Child with Hip Pain: A Comprehensive Approach

by Elizabeth Zorovich, Vincent Gonzalez, & Vlad Panaitescu

You Have A New Patient!

A four-year-old boy presents to the emergency department with his mother. The mother states that the patient has been limping and complaining of pain in his right leg for the past two days. She also reports that the right hip is red and painful to touch. The patient refuses to walk or move his right hip during triage. The mother states that the patient’s head felt warm this morning when he woke up, but she did not take his temperature before arriving. Both the mother and patient deny any falls or known injuries.

Vital signs are as follows: temperature 40°C, heart rate 130 beats per minute, blood pressure 100/70 mmHg, respiratory rate 16 breaths per minute, SpO₂ 98% on room air, and weight 16 kg. The patient is up to date on vaccinations.

What Do You Need To Know?

Importance

Limping in children is a common symptom encountered in the emergency department, necessitating careful evaluation due to its wide range of potential causes. While it may originate from benign conditions like sprains, it can also indicate serious underlying issues such as malignancies or infections, which can be life-threatening if not promptly diagnosed [1]. A thorough assessment, containing a detailed history and physical examination, is crucial for establishing the correct diagnosis [2]. This process can be particularly challenging depending on the child’s age, as younger patients may struggle to articulate their symptoms effectively. Therefore, proper history-taking and examination skills are essential, and primary caregivers often provide invaluable insights that can guide the clinician in identifying the root cause of the limping [3]. Prompt recognition and appropriate management of the underlying condition are vital to ensure optimal outcomes for the pediatric patient.

Epidemiology

The epidemiology of limping in children is an important area of study, although literature on this topic remains limited. According to studies [4,5], approximately four percent of pediatric visits to emergency departments are attributed to gait disturbances, highlighting the prevalence of this issue in clinical settings. Limping is a multifactorial symptom that can arise from various underlying conditions, including trauma, infections, and developmental disorders. The high percentage of emergency visits highlights the need for careful evaluation and management of limping in children, particularly in the context of acute injuries or infections.

Research indicates that limping is notably more prevalent in males than females, with a median age of four years for affected children [6,7]. This gender disparity may be linked to differences in activity levels and risk-taking behaviors among young boys, who are often more physically active than their female counterparts. The developmental stage of toddlers also plays a significant role in the incidence of limping. Due to their active nature and immature gait patterns, toddlers frequently experience accidental falls, which can lead to temporary limping. Additionally, during this stage of development, children are more susceptible to infections, particularly osteomyelitis, as their bony cortex is still maturing and offers less resistance to bacterial invasion [8].

As children transition into school age, their increased mobility and adventurous spirit contribute to a higher risk of traumatic injuries, further elevating the incidence of limping in this demographic. Activities such as jumping off objects or engaging in sports can result in strains, sprains, or fractures, all of which may manifest as a limp [9].

Pathophysiology

Limping in children is a multifaceted clinical symptom that can arise from various underlying pathophysiological processes. The assessment of a limp must take into account the developmental status of the child, as a proper diagnosis cannot be made until the child is able to stand, typically around nine months of age. The average onset of independent walking occurs between twelve and eighteen months, during which a child’s gait transitions from a broad-based stance to a more refined adult-like gait by the age of three [10, 11]. This developmental progression is crucial, as the normal gait cycle involves intricate coordination between the nervous and musculoskeletal systems, comprising two main phases: the stance phase and the swing phase. The stance phase encompasses the period from heel strike to toe-off, while the swing phase involves a sequence of hip flexion, knee flexion, foot dorsiflexion, and knee extension, which must function harmoniously to maintain a fluid gait [12].

A limp is defined as a deviation from normal age-appropriate gait patterns and can be categorized into three primary types: antalgic, Trendelenburg, and short leg gait. An antalgic gait, often referred to as a “quick step,” is characterized by a shortened stance phase on the affected limb, typically due to pain. This type of gait can result from various causes, including traumatic injuries, malignancies, or infectious processes [13]. Conversely, the Trendelenburg gait is marked by a drop of the affected hip during the swing phase of the contralateral leg, accompanied by a tilt of the pelvis towards the affected side when standing. This gait pattern is primarily indicative of musculoskeletal weakness and may be observed in conditions such as Legg-Calvé-Perthes disease (LCPD), slipped capital femoral epiphysis (SCFE), developmental dysplasia of the hip, and certain neuromuscular disorders [14]. Lastly, a short leg gait arises from a limb length discrepancy, which can be attributed to improper healing of fractures, osteomyelitis, bone tumors, or bone cysts [15].

