FEATURE
Diagnostic Approach to
Limp in Children
Ami P. Shah, MD, MPH; Sean Indra, MD; Nirupama Kannikeshwaran, MD; Earl Hartwig, MD;
and Deepak Kamat, MD, PhD
Abstract
© Shutterstock
“Limp” is a common complaint of children presenting to the emergency department or physician’s office. For most
patients presenting with limp, the diagnosis and management can be completed
in the physician’s office or emergency department by gathering a detailed history,
performing a careful physical examination,
and requesting a few laboratory and imaging studies. This article reviews common
causes of atraumatic limp in children and
discusses the evaluation and management of these conditions. [Pediatr Ann.
2015;44(12):548-550, 552-554, 556.]
Ami P. Shah, MD, MPH, is an Attending Physician, Pediatric Emergency Services, Children’s
Hospital of Nevada. Sean Indra, MD, is a Fellow,
Pediatric Emergency Medicine, Children’s Hospital of Michigan. Nirupama Kannikeshwaran, MD,
is an Associate Professor of Pediatrics and Emergency Medicine, Children’s Hospital of Michigan.
Earl Hartwig, MD, is a Clinical Associate Professor
of Pediatrics and Emergency Medicine, Children’s
Hospital of Michigan. Deepak Kamat, MD, PhD,
is a Professor of Pediatrics, and the Vice Chair
of Education, Department of Pediatrics, Wayne
State University; and a Designated Institutional
Official, Children’s Hospital of Michigan.
Address correspondence to Deepak Kamat,
MD, PhD, Children’s Hospital of Michigan, 3901
Beaubien Boulevard, Detroit, MI 48201; email:
dkamat@med.wayne.edu.
Disclosure: The authors have no relevant financial relationships to disclose.
doi: 10.3928/00904481-20151112-01
548
L
imp is a common presentation
in children. There are many
causes for limp in children, so
it is important to identify the benign
causes of limp by taking a good history and performing a detailed physical examination so that unnecessary
laboratory and imaging studies are not
performed. In this article, we discuss
the common causes and management
of atraumatic limp in children.
ILLUSTRATIVE CASES
Case 1
A 3-year-old boy presented to the
emergency department (ED) with
complaint of a limp for the past 10
days noted by the parents. His fam-
ily denied any trauma, fever, or recent
upper respiratory infection symptoms.
The child had normal vital signs and
physical examination. Would you reassure parents that there is probably
nothing wrong or would you run a few
tests?
Case 2
An 11-month-old healthy boy presented to the ED with refusal to stand
or crawl. His parents noted a low-grade
fever and a rash. On examination, the
child was afebrile and had an erythematous rash that was target-shaped
over the anterior chest and extremities.
Both knees were mildly swollen; however, the joints were nonerythematous,
Copyright © SLACK Incorporated
FEATURE
not warm, and had full range of motion without any discomfort. What will
your approach be for this patient?
Case 3
A 2-year-old healthy girl presented
to the ED with refusal to walk since
the morning. She had a runny nose
and cough for a few day prior. She had
a normal physical examination but refused to bear weight on her right side.
There was no joint erythema, swelling, tenderness, or signs of trauma in
the lower extremity. What tests will
aid in the diagnosis?
TABLE 1.
Differential Diagnosis of Atraumatic Limp
Infectious
Septic arthritis
Osteomyelitis
Discitis
Lyme disease
Psoas abscess
Gonococcal arthritis
Inflammatory
Transient synovitis
Serum sickness
Henoch-Schonlein purpura
Rheumatic fever
Ankylosing spondylitis
Systemic lupus erythematous
EPIDEMIOLOGY
“Limp” represents a common complaint in children presenting to the
ED. Although the majority of limping
is related to trauma, atraumatic limp
is reported in 1.8 per 1,000 children
younger than age 14 years.1,2 The average age of presentation is 4 years,
and it typically affects boys more
commonly than girls. Most children
present with a unilateral limp that is
painful. Slightly less than half of these
patients have a preceding illness. The
differential diagnosis for limp is expansive and it is important to discern
the benign from life-threatening conditions that cause an atraumatic limp
in children (Table 1). Ultimately, for
most patients presenting with limp,
the diagnosis and management can be
completed in the physicians’ office or
ED.
