Limp and hip pain

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim

To guide staff with the assessment and management of limp and hip pain.

Background

Limping may be due to pain referred from elsewhere:

  • pain from the hip may refer to the thigh or knee
  • pain from the spine or genitalia may refer to the hip
  • always consider the possibility of non-accidental injury (NAI)
  • limping for less than 3 days without any red flags does not require investigation.

Assessment

History

Ask about:

  • trauma
  • fever
  • preceding infections
  • rate of onset
  • duration of limp / pain
  • rashes
  • drug exposure
  • features of systemic disease with joint involvement
  • morning stiffness.

Examination

General

  • Temperature
  • Inspect for rashes/bruises
  • Assess for signs of the 'unwell child':
    • poor perfusion
    • tachycardia/tachypnoea.

Gait

  • Fully mature gait is attained by the age of 4 years
  • Running accentuates any pathological features of gait
  • Recognised gait patterns include:
    • antalgic gait due to a pain in the lower limb
    • trendelenburg gait due to weakened hip abductors or an unstable hip fulcrum e.g. Perthes disease, slipped upper femoral epiphysis (SUFE)
    • spastic gait as seen in cerebral palsy
    • proximal muscle weakness gait seen in neuromuscular conditions.

Standing

  • Examine the back and spine for tenderness or deformity (discitis may cause exaggerated lordosis)
  • Look for pelvic tilt.

Supine

  • Examine each joint separately for tenderness, swelling, effusion, erythema, warmth and range of movement
  • Disorders of the hip usually cause restriction of hip abduction and internal rotation and pain on these movements
  • Severe restriction of movement suggests septic arthritis
  • Note the position held by the child at rest
  • Check the foot for embedded foreign body
  • Assess for leg length discrepancy
  • Look for muscle atrophy, tenderness, weakness or abnormal reflexes
  • Neurological examination.

If no clear cause for limp is found on examination of the lower limbs or spine, examine the groin and abdomen.

Investigations

In a well child with < 3 days history of limp

  • No investigations are required

In a sick child, seek advice from an ED senior doctor

  • Bloods: FBC, CRP, ESR, blood cultures
  • X-ray hip: lateral and AP pelvis
  • Hip ultrasound may be required
  • Discuss with paediatric orthopaedic team.

In children with fever or severe hip pain/spasm

  • Seek advice from an ED senior doctor
  • Blood tests: FBC, CRP, ESR, blood culture
  • X-ray hip: lateral and AP pelvis
  • Hip ultrasound may be required
  • Lateral frog-leg view X-ray needed if considering SUFE (25% are bilateral, therefore X-ray both sides)

Differential diagnoses

Transient Synovitis (Irritable Hip)

  • Most common cause of limping in pre-school children
  • Diagnosis of exclusion
  • Age range: 3 - 8 years
  • Boys : Girls ratio 2:1

Perthes disease

  • Age range: 4 - 12 years
  • Boys : Girls ratio 4:1

Slipped Upper Femoral Epiphysis (SUFE)

  • Age range: 10 - 15 years
  • Boys 12 - 15 years
  • Girls 10 - 13 years
  • Boys : Girls ratio 4:1
  • Typically overweight children

Management

  • If either a fever or raised ESR is present, the patient is 8 times more likely to have an infection or an autoimmune process than if both parameters are normal
  • If both these parameters are raised, more than 90% of cases will be due to an infectious or autoimmune cause.

Well children

  • Discharge home
  • Advise bed rest
  • Regular non-steroidal anti-inflammatory drugs (e.g. Ibuprofen, Naproxen)
  • Review in ED in 2 - 5 days
  • Earlier if the child becomes febrile or the condition worsens.

Sick children

  • Discuss with and admit under the orthopaedic team

Septic arthritis/osteomyelitis

  • Discuss with and admit under the orthopaedic team
  • Intravenous Antibiotics – consider (do not give without discussing with the orthopaedic team).

Perthes disease

  • Discuss with the orthopaedic team
  • Usually requires admission.

SUFE

  • Discuss with and admit under the orthopaedic team
  • Requires surgery.

Referrals and follow-up

  • Children with hip pain for longer than 4 weeks can be referred to the Paediatric Rheumatology Team
  • Ask their advice on the appropriate blood tests to do in the meantime.

Bibliography

  1. Fundamentals of Pediatric Orthopedics
  2. Staheli, Fundamentals of Pediatric Orthopedics By: Lynn T. Staheli 2015
  3. Textbook of Pediatric Emergency Medicine. 6th ed. Fleisher GR, Ludwig S. Philadelphia: Lippincott Williams & Wilkins, 2010.
  4. Textbook of Paediatric Emergency Medicine 2nd Edition Cameron Elesevier 2012
  5. Nelson Textbook of Pediatrics: 20th Edition Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Schor Publisher: Elsevier


Endorsed by:  Director, Emergency Department   Date:  Mar 2018


 Review date:   Mar 2021


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