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Red Flags

Clinical Features that suggest severe life threatening conditions:


  • Complete non-weight bearing.
  • Pseudo-paralysis of limb.
  • Any attempt to passively move the limb is resisted and causes extreme distress.
  • Severe and non-remitting pain.
  • Limb held in a position which accommodates increased joint volume due to effusion ; e.g., a flexed knee with a mild effusion.
  • Night pain and waking.
  • Fever.
  • Immunocompromised child - due to primary disease or medications.
  • Back pain in the unwell child.
  • If cultures are negative, consider rheumatic fever in endemic areas (e.g. school aged children from Maori, Pacific Islands, India or Asia).


  • Night pain.
  • Severe and non-remitting pain.
  • Bone pain.
  • Pallor.
  • Bruising.
  • Lymphadenopathy.
  • Hepatosplenomegaly.
  • Anaemia, thrombocytopenia.
  • Systemic symptoms (lethargy, weight loss, night sweats, fever).
  • Complete non-weight bearing.
  • Back pain in the unwell child.
  • Weight loss.

Non-accidental injury:

  • Delay in seeking medical attention.
  • History inconsistent with pattern of injury.
  • Explanation of injury incongruent with developmental stage of child.
  • Repeated presentations.
  • Unwitnessed injury.
  • Patterns of injury suggestive of non-accidental injury (e.g., bruising over soft tissue areas, multiple bruises, bruises that carry the imprint of an implement or instrument)
  • Distinctive burns e.g. round cigarette burn, forced immersion burn
  • Complete non-weight bearing with occult fracture
  • Type of fracture (e.g., metaphyseal fracture, posterior rib fractures, skull fracture, any type of fracture in a non-ambulant child).
  • Multiple injuries.
  • Unkempt appearance and poor hygiene.

Further information is available

NICE guidance regarding non-accidental injury

NICE Guidance on suspecting cancer in children 

NICE guidance on fever in young children 

 Further information about limp is available.