Joint Trust Guidelines for the Limping Child with No History of Trauma
A Clinical Guideline
For Use in:
By:
For:
Division responsible for document:
Key words:
Name and job title of document
author’s:
Name and job title of document
author’s Line Manager:
Supported by:
Assessed and approved by the:
Date of approval:
Children’s Assessment Unit
Medical and Nursing staff
Children (0-16) presenting with a limp or acute
lower limb pain but with no history of trauma
Women / Children
Limping, child, irritable, hip, septic, arthritis,
osteomyelitis, limp
Dr.Kate Armon ,Paediatric Consultant
Dr.Dipali Shah, Paediatric Registrar
Dr Bina Mukhtyar, Paediatric Consultant
Dr David Booth, Chief of Women’s and
Children’s Services
Miss Rachael Hutchinson, Mr Anish Sanghrajka
Paediatric Orthopaedic Consultants
Dr. P. Ambadkar, Children & Young People’s
Services, (JPUH)
Accepted by James Paget University Hospital on
17/07/2014 under the Tri-Hospital Clinical
Guidelines Assessment Panel (THCGAP)
Clinical Guidelines Assessment Panel (CGAP)
If approved by committee or Governance
Lead Chair’s Action; tick here √ Reported to
CGAP March 2016
11/03/2016
Ratified by or reported as approved
to (if applicable):
To be reviewed before:
This document remains current after this
date but will be under review
To be reviewed by:
Reference and / or Trust Docs ID No:
Version No:
Clinical Standards Group and Effectiveness
Sub-Board
Description of changes:
(for revised versions)
Compliance links: (is there any NICE
related to guidance)
If Yes - does the strategy/policy
deviate from the recommendations of
NICE? If so why?
11/03/2019
Dr. Armon
JCG0034 – Id 1235
2
No
N/A
This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and management of
relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline
must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available
and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from
relevant guidance should be documented in the patient's case notes.
The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare
through sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or misapplication of
this document.
Clinical Guideline for: The Limping Child with No History of Trauma
Author/s: Dr Armon, Dr Shah, Dr Mukhtyar
Approved by: CGAP
Date approved: 11/03/2016
Available via Trust Docs
Version: 2 Trust Docs ID: JCG0034 – Id 1235
Review date: 11/03/2019
Page 1 of 10
Joint Trust Guidelines for the Limping Child with No History of Trauma
Child with pain and limp.
No history of trauma.
Admit to CAU
1) Quick reference
History to include:
Previous viral symptoms?
Antibiotic use?
Fever?
Generally unwell / off food?
Duration of limp
B
Is there likely
hip
pathology?
No
Consider, investigate and treat
for other diagnoses as table
A
Yes
> 9 years
Age
?
D
Investigate:
X-ray affected bones / joints
FBC, ESR, CRP, Blood culture (cannula)
Suspected:
Fracture?
Osteomyelitis?
Septic arthritis?
Refer Paed Ortho (contacts below)
2-9 years
Limping
>1
week?
E
Yes
Any of:
WCC>12
ESR>20
CRP>40
Fever>38.5
No
F
AP and frog leg lateral hip XR.
If Perthes or SUFE, contact
Paed Ortho (contacts below)
If normal X-Ray return to flow
chart
No
Is s/he
unwell
?
Yes
No
Unwell (any of below):
Febrile
No history viral infection
Non-weight bearing
Pain and tenderness significant
Consider observation /
admission +/- orthopaedic
referral
Or discharge with open
access one week
Examination to include:
General health?
Temperature?
Gait, weight bearing?
Palpate and move all bones and
joints, localise problem.
Severity of pain?
C
Neurology- presence of DTR
Assess pain and give analgesia
(Ibuprofen 10mg/Kg)
If septic arthritis/osteomyelitis
considered highly likely, contact
paediatric orthopaedics urgently
(contacts below), proceed
through algorithm
<2 years
Letters in bold refer to later
sections of the text
Investigate:
FBC,ESR, CRP, BC
Are
bloods
abnormal?
Well (all of below)
Afebrile
History viral infection
Mild limp
Minimal restriction of
movements
Pain mild
Working diagnosis of transient
