Intended for healthcare professionals

Clinical Review

Evaluating the child who presents with an acute limp

BMJ 2010; 341 doi: (Published 20 August 2010) Cite this as: BMJ 2010;341:c4250
  1. Daniel C Perry, Monk research fellow and PhD student, orthopaedic surgery1,
  2. Colin Bruce, consultant paediatric orthopaedic surgeon and honorary senior lecturer1
  1. 1University of Liverpool and Alder Hey Hospital, Liverpool L12 2AP
  1. Correspondence to: D C Perry danperry{at}

    Summary points

    • Atraumatic limps are a source of concern to both the family doctor and emergency practitioner

    • Age is the key factor in forming a list of differential diagnoses

    • The hip is the most common source of pathology, and pain is often referred to the knee

    • A delay in the diagnosis of a slipped upper femoral epiphysis may worsen the outcome

    • Transient synovitis and septic arthritis may be difficult to differentiate so any clinical concern warrants urgent investigation

    A child may limp after trivial trauma, as a sign of local or systemic disease, or for no apparent reason. When there is a clear history of injury evaluation is usually straightforward. The diagnostic challenge is to distinguish between disease processes that are benign and self limiting (such as transient synovitis), acute or life threatening (such as septic arthritis or acute leukaemia), or chronic and disabling (such as Perthes’ disease). In most cases the causes are benign and self limiting, and around two thirds of patients can be managed in the emergency department and do not require referral to hospital.1 2

    Sources and selection criteria

    We searched Google Scholar and Medline (1965-2010) using the terms “limp”, “hip”, “Perthes”, “developmental dysplasia”, “transient synovitis”, “irritable hip”, and “slipped epiphysis”. We also searched bibliographies of retrieved articles for articles not indexed elsewhere and identified references from searches of our files. Only papers published in English were reviewed. No related Cochrane reviews were available. We selected articles if they were the best evidence available or best summary of the evidence. Some articles were included to place the review in historical context.

    Here, we review the epidemiology of acute limp and outline the pitfalls in diagnosis. We provide a framework for early assessment and management of the child who presents with a limp based on evidence from case series, laboratory studies, observational …

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