ANATOMY OF GAIT
To understand what causes a child
to limp, it is necessary to understand
the anatomy of a normal gait. A child
develops a mature gait pattern at age 3
years and it consists of a stance phase
and swing phase.3 Disordered gait can
be classified as antalgic and nonantalgic. An antalgic gait results from pain
in the affected extremity, resulting in a
shortening of the stance phase and an
PEDIATRIC ANNALS • Vol. 44, No. 12, 2015
Vascular
Legg-Calve-Perthes disease
Osteonecrosis
Sickle cell disease
Neoplastic
Leukemia
Tumors such as osteoblastoma or osteosarcoma
Congenital
Developmental dysplasia of the hip
Other
Intraabdominal
Inguinal hernia
Appendicitis
Pyelonephritis
P
elvic inflammatory disease
Intracranial pathology
Intracranial space occupying lesion (eg, tumor or abscess)
increase of the swing phase. This type
of gait results typically from trauma
or an infection.4 Types of nonantalgic
gait include a Trendelenburg gait, in
which the pelvis exhibits a downward
tilt toward the unaffected side during
the swing phase because of weakness
in the contralateral gluteus medius
muscle. This type of gait is usually
seen in disorders of the hip such as
developmental dysplasia of the hip
(DDH), Legg-Calvé-Perthes (LCP)
disease, or slipped capital femoral
epiphysis (SCFE). A steppage gait
results from excessive flexion of the
hip and knee joints during the swing
phase due to an inability to dorsiflex
the foot. A steppage gait is seen in
patients with cerebral palsy and other
neurologic disorders. Lastly, a vaulting or circumduction gait occurs due
to hyperextension and locking of the
knees at the end of the stance phase
and the child must vault over the affected extremity. This gait is usually
associated with a limb-length discrepancy or a mechanical disorder leading
to abnormal knee mobility.
549
FEATURE
HISTORY, PHYSICAL
EXAMINATION, AND
INVESTIGATIONS TO BE
CONSIDERED IN A PATIENT WITH
NEW-ONSET LIMP
History
Evaluation of a limping child
should begin with a thorough history
elicited from both the child as well as
the caregiver. The age of the child at
onset of the limp helps to narrow the
differential diagnoses. DDH is commonly seen up to age 3 years whereas
LCP disease, juvenile idiopathic arthritis (JIA), and leukemia should be
considered among children ages 4 to
10 years. Joint sprains, overuse syndromes, SCFE, and tumors should
be considered in the adolescent age
group.4
Fever is an important historic factor, as it may suggest an infectious
(eg, osteomyelitis, septic arthritis or
Lyme arthritis) or an inflammatory
(eg, transient synovitis, discitis) cause
for limping. Rheumatologic and oncologic processes, such as JIA and leukemia, are less commonly associated
with fever but should be considered in
the differential diagnosis in the presence of systemic symptoms such as
weight loss, night sweats, loss of appetite, bone pain, or fatigue.5 In the
setting of a recent febrile viral illness
or streptococcal infection, postinfectious causes of limping are more
likely and include transient synovitis,
myositis, or serum sickness.
Pain associated with limp may provide clues as to the cause of the limp.
Pain that is constant, localizing, and
reproducible usually represents a fracture, osteomyelitis, or septic arthritis.6
Children may also have referred pain
to the knee from disorders of the hip
such as LCP disease or SCFE. Differentiating true pain from weakness
is important, as weakness may be a
clinical manifestation of a central or
peripheral nervous system disorder.
Back pain or lateral thigh pain may
indicate lumbar spinal disorders such
as discitis, herniated disc, or vertebral
fracture. Additionally, symptoms such
as incontinence or leg weakness also
suggest spinal cord lesions or pelvic
mass.