synovitis of the hip
Discharge:
Analgesia (Ibuprofen
10mg/Kg/dose tds, Paracetamol
15mg/Kg/dose PRN)
Bed rest – few days only
Information
Return if symptoms persist 1
week or symptoms significantly
worse in interim
If return - XR and bloods
Yes
Admit:
Discuss with paediatric SpR / Consultant.
Refer to Paed Ortho
Consider USS and aspiration. Consider GA / Sedation / analgesia for procedure.
Clinical Guideline for: The Limping Child with No History of Trauma
Author/s: Dr Armon, Dr Shah, Dr Mukhtyar
Approved by: CGAP
Date approved: 11/03/2016
Available via Trust Docs
Version: 2
Trust Docs ID: JCG0034 – Id 1235
Review date: 11/03/2019
Page 2 of 10
Joint Trust Guidelines for the Limping Child with No History of Trauma
2) Objective of Guideline
To promote thorough assessment and rational management of children with
acute lower limb pain, limp or non-weight bearing, without a history of injury
or trauma.
3) Rationale for the recommendations
A pre-guideline survey found that both paediatricians and orthopaedic
surgeons were managing children presenting with a limp and a possible
diagnosis of irritable hip or septic arthritis. The management varied in
investigations undertaken, admission and follow-up arrangements. This
guideline was developed following a review of the literature and agreement
between specialties to rationalise the management of such children.
4) Broad recommendations
Any child (0-16) with lower limb pain, a limp or non-weight bearing and no
history of trauma should be referred to the paediatric team on call (Dect
phone 6580 or bleep 0009). The child should be seen on the Children’s
Assessment Unit.
A. Major differential diagnoses of a child with a limp.
Condition
Septic arthritis (hip or
other joint)
Typical features
Any age. Most common <2yrs. Very painful (pseudoparalysis). Often non-weight bearing. Fever and unwell,
decreased ROM of affected joint. See Kocher criteria
(section D). CRP > 20 is likely to be associated with septic
arthritis.
Osteomyelitis
Any age, similar features to septic arthritis BUT often more
indolent presentation. Partial treatment with antibiotics
common. Look for bone tenderness. In under 2’s often coexists with septic arthritis
Transient synovitis of 3-9 years. Post viral. Pain and limp, decreased ROM of hip
the hip (Irritable hip)
but not as painful as septic arthritis
Fracture – nonTake history carefully. Be alert to late presentations,
accidental injury or
inconsistencies. Toddler fracture – often minor fall resulting
unrecognised trauma in undisplaced tibial fracture. Be aware of fractured fibula
Inflammatory arthritis
Joint swelling and heat (not detectable in hip). Decreased
(reactive, JIA, lyme
ROM but not as painful as septic arthritis. Longer history.
disease, HSP)
Limping and pain and stiffness worse in morning/ after
period of rest
Late presentation of
Delayed walking, always walked with limp. Asymmetrical
Developmental
skin creases, shortened leg, limitation of abduction in
Dysplasia
flexion
Perthes disease
4-10 years, boys>girls. Limp with groin, thigh or knee pain.
Decreased ROM with internal rotation of hip often reduced
first
Slipped upper femoral 8-15yrs boys>girls. Longer history limp, sudden minor
epiphysis (SUFE)
trauma often worsens pain and leads to presentation, knee
pain common, decreased ROM hip
Neoplasia (leukaemia, Night pain. General malaise. Weight loss, hepato-spleno
Clinical Guideline for: The Limping Child with No History of Trauma
Author/s: Dr Armon, Dr Shah, Dr Mukhtyar
Approved by: CGAP
Date approved: 11/03/2016
Available via Trust Docs
Version: 2 Trust Docs ID: JCG0034 – Id 1235
Review date: 11/03/2019
Page 3 of 10
Joint Trust Guidelines for the Limping Child with No History of Trauma
osteosarcoma etc.)
megally, pallor, bruising
Assessment
Initial assessment and documentation:
Pain - assess on pain scales according to age. Give appropriate
analgesia
Temperature, pulse, respirations.
Weight (height if able to stand)
Medical assessment:
B. Key points of history

