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RAG rating
n/a
Document type
Clinical pathways
Place
Hertfordshire and West Essex ICB
Output type
Clinical Pathways
Pathway
Limping Child Pathway

Limping Child | Paediatric


Pathway published: March 2024.
  • A limp is defined as an asymmetric gait, and is a deviation from a normal age-appropriate gait pattern.

 

  • It is a clinical presentation and not a diagnosis, and is secondary to pain, weakness, or deformity as a result of a wide variety of causes, ranging from mild self-limiting conditions (such as transient synovitis) to severe and potentially life-threatening conditions (such as septic arthritis and malignancy).
  • The differential diagnoses can be categorized according to age group, although some serious conditions may occur at any age.
  • The initial assessment of a child with a limp involves taking a detailed history and performing a careful physical examination to help identify the underlying cause. Red flags that may indicate an underlying serious disease or condition include:
    • Pain waking the child at night — may indicate malignancy.
    • Redness, swelling, or stiffness of the joint or limb — may indicate infection or inflammatory joint disease.
    • Weight loss, anorexia, fever, night sweats, or fatigue — may indicate malignancy, infection, or inflammation.
    • Unexplained rash or bruising — may indicate haematological or inflammatory joint disease, or child maltreatment.
    • Limp and stiffness worse in the morning — may indicate inflammatory joint disease.
    • Unable to bear weight or painful limitation of range of motion — may indicate trauma or infection.
    • Severe pain, anxiety, and agitation after a traumatic injury —  may indicate neurovascular compromise or impending compartment syndrome.
    • A palpable mass — may indicate malignancy or infection.
  • Referral for urgent specialist assessment should be arranged if the child:

 

  • Has a fever and/or red flags suggesting serious pathology.
  • Is suspected of being maltreated. 
  • Is younger than 3 years of age — transient synovitis is rare in this age group; septic arthritis is more common.
  • Is older than 9 years of age with painful or restricted hip movements (in particular internal rotation) — to exclude slipped upper femoral epiphysis.
  • Specialist assessment should be arranged (the urgency depending on clinical judgement) if:

 

  • The cause of the limp cannot be managed in primary care. 
  • There is uncertainty about the cause of the limp.
  • A child presents with a limp on multiple different occasions.
  • Children with a working diagnosis of transient synovitis can be managed in primary care.
    • Advice on rest and simple analgesia should be given, and parents/carers should be advised to take the child to an Accident and Emergency department immediately if symptoms worsen, a fever develops, or the child becomes unwell or unable to weight bear.
    • If symptoms are improving within 48 hours, the child should be reviewed 1 week from symptom onset to confirm complete resolution of symptoms. 
    • If symptoms worsen or fail to resolve, or there is any doubt about the diagnosis, urgent hospital assessment should be arranged.
  • If there is any history of trauma or focal bony tenderness on examination, an X-ray should be arranged.
    • A child with persistent limp and normal initial X-ray should be referred to paediatric orthopaedics or paediatric rheumatology department (the urgency depending on clinical judgement) for further investigation.
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