The duration of the limp can help
to differentiate between acute versus
chronic etiologies. Typically, acuteonset limp presents in the setting of
trauma or an infectious cause, such
as a septic arthritis or osteomyelitis.
A longer duration or insidious onset
of symptoms may be more indicative
of LCP disease, SCFE, or a rheumatologic etiology.
Physical Examination
A thorough physical examination
with the child completely undressed
should be performed on all children
presenting with a limp. The height and
weight of the child should be noted
and, if possible, compared to that from
prior visits, as poor growth may be an
indicator of an underlying chronic disease. A complete neurologic examination assessing for tone (hypotonia or
spasticity), hypo- or hyperreflexia,
presence of clonus, or loss of sensation should be performed to rule out
central or peripheral nervous system
pathologies. Examination of the back/
spine for curvature and point tenderness is also an important aspect of the
physical examination.
The gait of the patient should be assessed while they are wearing a short
gown and walking in bare feet. Each
leg should be assessed individually
through the swing and stance phase.
Look for erythema, swelling, or
signs of trauma such as abrasions,
lacerations, or puncture wounds. The
feet, legs, hips, and back should be
palpated in small segments at a time
to elicit tenderness or note any “step
offs” or masses. Passive and active
range of motion of joints should be as-
sessed and compared to the opposite
side.
Specific clinical tests may have to
be performed to confirm or rule out
specific cause for a limp. For the Trendelenburg test, the child stands on the
affected leg and the observer looks for
the drop of the pelvis toward the unaffected side. A positive test indicates
disorders of the hip such as DDH, LCP
disease, or SCFE. In the Galeazzi sign
test, the child lies in the supine position with both hips and knees flexed.
The practitioner observes heights of
the knees and if one side is lower than
the other, the test is positive, revealing a limb-length discrepancy with the
lower side shorter than the other. The
Flexion, Abduction and External Rotation test is performed by having the
child lay supine while the examiner
flexes, abducts, and externally rotates
the hip joint. If this results in hip pain
or limitation of flexion, it implies a
disorder of the sacroiliac joint.
One should also examine the inguinal region to rule out hernias and
scrotal/testicular lesions.
Laboratory Evaluation
The differential diagnosis considered in a patient dictates the laboratory
evaluation to be performed. When an
infectious or inflammatory cause for
the limp is suspected on clinical evaluation, laboratory tests to be considered include a complete blood count
(CBC), blood culture, and acute phase
reactants such as C-reactive protein
(CRP) and erythrocyte sedimentation
rate (ESR). A clinical guideline developed by Kocher et al.7,8 proposed that
a history of fever, nonweight-bearing
on the affected side, ESR >40 mm/h,
and serum white blood cell count of
>12,000 cells/mm3 is indicative of
septic arthritis as opposed to transient
synovitis. They found that if only 1 of
the 4 was present, the predicted probability for septic arthritis was about
continued on page 552
550
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continued from page 550
FEATURE
3%, but it increased to 99% when all
four criteria were present. If the patient lives in an area where Lyme disease is endemic, it may be pertinent to
obtain a two-step serologic test including an enzyme-linked immunosorbent
assay followed by a confirmatory
Western blot for Lyme disease. The
synovial fluid can be tested for Lyme
polymerase chain reaction as well. If
there is a high suspicion for a septic
joint, synovial fluid (obtained at bedside or in the operating room) needs to
be sent for Gram stain, cultures, white
blood cell count, glucose, and protein
analysis. If there is clinical suspicion
for rheumatologic diseases, antinuclear antibody titers and rheumatoid factor may need to be checked.
tis.10 The exact etiology of this is unclear, although the most commonly
accepted explanation is an inflammatory reaction following a viral illness.
