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Probability diagnosis

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Post trauma/intense exercise causing strain syndromes Ill-fitting shoes

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Hip disorders, esp. transient synovitis

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Heel disorders (12–14 years)

++

Serious disorders not to be missed

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Toddlers

Developmental dysplasia hip (DDH)

Child abuse

Septic arthritis

Foreign body (e.g. needle in foot)

4–8 years

Perthes’ disorder

Transient synovitis

Adolescents  

Slipped capital femoral epiphysis (SCFE)

Avulsion injuries (e.g. ischial tuberosity)

Osteochondritis dissecans of knee

Duchenne muscular dystrophy

All groups

Acute viral infections

Appendicitis

Septic infections:

  • septic arthritis

  • osteomyelitis

  • tuberculosis

Cerebral palsy

Rheumatic fever

Tumour (e.g. osteosarcoma)

Juvenile idiopathic arthritis (oligo articular)

Juvenile rheumatoid arthritis

Spinal disorders:

  • discitis

  • fracture

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Pitfalls (often missed)

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Foreign body (e.g. in foot)

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Osteochondritis (aseptic necrosis):

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  • femoral head: Perthes’ disorder

  • knee: Osgood–Schlatter disorder

  • calcaneum: Sever disorder

  • navicular: Köhler disorder

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Myalgia = ‘growing pains’

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Overuse syndrome (esp. adolescent):

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  • patellar tendonopathy (jumper’s knee)

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Stress fractures (e.g. tibia, femoral neck, navicular)

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Key history

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Ask about a history of trauma, foci of infection including the skin and any unusual developmental problems. Trauma, sepsis, synovitis and DDH are perhaps the most common reasons for a child to limp and refuse to walk. A painless waddling gait suggests DDH or Perthes’ disorder.

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   The limp must be considered to be due to a definite organic cause. It is appropriate to focus initially on the hip. Ask about the relationship of the limp to exercise and footwear.

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Key examination

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  • The hip and the knee joints should be examined carefully if the source of the limp has no specific localisation

  • Get the child to walk and run on the toes and heels. Note the gait and check whether it is antalgic (painful), hemiplegic (arm held out in a balancing action) or Trendelenburg (classic for DDH). Look for evidence of muscle dystrophy

  • Never forget to examine the soles of the feet and between the toes

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Key investigations

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Consider:

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  • FBE and ESR/CRP

  • blood culture

  • needle aspiration of joint

  • radiological: plain X-ray, ultrasound, bone scan, CT or MRI scan.

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Diagnostic tips

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  • Multiple fractures and epiphyseal separations in toddlers are highly suggestive of child battering—order a skeletal survey if suspected.

  • An acute limp may be due to injury, infection (osteomyelitis, septic arthritis), spinal injuries, a fracture or an irritable hip (synovitis).

  • Chronic cases include cerebral palsy, DDH, Perthes’ disorder and chronic SCFE.

  • Infections of and around the hip joint are most common in infancy. Classically, the hip is held immobile in about 30% of flexion with slight abduction and external rotation.

  • Hip pathology can cause pain in the knee.

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