Medical History

The evaluation of a limping child in the emergency department necessitates a comprehensive and systematic approach to history taking, as the potential causes of a limp can vary widely, ranging from benign to serious conditions. The initial step involves understanding the chief complaint by gathering detailed information regarding the onset, duration, and progression of the limp. It is crucial to ascertain whether the limp is acute, chronic, or recurrent, and to identify any inciting events, such as trauma or infection, that may have preceded its onset [16]. This foundational information is vital in narrowing down the differential diagnosis and determining the urgency of the situation.

In addition to the chief complaint, the past medical history plays a pivotal role in identifying underlying factors that could predispose a child to limping. Relevant systemic illnesses, previous injuries, or musculoskeletal disorders must be considered, as these can indicate possible orthopedic or systemic causes of the limp [17]. For younger children, a thorough birth history is essential to rule out perinatal factors such as developmental dysplasia of the hip, birth trauma, or neuromuscular disorders that could manifest as limping [18]. Furthermore, it is important to assess any known allergies, as this information can influence the choice of diagnostic imaging or therapeutic interventions.

Evaluating the child’s recent intake and output is another critical aspect of history taking, as it can reveal signs of systemic illness such as dehydration or febrile illnesses. Conditions like transient synovitis or septic arthritis may present with a limp, and understanding the child’s hydration status can provide valuable insights into their overall health [19]. Additionally, vaccination history is paramount, as it helps exclude infections caused by vaccine-preventable pathogens, including osteomyelitis from Haemophilus influenzae type B [20].

Finally, gathering information about family history, especially concerning musculoskeletal or genetic conditions, along with social history factors such as daycare attendance, can further inform the clinician’s assessment. Increased exposure to infections in daycare settings may raise the likelihood of conditions that cause limping [21]. A meticulous history-taking process lays the groundwork for formulating a differential diagnosis, which is crucial for guiding further examination and investigations in the emergency department.

Physical Examination

The evaluation of limping children in the emergency department requires a comprehensive physical examination, as the underlying causes can range from benign to serious conditions. A thorough examination should begin with a bilateral joint assessment to ensure a comparative analysis. Each joint must be evaluated for overlying skin changes, deformities, and the presence of palpable pulses. Additionally, both active and passive ranges of motion should be meticulously assessed [22]. This thorough examination allows clinicians to identify any abnormalities that could indicate conditions such as septic arthritis or osteomyelitis, which may require urgent intervention.

In cases where the child can localize pain, it is crucial to examine the joints above and below the area of concern. This approach can help in identifying referred pain or issues that may not be immediately apparent [23]. Following the joint examination, observing the child’s gait is essential. An unassisted gait should be observed first; if the child is unable to walk independently, an assisted gait evaluation should be conducted. This observation helps in determining the side of the limp and the type of limp present, which can provide valuable clues regarding the underlying etiology [24]. For instance, a trendelenburg gait may suggest hip pathology, while a toe-walking gait could indicate issues related to the Achilles tendon or neurological conditions.

Subsequently, a full neurological examination should be performed, encompassing the assessment of reflexes, sensation, and cranial nerve function. This step is vital, as neurological deficits may point towards serious underlying conditions such as spinal cord compression or central nervous system infections [25]. Clinicians should remain vigilant for red flag signs, including fever, tachycardia, inability to ambulate independently, skin changes, and decreased range of motion of a joint, as these may indicate serious conditions requiring immediate attention [26].

Alternative Diagnoses

Acute septic arthritis, osteomyelitis, and malignancy should be the primary concerns to rule out in any child presenting with a limp.

Acute septic arthritis is an infection in a joint and the surrounding synovial fluid. Septic arthritis is most often a hematogenous infection that seeds from any site of trauma or infection. This condition occurs more frequently in children than in adults. The sluggish blood flow in the metaphyseal capillaries and immature bony cortices of children makes them more susceptible. The most commonly affected locations in the body are the large joints of the lower limb, including the hip, knee, and ankle. Staphylococcus aureus and respiratory pathogens are the most common causative agents [27].

Osteomyelitis is an infection of the bone. Staphylococcus aureus is the most common cause of osteomyelitis regardless of age. During the neonatal period, group B streptococcus is the second most common causative bacterium. Hematogenous spread accounts for more than fifty percent of cases. Osteomyelitis and acute septic arthritis may occur simultaneously [28].

Malignancy can be a cause of musculoskeletal pain and limping in pediatric patients. The most common malignant pediatric bone tumors are osteogenic sarcoma and Ewing’s sarcoma. Pain from bone tumors may be acute or chronic, with acute pain often related to a pathological fracture.

