University of Iowa Family Practice Handbook, Fourth Edition, Chapter 12

Pediatrics: Limp and Joint Pain

1. Joint Pain.
   1. Will have pain on weight bearing or refusal to bear weight. Pain on passive motion of joints involved with arthritis.
   2. Determine if true arthritis by exam, presence of fever, number of joints involved.
2. Limp.
   1. Pain from hip often felt as knee pain in children.
   2. Examine shoes and feet (look for tiny pebble in shoe bottom, etc.).
   3. General approach to the child with a limp.
      1. A conservative approach indicated, since very few children without systemic symptoms or true arthritis have any significant disorder. If pain persists or you suspect an acute arthritis, diagnostic evaluations can include a CBC with differential, ESR, anti-streptolysin O titer, rheumatoid factor, throat and urine cultures, ultrasonography for joint effusion, and radiographic studies of the hips. A joint tap should be done when there is clinical suspicion of a septic joint and an effusion by U/S.
   4. Differential Diagnosis and Approach
      1. Transient tenosynovitis (irritable hip).
         1. Most common cause of limp (well over 90% in some series).
         2. Frequently follows URI or streptococcal infection.
         3. May have joint effusion but not true arthritis.
         4. ESR--normal or mildly elevated.
         5. Generally resolves within 24 to 48 hours with rest and ibuprofen-acetaminophen. Close follow-up is indicated.
      2. Septic hip joint. A true emergency (see also Chapter 7).
         1. Generally febrile with elevated ESR, WBC >18,000/mm3, but lab values may be normal and may overlap with those of other illnesses.
         2. Will generally look sick and hold hip in flexion and external rotation.
         3. Effusion present on ultrasonography but may also have effusion with transient tenosynovitis (71%). Tap is diagnostic.
         4. Relatively sudden onset and rapid course.
         5. Treat with antistaphylococcal antibiotics. Requires orthopedic consultation and surgical intervention.
      3. Legg-Calvé-Perthes disease (aseptic necrosis of the femoral head).
         1. Most common between 5 and 10 years of age.
         2. Slow insidious onset of limp and hip pain, which is progressive. Have limitation of motion of the hip.
         3. Diagnosis by radiography of affected hip (see lucency of femoral head and eventually sclerosis and destruction of femoral head). Bone scan may reveal abnormalities earlier than a plain radiograph.
         4. Treatment requires consultation with orthopedics and includes rest, anti-inflammatories, and casting for more severe cases.
      4. Slipped capital femoral epiphysis.
         1. Generally seen in overweight teenagers, especially boys who are prepubertal.
         2. May have insidious onset of pain but can also follow acute trauma.
         3. May be pain with passive motion. Patient will hold hip in external rotation.
         4. Diagnosis by frog-legged radiographs of both hips.
         5. Treatment is by orthopedic referral and surgical fixation.
      5. Osgood-Schlatter disease.
         1. Characterized by pain over the tibial tubercle, which is usually unilateral. May have swelling over the area of pain.
         2. Usually occurs in active children between 10 and 15 years of age.
         3. Treatment is rest and NSAIDs and local heat.
      6. Diskitis.
         1. An inflammatory process of the disk or disks (usually L3 to L5), which may be infectious in cause (staphylococcal primarily).
         2. Presents with refusal to walk or limp, low-grade fever, and "tripod posturing" - leaning back with back extended onto outstretched arms when sitting.
         3. Generally have pain over involved disk area but may also have pain on straight-leg raising, hip motion.
         4. Sedimentation rate almost always elevated, but CBC may be normal. Disk space may be narrowed on radiograph. Bone scan will show inflammatory focus.
         5. Treatment is generally supportive with anti-inflammatories but may need antibiotics. Orthopedic consultation recommended.
      7. Juvenile rheumatoid arthritis.
         1. Defined as presentation of rheumatoid arthritis before 16 years of age.
         2. See chapter 7, rheumatology as well.
         3. 20% have "Still’s disease," which is JRA plus fever, thrombocytopenia, splenomegaly, generalized adenopathy.
         4. 40% have onset in one or a few joints.
         5. 40% have polyarticular onset similar to adult onset.
         6. 75% have complete remissions.
      8. Rheumatic fever. See Chapter 7 for details.
      9. Sickle cell crisis in appropriate populations (see Chapter 6).
      10. Other arthritides including manifestation of ulcerative colitis, Crohn’s disease, etc. Diagnosis by looking for and finding symptom complex.

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See related Provider Topics Bone Diseases or Bones, Joints and Muscles.

See related Patient Topics Bone Diseases or Bones, Joints and Muscles.

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