Managing children with acute non‐traumatic limp: the utility of clinical findings, laboratory inflammatory markers and X‐rays

Abstract

In acute non-traumatic limp, X-rays of the hips diagnose slipped upper femoral epiphysis, as such they should be routinely used from the age of 9 years upwards. Below this age they are of little value. Inflammatory markers have utility in risk-stratifying children and selecting a group in whom to proceed with definitive tests to exclude osteomyelitis or septic hip. Children with a short history and minimal symptoms can be managed with appropriate follow up and no investigations.

Implementation of an evidence based guideline reduces blood tests and length of stay for the limping child in a paediatric emergency department

“…The incidence of septic arthritis in our population (7%) was higher than expected from previous studies 13 14. Four out of the eight cases of septic arthritis and both cases of osteomyelitis had normal serum infection markers.…”

“…The rate of abnormal plain radiological findings in our study group was relatively high at 22%, with previous studies stating abnormal plain film rates of between 3% and 18% 14. Given the relatively high incidence of Perthes' disease found in our study (19/110 patients, 17%), with high ‘pick up’ rate on plain radiology (14/19 or 74% of these patients had abnormal plain radiology findings), it may appear difficult for clinicians to ‘opt out’ of performing plain x-rays in patients suspected of having Perthes' disease; but with early outpatient follow-up, plain radiography could be reserved for those patients in whom limp persists.…”

“…Many existing guidelines rely on blood results and plain radiology findings as discriminating factors but in many patients these investigations may be normal and/or unnecessary 10–15. One recent study found that abnormal plain radiology findings were present in only 3% of children under 9 years of age presenting with atraumatic limp 14. A combination of history and clinical features can point to a certain diagnosis or to more sinister pathology being present,14 and may prompt specific investigations being done.…”

Emergency Department Extremity Radiographs in the Setting of Pain Without Trauma: Are They Worth the Pain?

“…As an example, Reed et al published a 2009 study showing a 6% rate of acute and chronic positive findings in pediatric ED patients presenting with a nontraumatic limp, including 9 cases of slipped capital femoral epiphyses (SCFE), 4 patients with widened joint spaces and one each of questionable osteomyelitis, Legg Calve Perthes disease, and a lytic lesion in the femur (12). As is well-known, SCFE typically presents in the early teen years, associated with a growth spurt in overweight children who often have no or a minimal history of trauma and so represents a different patient population than the one we studied.…”

Diagnostic Approach to Limp in Children

“…Plain radiography has limited utility in children younger than age 9 years presenting with nontraumatic limp. 14,15 Plain radiography findings in osteomyelitis include periosteal bone thickening, lytic lesions, and new bone apposition (Figure 1). These findings may not be apparent until 10 to 14 days of illness.…”