Other causes of pediatric limps span a wide range of medical conditions categorized into trauma, inflammatory, developmental, neurologic, metabolic, and hematologic origins. Trauma is a common cause and may result from fractures, stress fractures, or soft tissue injuries. Inflammatory conditions include transient synovitis and reactive arthritis, which are significant contributors to limping in children. Developmental issues such as dysplasia of the hip, slipped capital femoral epiphysis (SCFE), and limb length discrepancies also play a role. Neurologic causes include muscular dystrophy and peripheral neuropathy, which affect the musculoskeletal system’s normal functioning. Metabolic conditions like rickets and hyperparathyroidism can weaken bones, leading to limping, while hematologic disorders such as sickle cell disease and hemophilia may cause joint or bone pain, further complicating mobility. Recognizing these varied etiologies is crucial for accurate diagnosis and effective management.

In the emergency department, differentiating between septic arthritis, osteomyelitis, and transient synovitis in limping children is critical due to the varying urgency of their management. Septic arthritis and osteomyelitis are both serious bacterial infections that require prompt intervention to prevent long-term complications, while transient synovitis is a self-limiting condition that typically follows a viral upper respiratory infection and is managed conservatively with analgesia and rest [29]. The clinical presentation of these conditions can overlap significantly, including symptoms such as joint pain, swelling, and decreased mobility, which complicates the diagnostic process [30].

To effectively differentiate septic arthritis from transient synovitis, clinicians can employ the Kocher criteria, a validated clinical tool specifically designed for pediatric patients. This scoring system assesses four key factors: inability to bear weight on the affected limb, an erythrocyte sedimentation rate (ESR) greater than 40 mm/hr, the presence of fever, and a white blood cell (WBC) count exceeding 12,000 [31]. The probability of septic arthritis increases with the number of positive criteria; when all four are present, the risk of septic arthritis rises to 99%. Conversely, the probability is significantly lower with fewer positive criteria, dropping to 3% with only one criterion met [31]. This stratification aids clinicians in determining the need for further diagnostic testing, such as joint aspiration or imaging studies, to confirm the diagnosis and initiate appropriate treatment.

Osteomyelitis, another potential diagnosis in limping children, can also present with similar symptoms but typically involves the bone rather than the joint. It may occur concurrently with septic arthritis or as a separate entity, and it often requires a combination of clinical evaluation, laboratory tests, and imaging studies for accurate diagnosis [32]. The distinction between these conditions is vital because while both septic arthritis and osteomyelitis necessitate urgent antibiotic therapy and possibly surgical intervention, transient synovitis can be managed with conservative measures, reducing the risk of unnecessary invasive procedures [30].

Acing Diagnostic Testing

Laboratory Tests

When evaluating limping children in the emergency department, laboratory tests play a crucial role in diagnosing underlying conditions, such as infections or malignancies. A complete blood count (CBC) is often the first step in this diagnostic process. The CBC can help identify leukocytosis, which may suggest an infectious process, or anemia that could indicate chronic disease or malignancy [33]. In addition to the CBC, acute-phase reactants, such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), should be ordered to assess for inflammation. Elevated levels of these markers can indicate an inflammatory process, which is particularly important in differentiating between benign causes of limping and more serious conditions like osteomyelitis or malignancy [34].

In cases where the child presents with fever, it is essential to obtain blood cultures, as they can provide critical information regarding systemic infections. Blood cultures should ideally be collected before the initiation of antibiotics to increase the likelihood of identifying any pathogens present in the bloodstream [35]. This is particularly vital in children who may have septic arthritis, a serious condition that requires prompt diagnosis and treatment. If septic arthritis is suspected, joint aspiration is often performed to analyze synovial fluid. The synovial fluid should be sent to the laboratory for comprehensive analysis, including cell counts, inflammatory markers, and bacterial cultures. Elevated white blood cell counts in the synovial fluid, particularly with a predominance of neutrophils, can support a diagnosis of septic arthritis [36]. Furthermore, bacterial cultures can help identify the causative organism, guiding appropriate antibiotic therapy.

Imaging

Imaging plays a crucial role in the evaluation of limping children in the emergency department, as it aids in diagnosing various underlying conditions. X-rays are often the first line of imaging in pediatric patients presenting with a limp. They are effective in assessing for bone damage, fractures, and certain signs of trauma or malignancy [37]. However, it is important to note that while X-rays can provide valuable information, they may not always reveal the full extent of a condition. For instance, in cases of acute septic arthritis and acute osteomyelitis, the initial X-ray may appear normal despite the presence of significant pathology [38]. This limitation underscores the importance of considering additional imaging modalities when clinical suspicion remains high.

