This referral guide is intended to cover new presentations of limp in children without a clear history of trauma.  Limp is a clinical presentation, not a diagnosis.  This guide considers the possible diagnoses and important things to cover during clinical assessment. 

When assessing a child with atraumatic limp, age is important as well as nature and duration of the limp. Different diagnoses are more common at different ages.  The table below shows the most common differential diagnoses by age.

Toddler (1-4 years) Child (4-10 years)

Adolescent (> 10 years)
Developmental dysplasia of the hip (DDH) Transient Synovitis of the hip (Irritable hip) Perthes Disease (avascular necrosis of the femoral head)
Osteomyelitis or Septic Arthritis Perthes Disease (avascular necrosis of the femoral head) Slipped upper femoral epiphysis (SUFE)
Transient Synovitis of the hip (Irritable hip) Less likely in children < 2 years Osteomyelitis or Septic Arthritis Overuse syndromes/stress fractures
Toddlers Fracture   Viral myositis (usually bilateral)  
At all ages, consider oncological diagnoses eg: ALL or primary bone tumours    
At all ages, consider abdominal pathology eg: testicular torsion, appendicitis, constipation    

 

Always consider safeguarding especially if the history is inconsistent or presentation is delayed. Oncological diagnoses (ALL, bone tumours) can present at any age. 

Abdominal pathology can present as a limp (appendicitis, constipation, testicular torsion) so all children need abdominal systems examination as below.

History:

Important questions to ask in a comprehensive history are:

  • Pain
    • Site, severity, duration, exacerbating and relieving factors
    • Ability to weight bear
    • Possibility of referred pain (from testes, abdomen, back)
    • Timing of pain (night pain waking from sleep more likely to be neoplastic)
    • Improves or worsens with activity
  • Limp
    • Duration
    • Unilateral vs bilateral (bilateral more likely to be myositis)
    • Precipitating factors – history of precipitating viral illness: sore throat, URTI, diarrhoeal illness, chicken pox
  • Systemic symptoms
    • Fever/sweats
    • Loss of appetite/fatigue
    • Weight loss
    • Recent antibiotics use (may make osteomyelitis or septic arthritis harder to diagnose)
  • Family history of rheumatological, neuromuscular disease or haemoglobinopathies

Examination:

  • Is the child generally well or unwell? General examination including temperature and heart rate.
  • Is there fever (usually associated with increased risk of infection/sepsis)
  • Unusual bruising may indicate the possibility of child maltreatment or an underlying malignancy
  • Generalised lymphadenopathy or rash may indicate infection, inflammatory joint or haematological disease
  • Observe gait – can the child weight bear?
  • Focussed neuro examination
  • Observe, palpate and move all bones and joints  (look for heat, erythema, swelling, restriction of movement)
  • Observe back – palpate for tenderness
  • Abdominal examination (check testes in boys)

Recent height and weight in red book/ centile chart

 

The following are considered ‘Red Flags’ and necessitate prompt referral via the Paediatric Assessment Unit (PAU).

  • Not weight bearing
  • Systemic upset, including fever (>38.5oC), malaise, weight loss, sweats
  • Red, hot joint
  • Pain waking child at night
  • Unexplained rash/ unusual pattern or quantity of bruising
  • Neurological deficit
  • Very young children (< 2years of age)
  • Safeguarding concerns (inconsistent history, delayed presentation, incongruent pattern of injury, vulnerable child – due to social or medical reasons)
  • Any child with a known immunodeficiency (asplenia, chromosomal abnormality, inherited immunodeficiency)
  • Children with a diagnosis of Sickle Cell Disease need urgent review and should have ‘Direct Access’ to PAU.

Children with any ‘Red Flags’ will be seen in the Paediatric Assessment Unit and any required investigations will be arranged there. 

If considering a diagnosis of Perthes or SUFE, an AP film of both hips (plus frog leg view in possible SUFE) is useful.  This is usually done as part of a Paediatric/Orthopaedic assessment.

Please remember that a ‘normal’ x ray does not exclude osteomyelitis as changes are often seen 7-10 days after symptoms first appear.  Please refer to Paediatrics and do not be reassured by a normal x ray report.

If the working diagnosis is simple transient synovitis with a short history (< 24 hours) and the child is well, with no ‘Red Flags’, the child can be managed at home.  The parents should be given advice to give regular analgesia, including NSAIDs (unless contra indicated) and given safety netting advice.  If the child worsens, or develops systemic symptoms, they should return urgently either to GP or A&E.

If the child remains well, they should be reviewed in 48 hours.  If the limp has completely resolved and they are otherwise well, no further investigations are needed.

In all other scenarios, the child will need Paediatric (and possibly Orthopaedic) review.  Please see below for referral information.

Please refer same day for any children with ‘Red Flags’.  They will be directed to our Paediatric Assessment Unit and may need investigations including blood tests (for FBC, ESR, CRP, blood culture if pyrexial), and x rays.  They may also be seen by the Orthopaedic Team depending on the working diagnosis.  Urgent (same day) referrals should be discussed with PAU using the PAU phone (via switchboard) or the registrar bleep (out of hours, also via switchboard).

If there are no ‘Red flags’ but limp is persistent, the child may be suitable for review in one of our Rapid Access Clinics.  Currently, children are referred via email: Khft.paediatric-rapidaccessreferrals@nhs.net which is checked daily.

If you are unsure or would like to discuss the referral, please contact us via Kinesis for non-urgent advice.

Here is the NHS page for parents on a limp in children:

https://www.nhs.uk/conditions/limp-in-children/