Pain – site, severity, radiation, duration, exacerbating and relieving
factors. Limp – similar detail

A history of preceding viral symptoms is often found in irritable hip.

Preceding streptococcal sore throat / diarrhoeal illness in reactive
arthritis

Fever height, duration, frequency

Recent antibiotic use may mask or partially treat a septic arthritis /
osteomyelitis

Is the child considered to be generally well or unwell? Is s/he eating and
drinking normally

Duration of symptoms – between 1 and 5 days associated with
increased risk of infection
C. Examination key points

Is the child generally well or unwell?

What is the gait and are they able to weight bear?

Observe, palpate and move all bones and joints (look for heat,
erythema, swelling, pain, restriction)

Severity of pain?

Fever ≥38.5°C is likely to be associated with increased risk of infection

Conduct a detailed neurology examination, including eliciting deep
tendon reflexes (DTR). Remember, a child who is not weight bearing
and has abnormal neurological findings like absent reflexes may have
an underlying neurological cause to their limp
Follow algorithm for management.
If Septic arthritis or osteomyelitis are suspected:
1. Inform paediatric orthopaedic team as soon as possible:
In working hours:
Clinical Guideline for: The Limping Child with No History of Trauma
Author/s: Dr Armon, Dr Shah, Dr Mukhtyar
Approved by: CGAP
Date approved: 11/03/2016
Available via Trust Docs
Version: 2
Trust Docs ID: JCG0034 – Id 1235
Review date: 11/03/2019
Page 4 of 10
Joint Trust Guidelines for the Limping Child with No History of Trauma
Mrs Hutchinson - middle grade 0339, secretary 2596 (SHO 0345) or mobile
via switchboard
Mr Sanghrajka – middle grade 0327, sec 2710 (SHO 0349) or mobile via
switch board (bleep 0997, 0996)
Nurse specialist, Jan Wilkins 3266 (bleep 0298)
Out of hours:
Bleep on call orthopaedic middle grade 0996 (SHO 0997)
2. Please try to obtain synovial fluid or tissue biopsy before commencing
antibiotics to increase chance of culturing organism, and determining
sensitivities.
D. All children < 2 years
This age group are difficult to assess. Sudden onset of non- weight bearing or
limp is highly unlikely to be irritable hip and may include all the differential
diagnoses (except Perthes or SUFE). Careful and full examination is
imperative if clues concerning non-accidental injury, osteomyelitis and septic
arthritis at any site or inflammatory arthritis are to be detected. Fully expose,
palpate and move all bones / joints. Ensure full general examination is done
including ENT and urine dip if febrile. Consider haemarthroses in child with
excessive bruising. Developmental dysplasia of hip may present late with limp
in first walking toddler.
X-Ray affected bones / joints (or whole of lower limb if very difficult to localise
problem). If a fracture is present consider mechanism and any child protection
issues. Refer to orthopaedics for fracture management (bleep orthopaedic SpR
on call).
If no fracture, consider differential diagnosis and request blood tests
accordingly (FBC, ESR, CRP, Blood culture as a minimum). Request ASO
titre, anti-DNAse B and viral serology if reactive arthritis likely. ANA,
autoantibody screen, immunoglobulins and rheumatoid factor are indicated if
arthritis is likely but are not required urgently, or at first presentation.
Differentiating between septic arthritis of the hip and irritable hip:
Kocher Criteria (see ref. kocher 1999)
In a retrospective case series, the following features or ‘criteria’ were found to
be independently associated with septic arthritis:

non-weight-bearing on affect side

ESR greater than 40 mm/hr

Fever ≥38.5°C

WBC >12,000
The more criteria were met, the risk of septic arthritis increased:
One of four criteria = 3%
Two of four = 40%
Three of four = 93%
Four of four = 99%
Clinical Guideline for: The Limping Child with No History of Trauma
Author/s: Dr Armon, Dr Shah, Dr Mukhtyar
Approved by: CGAP
Date approved: 11/03/2016
Available via Trust Docs
Version: 2
Trust Docs ID: JCG0034 – Id 1235
Review date: 11/03/2019
Page 5 of 10
Joint Trust Guidelines for the Limping Child with No History of Trauma
In addition, CRP>20 has been shown to be associated with increased infection
risk.
E. Children 3-9 years
This is the commonest age group for irritable hip. The key is not to miss
children with a septic hip joint since severe destruction of the joint can occur
within 24 hours if not treated. If they are non-weight bearing despite analgesia
and you suspect infection, inform the paediatric orthopaedic team early. If any
doubt, investigate with blood tests (FBC, CRP, ESR and BC as minimum) and
consider USS and aspiration / observation / admission / paediatric orthopaedic
opinion. If Perthes is seen on X-ray refer to paediatric orthopaedic team.
.
F. All children > 9 years
Request AP and frog leg lateral hip X-ray to look for SUFE or Perthes – refer
urgently to paediatric orthopaedic team if abnormal.
Decide on further investigation dependent on whether you think the child is well
or unwell (follow algorithm).
G. Admission guidance
Any child who is not able to weight bear after appropriate analgesia should be
admitted.
If a child is generally unwell (fever and/or significant pain and tenderness) they
need investigation and likely admission for a period of observation. A paediatric
orthopaedic opinion should be sought for any admitted child.
Parents should be given open access to phone the children’s assessment unit
and return to hospital in the next 2 weeks with the same problem. The parent
information sheet at the end of this guideline should be given to them, with
instruction to return if:
The child is not better after 7 days of rest

