Evaluating the child who presents with an acute limp
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4250 (Published 20 August 2010) Cite this as: BMJ 2010;341:c4250
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Anecdotal evidence of delays in the diagnosis of serious pathology in children presenting to our unit with a limp prompted us to audit our evaluation of the limping child against guidance found in the literature(1,2).
We conducted a retrospective case-note review of thirty children presenting with a non-traumatic limp in the preceding nine months. Data was collected on initial clinical assessment, investigations, diagnosis, and follow-up.
Documentation of examination findings was poor. There was no comment of gait in half of the cases, and no record of a hip examination or abdominal examination in a fifth of cases. Nineteen children had a pelvic X-ray, most without a proper indication. Only six children had a hip ultrasound. Two children who were discharged with a benign diagnosis re-presented with worsening symptoms and were found to have septic arthritis. They both had had a pelvic X-ray, but no hip ultrasound. Half of the children had follow-up arranged, the timing of which varied greatly.
We concluded that our evaluation of children presenting with a limp is inadequate. Many children are unnecessarily exposed to radiation, yet we seem to miss the ones with serious pathology. Coupled with the poor quality of clinical documentation, this has raised questions about the ability of our junior doctors to carry out a proper assessment of the limping child. The use of pelvic X-rays rather than hip ultrasound as first line investigation was also identified as an undesirable practice. These findings have called for the urgent development of a local guideline in conjunction with the orthopaedic and radiology departments, to assist our doctors in assessing, investigating, and following-up the limping child.
1.Perry DC, Bruce C. Evaluating the child who presents with an acute limp. BMJ 2010; 341:444-449
2.Fischer SU, Beattie TF. The limping child: epidemiology, assessment and outcome. J Bone Joint Surg Br. 1999;81:1029-34.
Competing interests: No competing interests
Re: Evaluating the child who presents with an acute limp
Perhaps the articles below, published in refereed medical journals, will help the diagnosis of the "child with a limp"?
Ozturk et al. 1999. Scurvy associated with poliovirus infection mimicking paralytic disease: a diagnostic challenge. O.M.U. Tip Dergisi; 16(3): 243-247.
Ratanachu-EK, et al. 2003. Scurvy in pediatric patients: a review of 28 cases. J Med Assoc Thailand; 86 suppl 3: S734-S740.
Velandia et al. 2008. Scurcy is still present in developed countries. J Gen Intern Med; 23(8): 1281-1284.
Noordin et al. 2012. Skeletal manifestations of scurvy: a case report from Dubai. Case reports in Orthopedics; Article ID 624628, 5 pages. doi:10.1155/2012/624628.
By the way, it has to be sodium ascorbate, a non-acidic form of vitamin C.
Competing interests: No competing interests