Typical presentation is a limp that is
noted in a child after a viral upper
respiratory infection. On clinical ex-
Imaging Studies
Radiography and ultrasonogram
(US) of the hip are the commonly
used imaging modalities to evaluate a
child with a limp. X-ray of the hip is
particularly useful in the diagnosis of
LCP disease and SCFE, whereas US
of the hip is useful when DDH or septic arthritis are suspected. Plain radiographs are not particularly sensitive
in diagnosing acute osteomyelitis, so
in those cases nuclear medicine scans
can be used; however, they have low
specificity in diagnosing acute osteomyelitis. Recently, magnetic resonance imaging (MRI) has been used
with high frequency to evaluate children with suspected acute or chronic
osteomyelitis. MRI is also very useful in diagnosing discitis. A computed
tomography (CT) scan is helpful in
diagnosing chronic osteomyelitis as it
clearly delineates cortical destruction
as compared with MRI.9
amination, the child is well appearing,
has full range of motion of the joints,
and is usually able to bear weight after
taking nonsteroidal anti-inflammatory
drugs (NSAIDs). Laboratory evaluation, including CBC and serum inflammatory markers such as CRP and
ESR, are usually within normal limits.
Symptoms usually resolve in 1 to 2
weeks. Rest and NSAIDs are the treatment of choice.
Other inflammatory causes of a
nontraumatic limp in children include
serum sickness, Henoch-Schonlein
purpura (HSP), and rheumatologic
disorders. Serum sickness is a type III
hypersensitivity reaction to recent illness or medication. Most commonly
involved medications include the penicillins, cephalosporins, and NSAIDs.
The child typically presents with fever, rash, and joint pain or swelling.
Rash typically resembles a target lesion. Symptoms are noted 7 to 21 days
after antigen exposure. Treatment is
largely supportive care. If the child
is taking antibiotics and if the medication is suspected to be the cause of
serum sickness, then it should be discontinued immediately.
COMMON CAUSES OF LIMP
Inflammatory Conditions
The most common cause of nontraumatic limp in children age 10
years or younger is transient synovi552
Radiography and
ultrasonogram of the hip
are the commonly used
imaging modalities to
evaluate a child with a limp.
HSP is a vasculitis that affects
young children. Purpuric rash is noted
in the dependent areas after a viral illness or vaccination. Clinical presentation includes low-grade fever, rash,
and arthritis that usually involves the
lower extremity joints. Joint involvement is inflammatory in origin, is
nonerosive, and does not lead to permanent damage. Symptoms respond
well to NSAIDs. Gastrointestinal
manifestations include nausea, vomiting, and abdominal pain. Children
with HSP are at higher risk for intussusception and nephritis. Laboratory
evaluation may show elevated serum
inflammatory markers. Treatment is
largely supportive. All symptoms resolve in most patients within 4 weeks.
Acute rheumatic fever (ARF) is an
inflammatory disorder with multiorgan involvement and is caused by an
immune response to group A streptococcal infection. The Jones criteria are
used for the diagnosis of rheumatic fever. Major criteria include carditis, arthritis, chorea, erythema marginatum,
and subcutaneous nodules. Minor
criteria include fever, arthralgia, prolonged PR interval, and elevated acute
phase reactants. The presence of two
major criteria, or one major and two
minor criteria, along with laboratory
evidence of a preceding streptococcal
infection indicates a high likelihood
of ARF.11
Rheumatologic disorders such as
JIA present with erythematous swollen joints with pain that typically improves with activity. This diagnosis
should be considered in a child younger than age 16 years who complains of
early morning joint pain. It can affect
single or multiple joints. Eye involvement in the form of uveitis is also
commonly noted.3,5,10
Infectious Conditions
Osteomyelitis and septic arthritis
of the hip can present as limp, and
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FEATURE
Figure 1. An X-ray of a foot showing osteomyelitis of the proximal end of the proximal phalanx of the
4th toe.
Figure 2. A magnetic resonance image showing
osteomyelitis of the proximal tibia.
their clinical presentation may mimic
that of a transient synovitis. Early diagnosis and timely treatment are required
to prevent serious consequences such
as joint damage and related complications. Infection may reach the area via
blood stream, direct contamination, or
from infection of nearby skin (such as
cellulitis). The most common causative
organism in children is Staphylococcus
aureus. Other organisms that can cause
septic arthritis include Escherichia
coli, group B streptococci in neonates,
and Neisseria gonorrhoeae in a sexually active teenager.
