Emergency Medicine

Paediatric Emergencies 369

Limping Child

8 Refer patients to the paediatric team for admission and observation if:
(i) Symptomatic following significant ingestion.
(ii) Potentially toxic ingestion.
(iii) Presenting late at night and require overnight observation.
(iv) Deliberate self-harm is suspected, for psychiatric assessment.

9 Specific poisonings and their treatments are described on pp. 179–189 in
Section V, Toxicology.

LIMPING CHILD

DIAGNOSIS

1 This diagnostic dilemma presents frequently to the ED. The causes of limp
range from serious conditions such as a bone tumour and septic arthritis to
minor complaints including painful shoes or a plantar wart.

2 Remember to consider the spine, pelvis, hip and lower limb as a potential
source of pain or disability.

3 Ask about the onset of symptoms, any history of trauma, localized pain and
associated systemic sy mptoms such as fever or rigors.

4 Check the vital signs, evaluate gait and perform a lower extremity neuro-
logical examination as the pain allows. Examine and treat the patient on a
trolley with the parents present to alleviate anxiety. Test the full range of
movement of all lower limb joints bilaterally.
(i) The hip is the most common source of pathology, but as pain is
often referred to the knee, always examine both.

5 Age is the key factor in forming a list of differential diagnoses. Typical causes
specific to age include:
(i) Age 1–3 years
(a) infection: septic arthritis and osteomyelitis
(b) developmental dysplasia of the hip
(c) trauma: toddler’s fracture, stress fracture, puncture wound
(d) cerebral palsy, neuromuscular disease, tumours and
congenital hypotonia.
(ii) Age 4–10 years
(a) transient synovitis ‘irritable hip’
(b) Perthes’ disease
(c) infection: septic arthritis and osteomyelitis
(d) trauma: fractures, dislocations and ligamentous injuries
(e) rheumatoid disease and Still’s disease
(f) leukaemia.