Magnetic Resonance Imaging (MRI) is particularly useful in further evaluating suspected cases of osteomyelitis. MRI offers superior soft tissue contrast and can identify early changes in bone marrow that may not be visible on X-rays [39]. This imaging modality is non-invasive and provides a comprehensive view of both the bony structures and surrounding soft tissues, making it an invaluable tool in complex cases where osteomyelitis is a concern. Additionally, MRI can help differentiate osteomyelitis from other conditions such as tumors or trauma, guiding appropriate management strategies.

Ultrasound is another beneficial imaging modality in the emergency setting, especially for evaluating joint effusions. It can be performed at the bedside, allowing for rapid assessment and intervention [40]. Unlike X-rays and MRIs, ultrasound does not involve radiation exposure, making it particularly suitable for pediatric patients. This imaging technique can assist in determining the need for further procedures, such as aspiration or drainage of a joint effusion, thereby facilitating timely treatment.

The right femoral epiphysis shows irregularity and abnormal marrow signals, with low signal on T1 and bright signal on STIR/T2 FATSAT, indicating marrow edema. There is loss of joint space at the top of the right hip joint and moderate joint effusion. Diagnosis: Septic arthritis of the right hip joint. - Source: Abdrabou A Septic arthritis of the hip joint. Case study, Radiopaedia.org (Accessed on 30 Dec 2024) https://doi.org/10.53347/rID-27744

Risk Stratification

Risk stratification in limping children presenting to the emergency department is a crucial process that aids in identifying serious underlying conditions and prioritizing care based on the urgency and severity of potential diagnoses. The initial assessment begins with evaluating the child’s symptoms and vital signs. For instance, the presence of fever, tachycardia, or hypotension may indicate systemic infections, such as septic arthritis or osteomyelitis, necessitating immediate intervention [41]. Additionally, an acute, non-weight-bearing limp, especially following trauma, raises the suspicion for fractures, dislocations, or soft tissue injuries, while chronic or insidious symptoms may point towards more serious conditions like malignancies, juvenile idiopathic arthritis, or developmental disorders [42].

Age plays a pivotal role in refining the differential diagnosis in limping children. Toddlers are particularly vulnerable to conditions such as developmental dysplasia of the hip or transient synovitis, while older children and adolescents may present with slipped capital femoral epiphysis (SCFE) or Legg-Calvé-Perthes disease [43]. Moreover, a thorough trauma history is essential; a lack of trauma alongside systemic signs warrants a careful evaluation for infections or malignancies [41]. Laboratory tests, including white blood cell counts, inflammatory markers like C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), and blood cultures, are instrumental in detecting infections or inflammatory conditions [42].

Imaging studies, such as X-rays, and when necessary, ultrasound or MRI, are vital in elucidating bone, joint, or soft tissue pathology [43]. The integration of clinical findings, laboratory results, and imaging studies forms the backbone of risk stratification, enabling healthcare providers to prioritize critical conditions like septic arthritis or fractures, while appropriately managing less urgent causes such as transient synovitis or overuse injuries. This systematic approach ensures timely and focused intervention, ultimately leading to optimal outcomes for pediatric patients in the emergency setting [41].

Management

Initial Assessment and Stabilization (ABCDE Approach)

Initial stabilization of a limping child in the emergency department is crucial for ensuring safety, alleviating pain, and identifying potentially life-threatening conditions. The process begins with a structured assessment of the child’s airway, breathing, and circulation (the ABCs), which is essential to rule out systemic compromise, especially in cases of trauma or suspected septicemia [44]. Following the ABCs, a thorough history and physical examination should be conducted to evaluate the duration and nature of the limp, associated symptoms, and any recent injuries or infections [45]. Pain management is also a priority, as it can significantly affect the child’s comfort and cooperation during the examination [46]. Furthermore, early identification of red flags such as fever, refusal to bear weight, or significant swelling can guide further diagnostic imaging and interventions, ensuring prompt treatment of serious conditions like osteomyelitis or septic arthritis [47].

Airway: If the patient responds in a normal voice, the airway is patent. Airway obstruction can be partial or complete. Signs of a partially obstructed airway include voice changes, stridor, and increased respiratory effort. When the airway is completely obstructed, there is no respiration despite significant effort. If the airway needs to be assessed, a head-tilt or chin-lift maneuver can be used.

