A Limping Child
Laura Cuthbert
Overview
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An unusual presentation
Key learning points
Differential diagnosis
Some specific examples
Case discussion
RCGP Curriculum
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8. Care of children and young
people
15.9 Rheumatology and conditions
of the musculoskeletal system
Case Presentation
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18m boy seen in A+E with limp
HPC
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Started limping R leg 6 hours ago
Now unwilling to put R leg on ground
Distressed, not feeding
No history of trauma- with parents all
day
No temps, no recent viral symptoms
etc
Case Presentation (cont)
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PMH
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DH
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Born AGH NVD at term, no complications
No history DDH
Viral induced wheeze
Otherwise fit and well
Salbutamol
UTD with imms
FH- nil
SH- only child, lives with mum and dad
Case Presentation (cont)
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O/E
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Apyrexial, obs normal
Happy in mum’s arms
CVS/RS/abdo examination unremarkable
R hip flexed
Unwilling to wt bear-distressed
No joint erythema/swelling/deformity
Good ROM at ankle/knee/hip
No obvious tenderness
?????????
Case Presentation (cont)
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Removing nappy revealed red,
swollen tender R testis
Testicular torsion!
My learning points
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Consider testicular torsion as cause
of abdo pain/distress/limp.
Presentation may not be classical in
young children
Always fully undress an infant for
examination
Limp in Children
Differential Diagnosis
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Multiple!!
Inflammatory
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Infective
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Septic arthritis, osteomyelitis, discitis
Trauma
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Transient synovitis, reactive, JIA
Soft tissue injury, fracture, chondromalacia
patella, Osgood Schlatter
Developmental
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DDH, Perthes, Avascular necrosis
Differential Diagnosis (cont)
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Neoplastic
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Other
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Leukaemia, sarcoma
Hernia, inguinal lymphadenopathy,
appendicitis, ingrown toenail, verucca
Don’t forget NAI
Septic Arthritis
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Hot, swollen, acutely tender joint
More difficult to identify at hip
Unwell, pyrexial
Raised WCC/ESR/CRP
Needs urgent aspiration and IV ABx
Usually S. aureus
Toddlers Fracture
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Typically age <3
Pain, unwilling to wt bear
May be minimal trauma, often
twisting injury
Tender swelling lower leg
Spiral # distal third of tibia
Long leg cast 4 weeks
Perthes Disease
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Avascular necrosis of femoral head
Boys:Girls 5:1
Age 4-8
Limp +/- pain
Reduced abduction and int rotation
Slipped Upper Femoral Epiphysis
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During adolescent growth spurt
Posterior slipping of femoral head
epiphysis
Increased incidence if obese
25% bilateral
Limp, hip/thigh/knee pain
Risk osteoarthritis and AVN
Surgically fixed
Transient Synovitis
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Most common cause of limp
Usually after viral URTI
Limp, reduced ROM, pain
Diagnosis of exclusion
Normal WCC/ESR/CRP and XRay
Self limiting, usually 7-10 days
Analgesia, rest, review.
Osgood Schlatter Syndrome
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Tender swelling over tibial tubercle
Repeated minor avulsion trauma
Excess physical exertion before
skeletal maturity
Rest/support
Case Study
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6yrs old boy, 1d hx of limp
History
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4d URTI symptoms and high temps,
E+D well, no hx trauma
Examination
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T38, coryzal, pink TMs and throat,
limping, restricted flexion and int
rotation
Case Study
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Differential Diagnosis
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Transient synovitis, septic arthritis,
osteomyelitis
Management?
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Admit for WCC/CRP
Transient synovitis is a diagnosis of
exclusion
Conclusion
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Common presentation
Multiple causes
Potentially serious- eg septic
arthirtis, SUFE
Low threshold for urgent
referral/xray
Remember full examination
Any Questions??