A 2-year old male attends with a history of not wanting to bear weight on his left leg since getting out of bed that morning. His mother gave him Paracetamol prior to their attendance to the Emergency Department (ED) and he is now observed to be limping whilst playing in the waiting room.
There is no history of traumatic injury, either from the nursery he attends, or from the time he has spent with his parents and older sibling. Birth history gives no additional information to support developmental dysplasia of the hip (Lindsay, 2016).
His mother also reports that his most recent illness was 3-weeks ago when he had a viral illness from which he recovered without any further symptoms.
Non-accidental injury is considered but excluded, as the history is consistent with the physical findings of the examination and normal bruising patterns are noted on the lower limbs (Leet & Scaggs, 2000). The child is observed to interact well with his parents as supported by the hospital play specialist observations.
On examination, physiological observations are within normal parameters including temperature recorded at 36.7 degrees centigrade. On walking the child is observed to place the left foot on to the ground for a shorter period of time than the right, which is exacerbated when the he is distracted and encouraged to run (antalgic gait). There is no obvious redness, heat or swelling noted of the left leg as compared to the right. Likewise, on palpation of the long bones no bony tenderness is elicited, however on assessment of range of joint movements pain and guarding is noted on the internal rotation of the left hip.
Abnormal or antalgic gait can have a number of causes in the preschool child the diagnosis of which can be difficult to make but is made easier by a thorough history and focused physical examination (Sawyer & Kapoor, 2009; Herman & Martinek, 2015).
Differential Diagnosis include:
– Transient Synovitis (Irritable Hip)
– Development Dysplasia of the Hip
– Trauma (fracture)
– Septic Arthritis
– Sarcoma (malignancy)
– Non Accidental Injury
With the presenting history a diagnosis of transient synovitis is most likely as described by the onset, collateral history of recent viral infection and initial response to analgesia. The current lack physical signs supporting infection of a joint would exclude septic arthritis at this point (Leet & Skagg, 2000). Furthermore, the lack of long bone tenderness would exclude fracture and specifically ‘Toddler’s Fracture’, the commonest traumatic injury in this age group (Sawyer & Kapoor, 2009).
– < 3-years (vulnerable to septic arthritis and maltreatment)
– limp and stiffness worse in the morning (inflammatory e.g. Transient Synovitis)
– redness, swelling or stiffness (inflammatory/infection e.g. Rheumatoid Arthritis/Septic Arthritis)
– unexplained rash/bruising (haematological disorder)
– severe pain, anxiety after trauma (compartment syndrome)
– pain waking the child at night (malignancy)
– weight loss, anorexia, fever, night sweats or fatigue (inflammatory/infection/
Imaging by Radiograph (X-ray)
Children should be x-rayed only when there are not clear indications for urgent assessment, when there is a history of trauma or when examination elicits specific bony tenderness (NICE, 2016).
Management plans should include a trial of anti-inflammatory analgesic such as ibuprofen with additional paracetamol in order to treat the mild/moderate level of pain experienced. Re-assessment for improvement in gait should be undertaken in order to confirm the diagnosis of transient synovitis, for some children the limp completely resolves.
Continued management should include regular anti-inflammatory analgesia and appropriate follow-up. Parents should be encouraged to attend for either ED clinic or GP review at 48-hours to ensure that the condition is resolving or to facilitate further investigation (NICE, 2015).
Next steps and further investigations may include blood tests for raised inflammatory markers including; CRP and ESR, WCC for infection and imaging such USS with same day referral to trauma and orthopaedic teams for further management (Perry & Bruce, 2010).
Driscoll, J. (2007) Practicing clinical supervision: a reflective approach for healthcare professionals (2nd edition). Elsevier. Edinburgh.
Herman, M. & Martinek, M. (2015) The limping child. Pediatrics in Review36(5): 184-197 cited in Acute Childhood Limp. [on-line] Clinical Knowledge Summaries http://cks.nice.org.uk/acute-childhood-limp#!scenario (accessed 31/07/16)
Lindsay, D. (2016) A limping child. [on-line] BMJ http://www.bmj.com/content/352/bmj.i476 (accessed 31/07/16)
Leet, A. & Skaggs, D. (2000) Evaluation of the acutely limping child. American Family Physician61(4):1011-18 cited in Acute Childhood Limp. [on-line] Clinical Knowledge Summaries http://cks.nice.org.uk/acute-childhood-limp#!scenario (accessed 31/07/16)
Perry, D. & Bruce, C. (2010) Evaluating the child who presents with an acute limp. BMJ 341 cited in Acute Childhood Limp. [on-line] Clinical Knowledge Summaries http://cks.nice.org.uk/acute-childhood-limp#!scenario (accessed 31/07/16)
Sawyer, J.R. & Kapoor, M. (2009) The Limping Child: A Systematic Approach to Diagnosis. American Family Physician 79(3):215-224 [on-line] http//:www.aafp.org/afp (accessed 01/08/16)