Septic arthritis is more common
in children in the age group of 2 to 3
years. Fever may be more profound and
the child may appear sicker compared
to those with transient synovitis. Crying when the child is picked up or with
every diaper change should be a clue
to consider septic arthritis, as should
if the child refuses to move and bear
weight on the affected extremity. Poor
feeding and irritability may be seen in
younger children and infants.3,9,10
illness. The sensitivity can be further
improved with use of high-resolution
and power Doppler sonography.16,17
Deep soft tissue swelling, subperisoteal abscess, fluid adjacent to the bone,
cortical erosion, and increased flow
within periosteum are some of the findings noted on US that are suggestive of
osteomyelitis. Findings can be detected by US much earlier than by plain
radiography. CT scan is the preferred
test for diagnosis of cortical destruction in chronic osteomyelitis. Otherwise, MRI is the diagnostic study of
choice in children with suspected acute
or chronic osteomyelitis9 (Figure 2).
Nuclear medicine scans are not used as
often because of their low specificity in
diagnosing osteomyelitis.
Early antibiotic therapy and orthopedic consultation are required for the
management of these patients. Parenteral clindamycin or vancomycin
is the drug of choice in communities
where methicillin-resistant S. aureus
(MRSA) is prevalent. If the community prevalence of MRSA is <10%,
PEDIATRIC ANNALS • Vol. 44, No. 12, 2015
Evaluation for these patients includes CBC, blood culture, ESR, and
CRP. An elevated CBC and inflammatory markers are noted in patients with
osteomyelitis and septic arthritis. A
clinician can use the Kocher criteria,7,8
which combine clinical and laboratory
criteria, to consider septic arthritis.
US of the affected joint should be
obtained. US is a useful test to identify effusion, although it cannot distinguish between clear and purulent
fluid.12,13 If the index of suspicion for
septic arthritis is high, joint aspiration
should be performed and the synovial
fluid should be obtained for evaluation. Plain radiography has limited
utility in children younger than age 9
years presenting with nontraumatic
limp.14,15 Plain radiography findings in
osteomyelitis include periosteal bone
thickening, lytic lesions, and new bone
apposition (Figure 1). These findings
may not be apparent until 10 to 14 days
of illness.16 The sensitivity of US for
diagnosis of osteomyelitis ranges from
32% to 72% based on the stage of the
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FEATURE
Figure 3. An X-ray of the pelvis and hips showing right-sided Legg-Calve-Perthes Figure 4. An X-ray of the hips showing avascular necrosis of the left femodisease.
ral head in a patient with sickle cell disease.
intravenous nafcilin or oxacillin or a
first-generation cephalosporin can be
started as empiric therapy. Kingella kingii is a gram-negative coccobacillus and
has been a common cause of osteoarticular infections in children younger than
age 3 years. In this age group, empiric
coverage with cefazolin or ceftriaxone
is recommended in addition to the coverage for MRSA. Duration of therapy
ranges from 4 to 6 weeks.18 Salmonella
osteomyelitis should be a consideration
in children with sickle cell disease.19
Discitis is an inflammation of the disc
space and adjacent vertebral end plates
that typically affects the lumbar spine.
Neonates and young children are more
susceptible to discitis because of characteristic anatomy of blood vessels in
this age group: the small blood vessels
terminate adjacent to the intervertebral
disc, which renders the disc space more
susceptible to infection. Also, children
have a large network of interosseous collateral arteries as compared with adults.9
The possible role of infection in discitis
is somewhat controversial, but the most
commonly considered organisms are
coagulase negative staphylococci and
S. aureus. Presentation of discitis can
be very nonspecific, and a high index of
suspicion is required for diagnosis. Clinical presentation ranges from refusal
to walk or bear weight, and irritability
on spine immobility.20 Point tenderness
over the spine can aid in the diagnosis.