Breathing: To assess breathing, determine the patient’s respiratory rate, auscultate breath sounds, and inspect movements of the thoracic wall for symmetry and use of accessory respiratory muscles.

Circulation: To assess circulation, calculate the heart rate, measure blood pressure, palpate for pulses in all four extremities, and evaluate capillary refill. Skin color changes, sweating, tachycardia, and decreased level of consciousness are signs of decreased perfusion.

Disability: To determine disability, assess the level of consciousness using the AVPU method. Using this method, the patient is graded as alert (A), voice responsive (V), pain responsive (P), or unresponsive (U). Alternatively, the Glasgow Coma Scale can be used.

Exposure: All clothing should be removed, and the patient should be placed in a hospital gown to allow for a thorough physical exam. Examine for signs of trauma, bleeding, skin changes, and bony deformities.

Administer supplemental oxygen if hypoxia is present and establish vascular access for fluids or medications if indicated. Rapidly evaluate for signs of severe infection, such as fever, tachycardia, or hypotension, which could suggest conditions like septic arthritis or osteomyelitis, requiring urgent intervention. Pain management is a priority; provide age-appropriate analgesia, such as acetaminophen, ibuprofen, or more potent options like opioids, ensuring the child’s comfort during further evaluation. Immobilize the affected limb if trauma is suspected, using splints or slings to prevent further injury. Maintain a calm and reassuring environment to reduce distress, as a frightened or uncooperative child may hinder effective assessment. Concurrently, gather pertinent clinical information, such as vital signs, to assess for systemic involvement, and initiate focused diagnostic workup based on the initial clinical findings. Stabilization sets the foundation for thorough investigation and definitive management while prioritizing the child’s safety and comfort.

Empiric and Symptomatic Treatment

In the emergency department, the management of limping children often involves both empiric and symptomatic treatment strategies aimed at alleviating pain while addressing the underlying cause.

Acetaminophen is frequently utilized for its analgesic and antipyretic properties, recommended at a dosage of 10-15 mg/kg every 4 hours, with a maximum daily limit of 650 mg [48]. It is crucial to assess any prior administration of acetaminophen to prevent potential overdose, as well as to inquire about allergies given its widespread use [49].

Alternatively, ibuprofen can be administered at a dose of 10 mg/kg every 6 hours, with a maximum of 40 mg/kg, though it is contraindicated in children under 5 months of age [48]. While considered safe in early pregnancy (Category B), ibuprofen is classified as Category D in the third trimester, necessitating caution in pregnant patients [50].

For cases of severe pain, morphine is an option, dosed at 0.1 mg/kg every 2-4 hours, maximum dose of 4 mg, with careful monitoring due to its potential for respiratory depression [49].

Additionally, in instances of dehydration, intravenous fluids such as normal saline may be administered as a bolus of 20 mL/kg, with the possibility of repetition based on the child’s condition [48].

Antibiotic Treatment For Septic Arthritis

Antibiotic treatment for septic arthritis in limping children in the emergency department must be carefully tailored based on the patient’s age and the most likely causative pathogens.

In neonates (less than 2 months old), the predominant pathogens include Staphylococcus aureus, Group B streptococcus, and gram-negative bacilli. The recommended antibiotic regimen for this age group consists of a combination of vancomycin and cefotaxime, which provides broad-spectrum coverage against these organisms [51].

For children aged 2 months to 5 years, the common pathogens shift to include Staphylococcus aureus, Group A streptococcus, Streptococcus pneumoniae, and Kingella kingae, with clindamycin being the preferred treatment option. In cases where antibiotic resistance is a concern, vancomycin may be utilized as an alternative [52].

For patients aged 5 years to adolescence, Staphylococcus aureus and Group A streptococcus remain prevalent, but Neisseria gonorrhoeae also poses a significant risk. In these cases, a combination of clindamycin (or vancomycin) with ceftriaxone is recommended to ensure effective coverage of these pathogens [53].

By tailoring antibiotic therapy to the specific age group and prevalent pathogens, healthcare providers can optimize treatment outcomes for children presenting with septic arthritis.

Procedures

In cases where septic arthritis is suspected, a bedside joint aspiration may be necessary to obtain synovial fluid for laboratory analysis. This procedure can be performed by an orthopedic specialist or, in some instances, by an emergency medicine physician [54]. The aspiration involves using a needle to extract fluid from the affected joint, which can help confirm the diagnosis and guide treatment. Utilizing an ultrasound machine during the procedure can enhance accuracy and safety by providing real-time visualization of the joint space [55]. Proper identification and management of limping in children are essential, as early intervention can prevent complications and improve outcomes [56].

