Makindo Medical Notes Comprehensive Medical Encyclopedia | Education for Healthcare Professionals

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Causes of a Limp in a Child

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Children may limp because of pain, weakness, deformity or to gain attention; the causes vary from sepsis to a spinal tumour and from a leg length discrepancy to a shoe that rubs. Serious causes must be excluded.

Summary of the Most Urgent Conditions

Septic Arthritis – Immediate intervention with antibiotics and possible surgery.
Osteomyelitis – Requires urgent antibiotics and imaging to prevent bone damage.
Slipped Capital Femoral Epiphysis (SCFE) Immediate non-weight bearing and surgery to prevent avascular necrosis.
Fracture Urgent intervention if there is significant displacement or open fracture.

The other conditions such as transient synovitis, Legg-Calvé-Perthes disease, and JIA can be managed less urgently but still require appropriate and timely diagnosis and treatment.

Clinical Assessment

Symptom onset: sudden or gradual?
Symptom duration
Concurrent events: recent viral infection, trauma, new shoes, new sport?
General health: is the child well?

Examination

Systemic exam: temperature, Pulse, BP
Examination all joints and soft tissues
A brief neurological examination
Measurement of leg length and an assessment of pain at rest or on weight bearing.

investigations

May need FBC, CRP etc.
Plain Pelvic radiographs should usually include both anteroposterior and ‘frog’ lateral views.
MRI in selected cases may be required.

Cause by age

Age (years)	Diagnosis
1–3	Late presenting developmental dysplasia of the hip; sepsis
3–10	Transient synovitis; Perthes’ disease
11–15	Slipped upper femoral epiphysis

Differentials

Cause	Clinical Presentation	Diagnostic Tests	Management
Septic Arthritis	Acute onset of severe joint pain, fever, inability to bear weight Swelling, redness, warmth over the joint Hip is most commonly affected	Joint aspiration: purulent fluid, positive culture Elevated WBC, CRP, ESR Ultrasound: shows joint effusion	Urgent IV antibiotics Surgical drainage or lavage Close monitoring for complications (e.g., osteomyelitis)
Osteomyelitis	Acute onset of pain, fever, swelling Refusal to bear weight Tenderness over the affected bone	X-ray: may be normal early but show bone changes later MRI: highly sensitive for detecting early osteomyelitis Blood cultures, elevated WBC, CRP, ESR	IV antibiotics (targeting suspected organisms) Surgical debridement if abscess or severe infection
Developmental Dysplasia of the Hip (DDH)	Often presents in infancy but can present later with limping Hip instability, asymmetric leg length Restricted hip abduction	Ultrasound in infants X-ray in older children	Pavlik harness in infants Surgical reduction in older children
Transient Synovitis (Irritable Hip)	Common in children aged 3-8 years Acute onset of hip pain and limp Low-grade fever (if any) Child usually well-appearing	Ultrasound: may show joint effusion Exclusion of septic arthritis (e.g., blood work) Normal blood tests (CBC, CRP, ESR)	Rest and reduced weight-bearing NSAIDs for pain relief Usually self-limiting, resolves in 1-2 weeks
Legg-Calvé-Perthes Disease	Insidious onset of limping and hip/knee pain More common in boys aged 4-10 years Limited hip abduction and internal rotation	X-ray: shows avascular necrosis of the femoral head MRI: early detection of necrosis	Activity modification and physiotherapy Bracing or casting to reduce stress on the hip Surgical intervention in severe cases
Slipped Capital Femoral Epiphysis (SCFE)	Adolescents (usually overweight) aged 10-16 years Groin, thigh, or knee pain Antalgic gait with limited internal hip rotation	X-ray: shows displacement of the femoral epiphysis Frog-leg lateral view is most diagnostic	Immediate non-weight bearing Surgical pinning of the femoral head to prevent further slippage Monitor for complications such as avascular necrosis
Juvenile Idiopathic Arthritis (JIA)	Chronic joint pain and swelling, limp that worsens in the morning Multiple joints may be affected Systemic symptoms (fever, rash) in some cases	Elevated inflammatory markers (CRP, ESR) Positive ANA or rheumatoid factor (in some cases) X-ray: may show joint space narrowing or erosions	NSAIDs or corticosteroids for inflammation DMARDs (e.g., methotrexate) in more severe cases Physical therapy to maintain joint function
Fracture	History of trauma or fall Local tenderness, swelling, and inability to bear weight Deformity may be present in severe cases	X-ray: confirms fracture CT or MRI in complex or occult fractures	Immobilization (casting or splinting) Surgical fixation in severe cases Pain management with analgesics

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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