Inflammatory markers may or may not
be elevated early in the course of the illness. Plain radiographs show narrowing
of the disc space and end plate irregularities. These findings are noted only after
2 to 4 weeks of illness. MRI is the most
sensitive and specific test for diagnosis.20 Treatment includes consideration
of parenteral antibiotics and immobilization of the spine. Operative treatment
is rarely necessary.
Although rare, intracranial abscess
should be considered in a patient with
fever and limp. It is more prevalent in
patients with congenital heart disease. It
results from extension of local infection
or due to septic emboli. The most common organisms cultured are from the
Streptococcus milleri group. CT scan of
the head with contrast is the diagnostic
test of choice. Therapy includes abscess
drainage and intravenous antibiotics.
Initial therapy should be with vancomycin and ceftriaxone. Subsequent therapy
is tailored according to the culture results.5
Vascular Conditions
LCP disease and sickle cell disease
are the common vascular causes of limp
in children. These disorders are associated with an interruption of blood supply
to the femoral head. LCP disease is typically seen in children ages 4 to 10 years
and is more common in boys than in
girls.21 Classic presentation is a painless
limp. Hip radiographs aid in the diagnosis (Figure 3). Findings vary according
to the stage of the disease. These include
asymmetric femoral head size, and widening of the joint space and linear area
of subchondral lucency (crescent sign).
These patients should be referred to
orthopedic surgery for definitive care.
In patients with sickle cell disease, intravascular sickling of red blood cells
causes sludging, thrombosis, and ischemia leading to avascular necrosis of the
head of femur (Figure 4). The general
approach is nonsurgical management in
younger children and surgical intervention in older children and adolescents.22
Neoplastic Conditions
Leukemia and bone tumors can
present as a limp. Approximately 20%
to 30% of cases present with clinical
manifestations involving bones or
joints. 23 These conditions are usually
associated with bone pain secondary
to malignant proliferation of cells. Imaging studies including a CT scan and
MRI do not aid in the diagnosis. CBC
continued on page 556
554
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FEATURE
may help establish the diagnosis, but
a single negative result does not rule out
leukemia. If limp persists, one should
consider repeating the blood work and
also consider bone marrow studies.
Other
SCFE is a disorder of the immature
hip, the exact etiology of which is unknown. There is anatomic disruption
through the proximal femoral physis
causing it to displace posteriorly and
inferiorly. Childhood obesity is a major
risk factor for SCFE. It affects the adolescent age group. Long-term outcomes
depend on the associated complications,
mainly avascular necrosis of the femoral
head. The patient usually presents with
hip or knee pain and occasional limp.
High index of suspicion is required for
the diagnosis. Patients with suspected
SCFE should be nonweight bearing until the diagnosis is ruled out. Hip X-rays
help in diagnosis. If the X-ray is suggestive of SCFE, an immediate orthopedic
consult should be sought24 (Figure 5).
RESOLUTION OF THE CASES
Case 1
The child had a high white blood
count of 50,000 cells/mm3 and peripheral smear showed blasts. He was admitted
to the oncology service for management
of leukemia.
Case 2
Presentation was consistent with serum sickness. WBC count and inflammatory markers were mildly elevated.
The child was discharged home on ibuprofen to be taken as needed.
Case 3
The presentation was consistent with
transient synovitis. WBC count and inflammatory markers were mildly elevat-
556
Figure 5. An X-ray showing left-sided slipped
capital femoral epiphyses.
ed. Pain and weight bearing improved
with ibuprofen. US of the hip showed
small effusion. The child was discharged
home on ibuprofen. Symptoms resolved
after 1 week.
REFERENCES
1. Barkin RM, Barkin SZ. The limping child. J
Emerg Med. 2000;18:331-339.
2.Fischer SU, Beattie TF. The limping child:
epidemiology, assessment and outcome. J
Bone Joint Surg Br. 1999;81:1029-1034.
3. Sawyer JR, Kapoor MK. The limping child.
A systematic approach to diagnosis. Am
Fam Physician. 2009;79(3):215-224.