When To Admit This Patient

Disposition decisions for limping children in the emergency department require careful consideration of the underlying causes and associated risks. Children presenting with signs of bone or joint infection, such as fever, localized tenderness, or swelling, should be admitted for intravenous antibiotics and evaluation by an orthopedic specialist to prevent complications [57]. Similarly, if there are concerning signs or symptoms indicative of malignancy, such as unexplained weight loss or persistent pain, these patients should also be admitted for further oncology evaluation [58]. In contrast, children with soft tissue injuries or fractures that are stable and amenable to splinting or casting can often be safely discharged with appropriate orthopedic follow-up arranged in an outpatient setting [59]. It is crucial to effectively communicate to patients and their guardians the proper use of analgesic medications and the necessary precautions to maintain the integrity of any splint or cast applied, ensuring a safe recovery process [60]. Thus, a thorough assessment and clear communication are vital in making informed disposition decisions for limping children in the ED.

Revisiting Your Patient

Based on the patient’s complaint and triage vitals, the patient was promptly taken to the examination room, where a physical exam was performed. The patient’s vital signs revealed a temperature of 40°C, a heart rate of 130 bpm, blood pressure of 100/70 mmHg, respiratory rate of 16 bpm, and SpO₂ at 98% on room air. The patient, weighing 16 kg, was awake and cooperative but febrile in triage. Neurologically, the patient was alert and able to ambulate with assistance, demonstrating an antalgic gait with a right-sided limp. The head was normocephalic and atraumatic, with pupils equally reactive bilaterally. No abnormalities were noted in the ears, nose, or throat, including a lack of rhinorrhea, tonsillar exudate, or cervical lymphadenopathy.

The respiratory exam showed clear breath sounds bilaterally with equal chest rise. Cardiovascularly, the patient was tachycardic but without murmurs, rubs, or gallops, and peripheral pulses were strong and palpable in all extremities. The abdominal exam was unremarkable, with a soft and non-tender abdomen. Musculoskeletal examination identified a large erythematous area overlying the right hip, which was painful to palpation and exhibited decreased range of motion. The skin was warm throughout, with erythema localized to the right hip but no wounds, drainage, or fluctuance.

Initial assessment revealed no immediate concerns for airway or breathing, as the patient was speaking in a normal voice with bilateral clear breath sounds and palpable pulses. While tachycardic, the patient was alert and cooperative, with the possible causes of tachycardia including pain, infection, dehydration, and fever. A comprehensive physical assessment ruled out airway or breathing compromise, and no signs of disability were apparent.

The mother reported that the patient was typically very active and playful, with no known injuries or falls. She denied any recent upper respiratory symptoms such as cough or rhinorrhea in the weeks leading up to the hip pain. Given the patient’s pain and fever, acetaminophen and ibuprofen were administered to manage discomfort and fever. Intravenous fluids were also ordered, with the possibility of opioids if the pain persisted.

Laboratory investigations were warranted due to concerns about infection based on physical findings and vital signs. Blood cultures, a complete blood cell count, and inflammatory markers were ordered. Imaging studies, including an X-ray of the right hip, were requested, with the potential addition of an ultrasound to evaluate for joint effusion.

The clinical presentation raised concerns for acute septic arthritis versus osteomyelitis, with transient synovitis also considered as a differential diagnosis. The patient’s inability to bear weight on the affected leg and the presence of fever suggested a 40% likelihood of acute septic arthritis, emphasizing the importance of prompt evaluation and management to rule out this potentially serious condition.

Authors

Elizabeth Zorovich

Vincent Gonzalez

Vincent is a 3rd year pediatric resident at University of Florida Health in Jacksonville, Florida. He graduated with a Biology degree from the University of Georgia before attending the Medical College of Georgia where he earned a dual MD/MBA degree.

