The differential diagnosis of limp is wide and varies with age.
Limp is a symptom and not a diagnosis.
- Red flag features include high fever, weight loss, night pain and lethargy. Infection and malignancy must be excluded.
- A limp persisting beyond two weeks requires referral to paediatrics, paediatric rheumatology or paediatric orthopaedics (pending local referral pathways).
- Morning stiffness (even if no obvious joint swelling) suggests inflammatory causes such as Juvenile Idiopathic Arthritis. Regression of motor milestones may be apparent.
- Many hip pathologies cause limp, but remember to assess other joints and think of extra-articular causes (including footwear and soles of feet for minor trauma or infection).
- Trauma including non-accidental injury, must be considered but it is noteworthy that children with pathology may be more prone to falling.
- Assessment will include history and examination, blood tests and imaging.
- It is important to examine all joints and not just the legs. pGALS is a useful and quick tool to assess all joints and guide further detailed examination.
- Motor milestones are important - if motor development is delayed consider a CK test early.
- It is important that a child with a limp has a follow up plan and parents have instructions for when to seek health care advice.
- the very young (under 3 years of age).
- the ill and febrile (red flags).
- the non-weight bearing.
- children with painful restricted hip movements.
- the child who is immunosuppressed.