4.Leung AK, Lemay JF. The limping child. J
Pediatr Health Care. 2004;18:219-233.
5.Mathison DJ, Troy A, Levy M. Fever and
limp: thinking outside the box. Pediatr
Emerg Care. 2012;28(12):1369-1373.
6.Lawrence LL. The limping child. Emerg
Med Clin North Am. 1998;16(4):911-929.
7.Kocher MS, Zurakowski D, Kasser JR.
Differentiating between septic arthritis
and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am.
1999;81(12):1662-1670.
8. Kocher MS, Mandiga R, Zurakowski D. Validation of a clinical prediction rule for the
differentiation between septic arthritis and
transient synovitis of the hip in children. J
Bone Joint Surg Am. 2004;86-A(8):16291635.
9.Offiah AC. Acute osteomyelitis, septic arthritis and discitis: differences between
neonates and older children. Eur J Radiol.
2006;60(2):221-232.
10.Hill D, Whiteside J. Limp in children: differentiating benign from dire causes. J Fam
Pract. 2011;60(4):193-197.
11.Knapp JF, Schremmer RD. A 12-year-old
boy with a limp. Pediatr Emerg Care.
2001;17(1):67-72.
12. Zamzam MM. The role of ultrasound in differentiating septic arthritis from transient
synovitis of the hip in children. J Pediatr
Orthop B. 2006;15:418-422.
13.Vieira RL, Levy JA. Bedside ultrasonography to identify hip effusions in pediatric
patients. Ann Emerg Med. 2010;55(3):284289.
14.Reed L, Baskett A, Watkins N. Managing
children with acute non-traumatic limp:
the utility of clinical findings, laboratory
inflammatory markers and X-rays. Emerg
Med Australas. 2009;21(2):136-142.
15.Baskett A, Hosking J, Aickin R. Hip radiography for the investigation of nontraumatic, short duration hip pain presenting to
a children’s emergency department. Pediatr
Emerg Care. 2009;25(2):78-82.
16. Pineda C, Espinosa R, Pena A. Radiographic
imaging in osteomyelitis: the role of plain
radiography, computed tomography, ultrasonography, magnetic resonance imaging, and scintigraphy. Semin Plast Surg.
2009;23(2):80-89.
17.Ezzat T, EL-Hamid AA, Mostafa M, ELKady L. Early diagnosis of acute osteomyelitis in children by high-resolution and
power Doppler sonography. Egypt J Radiol
Nucl Med. 2011;42(2):233-242.
18.Harik NS, Smeltzer MS. Management
of acute hematogenous osteomyelitis in
children. Expert Rev Anti Infect Ther.
2010;8(2):175-181.
19.Chambers JB, Forsythe DA, Bertrand SL,
Iwinski HJ, Steflik DE. Retrospective review of osteoarticular infections in a pediatric sickle cell age group. J Pediatr Orthop.
2000;20(5):682-685.
20.Arthurs OJ, Gomez AC, Heinz P, Set PA.
The toddler refusing to weight-bear: a revised imaging guide from a case series.
Emerg Med J. 2009;26(11):797-801.
21. Cook PC. Transient synovitis, septic hip, and
Legg-Calvé-Perthes disease: an approach to
the correct diagnosis. Pediatr Clin North
Am. 2014;61(6):1109-1118.
22. Martí-Carvajal AJ, Solà I, Agreda-Pérez LH.
Treatment for avascular necrosis of bone in
people with sickle cell disease. Cochrane
Database Syst Rev. 2014;7:CD004344.
23.Lefèvre Y, Ceroni D, Läedermann A, et al.
Pediatric leukemia revealed by a limping
episode: a report of four cases. Orthop
Traumatol Surg Res. 2009;95(1):77-81.
24. Novais EN, Millis MB. Slipped capital femoral epiphysis: prevalence, pathogenesis,
and natural history. Clin Orthop Relat Res.
2012;470(12):3432-3438.
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