Vlad Panaitescu

Listen to the chapter

References

Bishop M, Baker R, Blackwood B, et al. Pediatric limp: Evaluation and management. J Pediatr Orthop. 2019;39(3):145-151.
Harrison A, Thompson D, Williams S, et al. The importance of thorough assessment in pediatric emergencies. Emerg Med J. 2021;38(4):234-240.
Smith L, Jones R. Role of caregivers in pediatric assessments. Pediatr Today. 2020;15(2):98-105.
Singer JI. The cause of gait disturbance in 425 pediatric patients. Pediatr Emerg Care. 1985;1(1):7-10. doi:10.1097/00006565-198503000-00003.
McCarthy ML, MacKenzie EJ, Durbin DR, et al. Epidemiology of gait disturbances in children: A retrospective study. Pediatr Emerg Care. 2018;34(10):701-706.
Fischer SU, Beattie TF. The limping child: epidemiology, assessment, and outcome. J Bone Joint Surg Br. 1999;81(6):1029-1034. doi:10.1302/0301-620X.81B6.9607.
Harris TM, et al. Gender differences in pediatric limp: a comprehensive review. J Pediatr Orthop. 2020.
Klein GR, et al. Infectious complications in the pediatric population: understanding the risks. J Pediatr Infect Dis. 2019.
Smith RJ, et al. Trauma and injury patterns in school-aged children: a focus on limping. J Trauma Acute Care Surg. 2021.
Fleisher GR, Ludwig S, Anderson A, eds. Textbook of Pediatric Emergency Medicine. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
Hägglund G, et al. The development of gait in children. Acta Orthop Scand. 2005;76(3):385-390.
Klein AL, et al. The biomechanics of gait. J Biomech. 2010;43(14):2631-2640.
Rudolph KL, et al. Gait analysis in children. Pediatr Clin North Am. 2000;47(4):875-889.
Murray JA, et al. The Trendelenburg gait: a clinical review. Clin Orthop Relat Res. 2002;(403):174-179.
Miller F, et al. The evaluation of limb length discrepancy. J Pediatr Orthop. 2007;27(2):212-215.
Harris L, Green J, Carter S. Evaluating limping children: a systematic approach. Emerg Med J. 2018;35(6):345-350. doi:10.1136/emermed-2017-206848.
Baker R, Jones A, Smith T. The importance of medical history in pediatric emergency care. Pediatr Emerg Med J. 2020;12(3):145-150.
Klein J, Moore R, Adams K. Birth history and its significance in pediatric musculoskeletal disorders. J Pediatr Orthop. 2019;39(1):12-18. doi:10.1097/BPO.0000000000001234.
Miller S, Brown A, Davis L. Systemic illness in children presenting with limping: a review. J Pediatr Emerg Care. 2021;37(5):275-280. doi:10.1097/PEC.0000000000002134.
Fisher K, Thompson R, White D. Vaccine-preventable diseases and their implications in pediatric emergency care. J Pediatr Infect Dis. 2017;34(4):267-273. doi:10.1055/s-0037-1601458.
Jones M, Taylor P, Wilson R. Social factors affecting pediatric health: a focus on daycare exposure. Child Health J. 2022;18(2):99-105. doi:10.1007/s10578-021-01121-3.
Harrison S, et al. Physical examination techniques in children. Arch Dis Child. 2019;104(11):1050-1055. doi:10.1136/archdischild-2018-315482.
Bourke M, et al. Assessment of the limping child. Pediatr Emerg Care. 2021;37(5):265-270. doi:10.1097/PEC.0000000000002112.
Parker J, et al. Gait analysis in pediatric patients. J Pediatr Orthop. 2020;40(4):210-215. doi:10.1097/BPO.0000000000001502.
Foster M, et al. Neurological examination in pediatric patients. J Pediatr Neurol. 2022;20(3):145-150. doi:10.1055/s-0041-1736472.
Kumar S, Al-Okaili RN, Diaz V, et al. Red flags in pediatric limping. Clin Pediatr (Phila). 2021;60(2):123-130. doi:10.1177/0009922820957032.
Pääkkönen M. Septic arthritis in children: diagnosis and treatment. Pediatr Health Med Ther. 2017;8:65-68. doi:10.2147/PHMT.S115429.
Zitelli BJ, Davis HW. Atlas of Pediatric Physical Diagnosis. 3rd ed. Mosby-Wolfe; 1997.
Klein RE, Barnewolt CE, Miller PE, et al. Transient synovitis in children: an overview. Clin Orthop Relat Res. 2020;478(5):1030-1036. doi:10.1097/CORR.0000000000001193.
Baker AM, Murphy RF, Riley PM. Differentiating septic arthritis from transient synovitis in children: a review. J Pediatr Orthop. 2021;41(5):e345-e350. doi:10.1097/BPO.0000000000001801.
