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Pitfalls

Limp is a symptom and not a diagnosis

There are red flag conditions not to be missed.  The causes can be broadly divided into acute and chronic and are categorised by age.

Common pitfalls in making a diagnosis of limp include:

  • Ascribing limp to trauma and overlooking features that suggest other causes.
  • Referred pain (e.g., from the abdomen [and testes in boys], back or chest and hip pathology manifesting as knee pain).
  • Think beyond the hip (!) and examine the child comprehensively.
  • Assess for proximal muscle weakness; ask the child to get up from the floor (Gower's manoeuvre), jump or climb a step.
  • Classical clinical features of sepsis may be masked in the immunosuppressed child.
  • Mycobacterial infection can be easily missed.
  • Synovial fluid may be sterile in partially treated septic arthritis.
  • Labelling children with daytime symptoms as having “growing pains”.
  • Medically unexplained limp or physical symptoms warrant specific management and referral (i.e., discharge without a diagnosis and follow up plan is not advised).
  • The blood film may be normal in children with malignancy.
  • Radiographs are often normal in children with early sepsis or arthritis.
  • Acute phase reactants may be normal in children with inflammatory arthritis.
  • Rheumatoid factor is usually negative in children with inflammatory arthritis.
  • Antinuclear antibody and rheumatoid factor may be false positive in children without inflammatory joint or muscle disease.

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