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The limping child
Most limps are minor — but septic arthritis, SUFE, malignancy and NAI must not be missed. Use the child's age to frame the differential, rule out infection first, remember that knee pain can come from the hip, and always think about safeguarding in young children. Built for revision, not live patient decisions.
Settle them, and check the basics
infection firstRed flags — what each should make you think
Always examine the hip when a child has knee pain. SUFE often presents with knee or thigh pain (referred via the obturator nerve), and delayed diagnosis leads to slip progression and avascular necrosis.
First actions
- 🌡Observations
- 👀Watch them walk
- 🦵Examine from back to feet
- 🩸Bloods if infection possible
- 🩻X-ray
- ☎Paeds/ortho
Understand the child — differentials by age
age frames itBy age
- Under 4 — toddler's fracture (spiral tibia), septic arthritis/osteomyelitis, DDH, NAI, transient synovitis (less common), leukaemia
- 4–10 — transient synovitis (most common), Perthes disease (avascular necrosis of the femoral head, boys 4–8), septic arthritis, juvenile idiopathic arthritis, fractures
- 10–16 — SUFE, Osgood–Schlatter, overuse/sports injuries, bone tumours (osteosarcoma, Ewing's), JIA
Septic arthritis vs transient synovitis — Kocher criteria
- Non-weight-bearing
- Temperature above 38.5°C
- ESR above 40 mm/h
- WCC above 12 ×10⁹/L
- (CRP above 20 mg/L is often added)
The more criteria present, the higher the probability of septic arthritis. With 2 or more, get an urgent hip ultrasound and orthopaedic review for aspiration. Transient synovitis is a diagnosis of exclusion: a well child, often after a viral illness, who still bears some weight.
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Fever, non-weight-bearing, painful restricted joint movement; osteomyelitis: bone tenderness.
Kocher criteria, USS for effusion, aspiration; MRI for osteomyelitis.
Urgent orthopaedics — aspiration/washout, IV antibiotics after samples.
10–16, often overweight, hip/thigh/knee pain, limp, loss of internal rotation, leg externally rotated.
AP and frog-leg lateral X-ray of both hips (Klein's line; bilateral in up to a fifth).
Non-weight-bearing, urgent orthopaedic referral (surgical fixation). Unstable (can't weight bear at all) = emergency.
Night pain, weight loss, pallor, bruising, lymphadenopathy, hepatosplenomegaly, bone pain.
FBC + blood film, LDH, X-ray (lytic lesions, periosteal reaction).
Urgent paediatric oncology/haematology referral.
Non-mobile child with fracture, delay in presentation, inconsistent history, other injuries, multiple fractures of different ages.
Skeletal survey (via safeguarding pathway).
Safeguarding procedures, senior paediatrician.
Investigate — what to order, when, and what it tells you
test with a question in mindBloods
X-ray
Ultrasound
MRI
How the plan comes together
disposition · handoverhome
Well, afebrile, weight-bearing, normal bloods/X-ray: likely transient synovitis. Analgesia, rest, review in 24–48 h; return if fever, worse pain, or not weight-bearing. Persistent limp beyond 1–2 weeks needs review.
admit / urgent ortho
Fever with non-weight-bearing, Kocher ≥2, SUFE, abnormal bloods/X-ray, or safeguarding concern.
Hand over: age, Kocher criteria, X-ray findings, safeguarding considerations.
Age frames the differential, the hip explains the knee, Kocher sorts infection from synovitis, and in young children always ask whether the story fits the injury. Nicely done getting here.
Clerking template
copy or downloadThe limping child — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 10 knownFrequently asked questions
quick answersWhat are the red flags for the limping child?
- Fever + refusing to weight bear — think septic arthritis / osteomyelitis
- Obese adolescent with hip or knee pain — think SUFE
- Night pain, weight loss, bruising, pallor — think malignancy (leukaemia, bone tumour)
- Under 3, inconsistent history, other injuries — think non-accidental injury
- Systemically unwell — think sepsis
- Back pain in a child — think discitis / serious pathology
What is the initial management of the limping child?
- Observations — temperature, HR (fever + tachycardia = worry)
- Watch them walk — antalgic? Trendelenburg? refusing?
- Examine from back to feet — hip rotation (painful, reduced), knees, feet, spine
- Bloods if infection possible — FBC, CRP, ESR, blood culture
- X-ray — by age and site (AP + frog-leg lateral both hips for SUFE)
- Paeds/ortho — febrile, non-weight-bearing, or abnormal X-ray
Always alongside senior support and your local guideline.
What diagnoses must you not miss in the limping child?
- Septic arthritis / osteomyelitis — fever · won't weight bear
- Slipped upper femoral epiphysis — obese adolescent
- Malignancy — night pain · bruising
- Non-accidental injury — inconsistent story
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for the limping child?
- Bloods — FBC, CRP, ESR, blood cultures.
- X-ray — AP pelvis + frog-leg lateral for SUFE/Perthes.
- Ultrasound — Effusion — guides aspiration (doesn't distinguish septic from transient).
- MRI — Osteomyelitis, occult fracture, malignancy.
Admit or discharge: how is the plan decided for the limping child?
- Home — Well, afebrile, weight-bearing, normal bloods/X-ray: likely transient synovitis. Analgesia, rest, review in 24–48 h; return if fever, worse pain, or not weight-bearing. Persistent limp beyond 1–2 weeks needs review.
- Admit / urgent ortho — Fever with non-weight-bearing, Kocher ≥2, SUFE, abnormal bloods/X-ray, or safeguarding concern.
Is there a clerking template for the limping child?
Yes — there is a free clerking template for the limping child on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
Keep going
one more?More from Orthopaedics & Trauma
The BOAST approach and antibiotics.
Pain out of proportion — a limb emergency.
The red flags and the urgent MRI.
The hot joint you must aspirate.
The frailty pathway and the operation.
Describing, reducing and referring.