Key distinguishing features of the most common diagnoses
|Trauma||Irritable Hip||Viral Infection||JCA||Slipped Epiphysis|
|Stiff in Early Morning||No||No||No||Yes||No|
|Usually Over 10 Years Old||No||No||No||No||Yes|
|Many Joints Affected||No||No||Yes||Possible||No|
Likely:FBC, ESR/CRP, X-ray.
Small Print:Calcium, phosphate, alkaline phosphatase, creatine kinase, ASO titre, blood culture.
- FBC and ESR/CRP: WCC and ESR/CRP elevated in an underlying inflammatory or infective cause.
- Hip X-ray: May reveal fracture, slipped femoral epiphysis, congenital dislocation, Perthes’s and other significant disorders – but may be normal in the presence of serious pathology.
- Rheumatoid factor and autoimmune screen may be helpful if a connective tissue disorder is suspected.
- Serum calcium, phosphate and alkaline phosphatase: Calcium and phosphate low, alkaline phosphatase high in rickets.
- Creatine kinase: Markedly elevated in muscular dystrophy.
- ASO titre is raised in 80% of cases of rheumatic fever.
- In hospital, blood culture may identify the infecting organism in osteomyelitis and septic arthritis.
- Never forget to examine the soles of the feet and between the toes for obvious and potentially simple to treat, non-serious causes of limp.
- It’s worth investing some time gaining the child’s confidence – this will enable you to make a proper assessment and feel positive about your management.
- Parents may try to rationalise the symptom by recalling a recent minor episode of trauma, which is likely to be purely coincidental.
- Don’t forget referred pain. Hip pathology can cause pain in the knee.
- Marked restriction of movement and/or dramatic bony tenderness suggests a significant problem – especially fracture, septic arthritis and osteomyelitis.
- Fever with a limp requires an urgent specialist opinion. Admit to exclude osteomyelitis or septic arthritis.
- Beware the obese pubertal boy with groin pain and a limp – slipped femoral epiphysis is likely.
- Do not confine your assessment to the hip – for example, abdominal pain, especially appendicitis, can make a child limp.