Limping child

Question 1

Limping child:

What are the red flags?

Answer 1

symptoms greater than 7 days
trauma history
severe localised joint pain
nocturnal pain
cannot weight bear 
anorexia/lethargy or other constitutional symptoms

Question 2

Limping child:

What to look for on examination?

Answer 2

1) Ability to weight bear
2) skin changes such as erythema, rash, petechiae, ecchymosis
3) care giver interaction
4) fever
5) wasting

Question 3

Limping child:

Approach to managemet?

Answer 3

1) Any red flags = paediatric review (or more specialist area depending on suspected cause)
eg.
Septic arthritis = orthopaedic
Malignancy = oncology

2) Depending on cause may consider
- X-ray of offending joint/region
- USS
- bloods (CBE, CRP/ESR, CK, blood cultures)
- check urine for myoglobin if prodromal illness (rhabdomyolysis as complication of myositis)

General management

• simple analgesia
• if walking review in 3 -5 days

Question 4

Limping child:

What is Kocher Criteria for septic arthritis?

Answer 4

Need 3 or more to be considered very high risk of septic arthritis

• fever ≥38.5
• non weight weight bearing
• WCC ≥12
• CRP >20 OR ESR >40

Question 5

Limping child:

Causes of limping or non weight bearing child?

Answer 5

Most common diagnosis
<10yo
-Developmental Dysplasia of the Hip

• Toddlers fracture (fracture typically from twisting motion under the age of 3yo)
• transient synovitis of joint (prodromal viral illness, improves in 1 -2 weeks, weight bear as tolerated)
• Acute myositis
• Perthes disease (vascular insufficiency of femoral head resulting in breakdown, impact boys more than girls, tissue regrows but requires rest and reduced movement- can have longer term arthritis and pain associated)

> 10yo
-stress fractures or strains

• traction apophysitis (Osgood Schlatters and Severs)
• Slipped Upper Femoral Epiphysis (SUFE) (weakness of growth plate, increased incidence if obese, rapid growth, endorcrine disorder or male, clinically will have reduced abduction and internal rotation, if they flex the hip it will externally rotate, requires frog leg lateral x-ray for diagnosis and is managed surgically)

Other causes

• malignancy
• osteomyelitis
• non accidental injury
• septic arthritis
• reactive arthritis, henoch schonlein purpura, vasculitis