The child develops a high temperature or is generally not well in himself
or herself

The child is in more pain or is not able to put weight on their leg to walk

If they have any concerns they should phone 01603 289774
H. Joint ultrasound scans
Ideally this should be done by a paediatric or musculoskeletal radiologist
although establishing the presence or absence of a significant effusion should
be within the compass of most radiologists.
If an effusion is seen a radiological aspiration may be indicated. This should
only be attempted if the radiologist is experienced in performing this procedure.
It should be done with appropriate analgesia for the age of the child. In most
cases, a successful aspiration can be achieved without undue trauma to the
child using topical local anaesthetic alone, supplemented occasionally by
injected local anaesthetic. It is key that a thorough discussion with the parents
involving the child when appropriate takes place with consent obtained. In
Clinical Guideline for: The Limping Child with No History of Trauma
Author/s: Dr Armon, Dr Shah, Dr Mukhtyar
Approved by: CGAP
Date approved: 11/03/2016
Available via Trust Docs
Version: 2
Trust Docs ID: JCG0034 – Id 1235
Review date: 11/03/2019
Page 6 of 10
Joint Trust Guidelines for the Limping Child with No History of Trauma
some cases oral or intranasal sedation may be helpful, and/or the use of
entonox. There is a minority of children in who it will be impossible to perform
an aspiration without a general anaesthetic.
5) Clinical Audit Standards derived from guideline

Initial point of contact should be paediatric on call team

Appropriate investigation according to age

Any aspirations should be performed by paediatric or musculoskeletal
radiologists and consent taken first