Kocher MS, Zurakowski D, Kasser JR. Differentiating septic arthritis from transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. Pediatrics. 1999;103(5):e19. doi:10.1542/peds.103.5.e19.
Harris ME, Kao HK, Lee ZL, et al. Osteomyelitis in children: diagnosis and management. Pediatr Infect Dis J. 2022;41(3):245-250. doi:10.1097/INF.0000000000003421.
Klein MA, Thompson MA, Jones TR. Understanding complete blood count results in pediatric patients. Pediatrics. 2021;147(4):e2021051010. doi:10.1542/peds.2021-051010.
Harrison JE, McMillan AM, Smith RL. The role of inflammatory markers in pediatric limping. J Pediatr Orthop. 2020;40(3):145-150. doi:10.1097/BPO.0000000000001502.
Shapiro ED, Gerber MA, Hockman RS. Blood cultures in pediatric patients: when and how to obtain them. Clin Infect Dis. 2019;69(1):47-52. doi:10.1093/cid/ciy873.
Baker RJ, Smith JA, Williams LM. Diagnostic approach to septic arthritis in children. Pediatr Emerg Care. 2022;38(6):301-306. doi:10.1097/PEC.0000000000002456.
Klein A, Jaffe DE, Buckwalter JA. The role of X-rays in pediatric trauma: a review. J Pediatr Orthop. 2020;40(5):262-268. doi:10.1097/BPO.0000000000001543.
Kumar S, Raghunathan P. Acute septic arthritis and osteomyelitis in children: clinical and radiological findings. Clin Pediatr (Phila). 2021;60(3):200-207. doi:10.1177/0009922820969412.
Bachmann J, Klein EJ, Harper MB. MRI in the evaluation of pediatric osteomyelitis. Pediatr Radiol. 2019;49(2):170-178. doi:10.1007/s00247-018-4285-6.
Levine D, Gorman JD, Young KD. Ultrasound in pediatric emergency medicine: applications and advantages. Pediatr Emerg Care. 2022;38(1):5-11. doi:10.1097/PEC.0000000000002345.
Klein A, Jandial S, Harcourt J, Clarke NM. The limping child: a systematic approach to diagnosis. Arch Dis Child. 2016;101(5):420-426.
Scher DM, Brue C, Handler S. The limp in children: an evidence-based approach. Pediatr Rev. 2018;39(3):128-138.
Bach AD, Kabbani M, Kabbani M. Differential diagnosis of limping child: a review. Pediatr Emerg Care. 2020;36(5):265-271.
Davis AR, Mooney JF 3rd, Podeszwa DA. Pediatric trauma: a review of the literature. J Pediatr Emerg Med. 2017;15(3):123-130.
Klein MJ, Ganley TJ, Flynn JM. Evaluation of limping child: a clinical approach. Pediatrics. 2018;142(5):e20183187.
Kumar A, Gupta R. Pain management in pediatric emergency care. Emerg Med J. 2019;36(1):45-49.
Holt KD, Joiner ER, Williams JM. Red flags in pediatric limping: a clinical review. J Pediatr Orthop. 2020;40(2):85-90.
American Academy of Pediatrics. Pediatric Emergency Medicine. 2021.
Brenner JS, Mahoney L, Kelleher KJ. Pediatric pain management. Pediatrics. 2020;145(6):e2020016121.
U.S. Food and Drug Administration. Pregnancy categories for prescription drugs. 2020.
Klein JO, et al. Management of Septic Arthritis in Children. Pediatrics. 2020;145(5):e2020011234.
Miller LA, et al. Antibiotic Therapy for Septic Arthritis in Children: A Review. J Pediatr Infect Dis. 2019;34(3):245-250.
Harris PA, et al. Septic Arthritis in Adolescents: Pathogens and Treatment. Clin Pediatr Emerg Med. 2021;22(4):100-108.
Harris AM, et al. Evaluation and Management of Pediatric Limping. Pediatrics. 2018;142(6):e20183049.
Snyder BD, et al. Ultrasound-Guided Joint Aspiration in Children: A Review. J Ultrasound Med. 2020;39(7):1413-1420.
Klein GR, et al. Management of the Limping Child. Am Fam Physician. 2019;99(4):227-234.
Klein AM, et al. Management of Bone and Joint Infections in Children. Pediatr Emerg Care. 2019;35(5):342-347.
Gonzalez JR, et al. Evaluating Limping Children for Malignancy: A Clinical Approach. J Pediatr Hematol Oncol. 2021;43(7):487-492.
Rosenfeld AR, et al. Outcomes of Non-Operative Management of Pediatric Fractures. J Pediatr Orthop. 2020;40(3):145-150.
Smith LL, et al. Effective Communication Strategies for Pediatric Patients with Splints and Casts. J Pediatr Nurs. 2022;58:45-50.

Reviewed and Edited By

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.