         Child abuse

·         Transient synovitis of the hip

·         Perthes Disease

 

·         Slipped upper femoral epiphysis (SUFE)

·         Overuse syndromes / stress fractures

 

All ages:

  • infections; osteomyalitis, septic arthritis, discitis, Soft tissue, viral myocytis
  • trauma
  • non accidental injuries
  • malignancies – Acute lympoblastic leucamia , bone tumor
  • Rheumatological disorders and reactive arthritis
  • Intra-abdominal pathology, eg: appendicitis
  • Inguinoscrotal disorders, eg: testicular torsion
  •  Vasculitis, serum sickness
  •    Functional

 Examination:

  • General appearance, temp
  • Gait – running may exaggerate a limp bruise
  • Neurological examination – look for ataxia, weakness
  • Generalised lymphadenopathy (viral infection / haematological cause)
  • Excessive bruising or bruising in unusual places (NAI, haematological)
  • Abdomen, scrotum and inguinal area (masses)
  • Bony tenderness
  • All joints

Investigations- FBC, ESR, CRP, Xray hip in AP and frog leg view,USS,Bone Scan are included

Management- Specific management depends on diagnosis. Ensure adequate analgesia.

Bed rest is important for children with transient synovitis.

  • Analgesia; NSAID (eg ibuprofen) +/- paracetamol
  • Review with local doctor within 3 days.
  • Return to hospital if febrile, unwell or getting worse
  • Patients with symptoms for greater than 4 weeks can be referred to rheumatology clinic.
  • Red flags ——–àre  temperature more than 39 c , Sick child , Rash, Red joint

Slipped Upper Femoral Epiphysis

  • Late childhood/early adolescence.
  • Weight often > 90th centile.
  • Presents with pain in hip or knee and associated limp. Put on wheel chair soon after the diagnosis and need urgent referral.
  • The hip appears externally rotated and shortened.
  • There is decreased hip movement – especially internal rotation.
  • May be bilateral.

Perthes disease

  • Avascular necrosis of the capital femoral epiphysis.
  • Age range 2-12 years (majority 4-8yrs)
  • 20% bilateral
  • Present with pain and limp
  • Restricted hip motion on examination
  • Stretching ,physio ,strengthening exercise
  • Gate re education

Irritable Hip (transient synovitis)

  • Commonest reason for a limp in the pre-school age group.
  • Usually occurs in 3-8 year olds
  • History of recent viral URTI (1-2 weeks)
  • Child usually able to walk but with pain
  • Child otherwise afebrile and well
  • Mild-moderate decrease in range of hip movement – especially internal rotation.
  • Severe limitation of hip movement suggests septic arthritis.

Consider consultation with local paediatric/orthopaedic team:

  • Suspected cause of limp is infection of bone/joint, SUFE , Perthes or malignancy.
  • Child presenting on multiple occasions.
  • Uncertainty regarding diagnosis

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