Limping Child

Limping Child

Differentials

Developmental/Mechanical

• Perthes disease: Gradual, painless limp; knee pain; limb shortening; decreased internal rotation

• Slipped upper femoral epiphysis (SCFE): Presents in adolescents; knee or hip pain; externally rotated, shortened leg; often linked to obesity

• Transient synovitis: Occurs post-URTI or fever; self-limiting; typical in children aged 3–10

• Overuse injury/stress fracture: Associated with increased physical activity and growth plate irritation

• Minor musculoskeletal injury: Common in active children with trivial trauma

Infective/Inflammatory

• Septic arthritis: Presents with fever, inability to bear weight, and joint effusion; requires urgent treatment

• Osteomyelitis: Localised bone pain with tenderness, erythema, and systemic signs

• Juvenile idiopathic arthritis: Chronic joint pain and morning stiffness with persistent swelling

• Postviral myositis: Generally self-limiting and resolves within days

Other

• Malignancy: Leukaemia, lymphoma, or bone tumour; characterised by night pain, systemic symptoms, and localized tenderness

• Non-accidental injury: Unexplained trauma with inconsistent history and possible bruising

• Henoch-Schönlein purpura: May present with petechiae, joint swelling, and abdominal pain

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Red Flags

• Systemic symptoms including fever, weight loss, night sweats and fatigue indicating severe infection or malignancy

• Persistent limp lasting over 7 days or non-weight bearing status suggestive of septic arthritis or SCFE

• Localised, worsening or nocturnal pain raising suspicion of bone tumour

• Skin findings such as petechiae or bruising which may point to HSP, malignancy or non-accidental injury

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Examination

• Gait analysis: Look for antalgic, Trendelenburg or stiff gait patterns

• Hip range of motion: Assess for limitation, especially reduced internal rotation which may indicate Perthes disease or SCFE

• Knee examination: Evaluate for pain, effusion and tenderness

• Limb alignment: Note external rotation or shortening suggestive of SCFE

• Systemic assessment: Check for fever, pallor or bruising and inspect skin for petechiae

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Investigations

• No immediate tests if limp is mild and lasts <7 days without red flags

• Blood tests: Full blood count, CRP and ESR to assess for infection or inflammation

• Imaging: X-ray of the hip and knee to evaluate for structural abnormalities such as Perthes disease or SCFE; Ultrasound of the hip to detect joint effusion in cases of suspected septic arthritis or transient synovitis

• MRI: Consider if there is a suspicion of osteomyelitis, malignancy or if initial imaging is inconclusive

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Management

• Observation: Review in 3 days if the child is otherwise well and symptoms are mild

• Activity modification: Encourage rest from aggravating activities and allow weight bearing as tolerated in transient synovitis

• Pain management: Use paracetamol 15 mg/kg QID as required

• Perthes disease: Semi-urgent orthopaedic referral for children <8 years with activity restriction and physiotherapy; urgent referral for children >8 years as surgery may be indicated

• SCFE: Non-weight bearing measures and urgent orthopaedic referral to prevent complications such as osteonecrosis and early osteoarthritis

• Provide safety netting advice and arrange close follow-up if symptoms persist or worsen

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Notes

• Perthes disease commonly affects boys aged 4–8 years and is typically painless with decreased internal rotation

• SCFE is seen in adolescents, frequently associated with obesity, and may present with knee pain rather than hip pain

• Transient synovitis usually follows an URTI and resolves within 7 days

• Persistent or worsening symptoms require further investigation to exclude serious pathology such as septic arthritis, malignancy or non-accidental injury

• Multidisciplinary management including orthopaedics and physiotherapy improves long-term outcomes