Appropriate referral to orthopaedics

Irritable hips given analgesia and advise sheet
Monitoring of: Length of time in CAU, any delay in diagnosis and treatment of
septic arthritis / osteomyelitis
6) Summary of development and consultation process undertaken before
registration and dissemination
The authors listed above have developed the guideline and circulated for
comment from paediatricians, orthopaedic surgeons, paediatric/MSK
radiologists, nursing staff on CAU, A&E consultants, junior medical staff.
Changes were made following these discussions. This guideline applies once
referral has been made to paediatrics and NOT to children presenting in A&E.
7) Distribution list/ dissemination method
CAU, A&E, Intranet
Abbreviations
ANA – anti-nuclear antibody
AP – Antero-posterior
BC - Blood culture
CAU – Children’s Assessment Unit
CRP – C-reactive protein
DDH – Developmental Dysplasia of the Hip (previously known as congenital
dysplasia of hip)
ENT – Ear, nose and throat
ESR – Erythrocyte sedimentation rate
FBC – Full blood count
GA- general anaesthetic
HSP- Henoch Schönlein purpura
JIA – Juvenile idiopathic arthritis
MSK - musculoskeletal
ROM – range of movement
SHO – senior house officer
SpR- specialist registrar
SUFE – slipped upper femoral epiphysis
USS – ultra-sound scan
WCC – white cell count
XR – X-Ray
Clinical Guideline for: The Limping Child with No History of Trauma
Author/s: Dr Armon, Dr Shah, Dr Mukhtyar
Approved by: CGAP
Date approved: 11/03/2016
Available via Trust Docs
Version: 2
Trust Docs ID: JCG0034 – Id 1235
Review date: 11/03/2019
Page 7 of 10
Joint Trust Guidelines for the Limping Child with No History of Trauma
References/ source documents
Kinnaird TP, Beach RC. Fractured fibula can mimic irritable hip. Arch Dis Child
2003;88:167
Tuten HR, Gabos PG, Kumar SJ, Harter GD. The limping child: a manifestation
of acute leukaemia. J Pediatr Orthop 1998;18:625-9
Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis
and transient synovitis of the hip in children: an evidence-based clinical
prediction algorithm. J Bone & Joint Surg-Am 1999;81:1662-70
Luhmann SJ, Jones A, Schootman M, Gordon JE, Schoenecker PL, Luhmann
JD. Differentiation between septic arthritis and transient synovitis of the hip in
children with clinical prediction algorithms. J Bone Joint Surg Am 2004;86:95662
Fischer SU, Beattie TF. The limping child: epidemiology, assessment and
outcome. J Bone Joint Surg Br 1999;81:1029-34
Kermond S, Fink M, Graham K, Carlin JB, Barnett P. A randomised clinical
trial: should the child with transient synovitis of the hip be treated with nonsteroidal anti-inflammatory drugs? Ann Emerg Med 2002;40:294-9
Beach RC. Minimally invasive approach to management of irritable hip in
children. The Lancet 2000;355:1202-03
Jung ST, Rowe SM et al. Significance of laboratory and radiologic findings for
differentiating between septic arthritis and transient synovitis of the hip. J
Pediatr Orthop 2003;23:368-72
JaiKumar,Manoj Ramachandran, David Little,Michalis Zenios Pelvic
Osteomylitis in children,
Journal of Paediatric Orthopaedics B 2010, 19: 38-41
R.A.Delaney, B Leneham, L O’Sullivan, A.J.McGuinness, J.T.Street, Ir.Med.Sc
:(2007)176:181-187
Markus Pa¨a¨kko¨nen , Markku J. T. Kallio , Pentti E. Kallio , Heikki Peltola,
Clin Orthop Relat Res (2010) 468:861–866
M Paakkonen, H Peltola, Management of a child with suspected acute septic
arthritis, arch Dis Child 2012: 97: 287-292
Clinical Guideline for: The Limping Child with No History of Trauma
Author/s: Dr Armon, Dr Shah, Dr Mukhtyar
Approved by: CGAP
Date approved: 11/03/2016
Available via Trust Docs
Version: 2
Trust Docs ID: JCG0034 – Id 1235
Review date: 11/03/2019
Page 8 of 10
Joint Trust Guidelines for the Limping Child with No History of Trauma
Appendix 1
Parent information sheet
Transient synovitis of the hip (irritable hip)
What is irritable hip?
All the freely movable joints of the body have a lubricating lining called the
synovial membrane. Irritable hip occurs when the membrane becomes
inflamed for a short period of time (otherwise known as ‘transient synovitis’).
The inflammation causes pain. The synovial membrane produces more than
it’s usual thin film of lubricating fluid when it is inflamed and this can result in
more pain in the joint. Irritable hip occurs in children (usually aged between 3
and 10 years) and is more common in boys than girls.
What causes irritable hip?
Unfortunately no one knows the cause. It may be due to a virus, or perhaps a
reaction to an infection somewhere else in the body.
What problems can it cause?
The inflammation in the joint sometimes happens after a flu-like illness. A child
will complain of pain in one hip on walking. The pain can be felt in the groin,
thigh or even the knee on that side. You may notice that your child is walking
unevenly or limping.
How is the diagnosis made?
The diagnosis is usually made from the history and description of the problem
and from the examination and observation of your child. It may be that X-rays
and / or blood tests are taken, but this is not always necessary. Your doctor will
want to rule out other, more serious problems that can look similar to irritable
hip. One of the most important of these is a bacterial infection in the hip, which
needs to be diagnosed and treated relatively quickly to prevent any damage
occurring to the hip joint.
How should it be treated?
Children with irritable hip may find walking and standing painful. They should
be allowed to rest so that pain is avoided. It may help to lie on their back and
find the most comfortable position for their leg. An anti-inflammatory medicine,
such as ibuprofen may be recommended to ease the swelling of the synovial
membrane. Simple pain killers such as paracetamol may also help. Your child
should not take part in sporting activity (apart from gentle swimming) for a
couple of weeks after the illness.
What should alert me to come back to hospital?
You have been given open access to phone the children’s assessment unit
and return to hospital in the next 2 weeks with the same problem. You should
return if:

Your child is not better after 7 days of rest.

Your child develops a high temperature or is generally not well in
himself or herself.

Your child is in more pain or is not able to put weight on their leg to
walk.

If you have any concerns, don’t hesitate to phone the Children’s
Clinical Guideline for: The Limping Child with No History of Trauma
Author/s: Dr Armon, Dr Shah, Dr Mukhtyar
Approved by: CGAP
Date approved: 11/03/2016
Available via Trust Docs
Version: 2
Trust Docs ID: JCG0034 – Id 1235
Review date: 11/03/2019
Page 9 of 10
Joint Trust Guidelines for the Limping Child with No History of Trauma
Assessment Unit on 01603 289774.
Clinical Guideline for: The Limping Child with No History of Trauma
Author/s: Dr Armon, Dr Shah, Dr Mukhtyar
Approved by: CGAP
Date approved: 11/03/2016
Available via Trust Docs
Version: 2
Trust Docs ID: JCG0034 – Id 1235
Review date: 11/03/2019
Page 10 of 10