Limp – Emergency management in children

Purpose

This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) with an unexplained limp in Queensland. This guideline does not cover the management of all conditions that can present with limp but focuses on identifying the more common serious conditions (including septic arthritis) that require timely specialist referral.

This guideline has been developed by senior ED clinicians across Queensland, with input from Orthopaedic and Rheumatology specialists, Queensland Children’s Hospital, Brisbane. It has been endorsed for use across Queensland by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.

Introduction

Normal (adult-type) gait is a smooth, rhythmic near-effortless movement with 60% of time spent in stance phase (from heel strike through stance to toe off) and 40% in swing phase. The immature toddler gait shows short stride length, fast cadence, slow velocity and wide base (Payares-Lizano, 2020)

A limping gait is any variation from normal gait. Most common variations include:

• Antalgic: shortened stance phase to limit time spent  weight bearing
• Equinus: toe-walking, can be habitual,  idiopathic, caused by calf pain, clubfoot, leg length discrepancy or cerebral  palsy
• Trendelenburg: shifting of weight to affected  side during stance due to weak hip abductors. Can be seen in Legg-Calve-Perthe,  developmental dysplasia of the hip, slipped capital femoral epiphysis, muscular  dystrophy and hemiplegia cerebral palsy
• Circumduction: leg swings laterally to avoid  tripping in limb-length discrepancy or foot or ankle pathology

Limp in children is a single sign of an underlying pathology. Children present to ED with a wide spectrum of possible causes for a limp ranging from benign to life or limb threatening conditions.  Causes of limp can be limb related, including from joint, bone and soft tissue pathology as well as not limb related, eg neurological, intra-abdominal etc. Underlying pathologies can be stratified by aged (table 1).

Common causes of acute limp by age and order of incidence

Other differentials include, but are not limited to, spina bifida, cerebral palsy, muscular dystrophy, rheumatological conditions, abdominal and genital pathology and neurological conditions. These diagnoses are unlikely to present with the only symptom being a limp.

Of the broad range of differentials there are six diagnoses that require early intervention and treatment and therefore are the six key diagnoses not to miss⁹.

1. Septic arthritic
2. Osteomyelitis
3. Malignancy
4. Toddler’s fracture
5. Legg-Calve-Perthes Disease
6. Slipped Upper Femoral Epiphysis
7. Non-Accidental Injury

The focus of this guideline is to differentiate the children  who have a serious underlying pathology requiring urgent or emergent intervention from the larger group who do not have a serious cause for their limp. Transient synovitis is a common, self-limiting cause of limp in children presenting to the emergency department.

Assessment

Given the spectrum of conditions that cause a child to limp, the differential remains broad and a unifying diagnosis can be elusive. In most cases, a thorough history and physical examination can significantly narrow the differential. Additional investigations may be required to delineate between conditions with similar symptoms.

History

History taking should include specific information on:

• onset and course of limp
• history of trauma
• pain history - including localisation, magnitude, pain migration, number of joints involved, exacerbating/ relieving factors
• constitutional symptoms such as fevers, malaise, anorexia, weight loss, night sweats
• Bleeding history- excess bruising/bleeding, prolonged/frequent epistaxis, prolonged bleeding after invasive procedures.
• preceding illness  including sore throat or skin infections
• previous or recurrent injuries (haemophilia, or should raise suspicion of NAI especially in infants and younger children)
• social history
• Indigenous status
• developmental delay

Examination

Clinical examination should include:

• general examination with attention to vital signs and  appearance, bruising and lymphadenopathy
• neurological examination - symmetry of limbs, muscle  atrophy, power, tone, reflexes and coordination, including ataxia
• joint examination (including joint above and below) assessing swelling, tenderness, warmth, active and passive mobility
• point bony tenderness (may indicate osteomyelitis)
• abdomen, scrotum and spine examination to exclude referred pain from other possible causes

Investigations

Investigations required will depend on the assessment.  Children presenting within a few days of onset of the limp and with no red flags may not require any investigations.

The following investigations can be considered depending on history and examination findings.

Investigations for a child with a limp

Management

Refer to the flowchart [PDF 438.37 KB] for a summary of the recommended assessment and investigation for a child presenting to ED with an unexplained limp.

The appropriate management will be guided by the outcome of the assessment.

If suspected septic arthritis and unwell or septic, give urgent empiric antibiotics after blood cultures obtained. Do not delay whilst waiting for operative intervention. This management should be as per statewide sepsis protocols.

Prompt referral to orthopaedic service as per local practice is required for all children with concerns of serious underlying pathology.

Consider seeking orthopaedic advice as per local practice for a child with a persistent limp (greater than one week) and a normal X-ray.

If unwell or septic, give urgent empiric antibiotics after blood cultures obtained. Do not delay whilst waiting for operative intervention. This management should be as per statewide sepsis protocols.

Malignancy

Toddler’s fracture

Legg-Calve-Perthes Disease

Slipped Upper Femoral Epiphysis

The focus of this guideline is to differentiate the children who have a serious underlying pathology requiring urgent or emergent intervention from the larger group who do not have a serious cause for their limp. Other important causes of limp are included here. Be aware this list is not exhaustive.

Escalation and advice outside of ED

Clinicians can contact the services below if escalation of care outside of senior clinicians within the ED is needed, as per local practices. Transfer is recommended if the child requires a higher level of care.

Child with septic arthritis (requires time-critical care)

Non-critical child

Inter-hospital transfers

Disposition

When to consider discharge from ED

Most children who do not have serious underlying pathology can be managed supportively at home, with appropriate advice around when to represent for review at either their GP or the ED.

Parents should be advised to represent for medical review (GP or ED) if the child:

• develops a fever
• worsening joint pain, nocturnal pain, refusal to weight bear despite analgesia
• is not improving after 3 days or symptoms persist for greater than 14 days
• becomes tired, lethargic or unwell in themselves

Follow-up

Recommended follow-up is based on the outcome of the assessment. Follow-up is not routinely required for children for whom no serious underlying pathology is suspected.

When to consider admission

As per advice for children requiring specialist referral.

Consider admission for any child who cannot weight bear and is no longer mobile.

Related documents

• Paediatric Sepsis Pathway [PDF 4229.69 KB]
• Paediatric Bone and Joint Infection management Guideline
• CHQ-GDL-01057 Antimicrobial treatment: Antibiotic duration and timing of the switch from intravenous to oral for common bacterial infections in children - Paediatric Guideline [PDF 647.54 KB]
• Haemophilia – Emergency Management in children flowchart
• Acute Rheumatic Fever skill sheet [PDF 578.45 KB]
• Limp fact sheet