Clinical Practice Guidelines

The limping or non-weight bearing child

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    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also:


    • Some important diagnoses will differ according to the age of the child and are relatively age specific - see Table below, as well as Additional Notes.

    Common diagnoses defined by age

    Toddler (1-4 years)

    Child (4-10 years)

    Adolescent (>10 years)

    • Developmental dysplasia of the hip (DDH)
    •  Toddlers fracture
    • Transient synovitis of the hip (Irritable hip)
    • Child abuse


    • Slipped upper femoral epiphysis ( SUFE)
    • Overuse syndromes / stress fractures


    All ages:

    • Infections: Osteomyelitis / Septic Arthritis, discitis, soft tissue, viral myositis
    • Trauma (see Fractures)
    • Non accidental or inflicted injury (see Child abuse guideline) - fracture, sprain, haematoma
    • Malignancy - Acute lymphoblastic leukaemia, bone tumours, eg: spine or long bone
    • Rheumatological disorders and reactive arthritis
    • Intra-abdominal pathology, eg: appendicitis
    • Inguinoscrotal disorders, eg: testicular torsion
    • Vasculitis, serum sickness
    • Functional limp


    Important features in the history include:

    • Duration of symptoms
    • Complete refusal to weight bear 
    • Trauma - there is often a coincidental history of trauma in a non-traumatic condition or there may be no history of trauma and the child may have a significant injury.
    • Preceding illness - there is often a history of a simple viral infection preceding a transient synovitis or reactive arthritis
    • Fever or systemic symptoms - suggests infective or inflammatory causes
    • Pain - site and severity. Pain on changing the nappy, causing back flexion, may be present in discitis
    • Morning stiffness
    • Previous injuries or child protection concerns


    • General appearance, temp
    • Gait - running may exaggerate a limp
    • Neurological examination - look for ataxia, weakness
    • Generalised lymphadenopathy (viral infection / haematological cause)
    • Excessive bruising or bruising in unusual places (NAI, haematological)
    • Abdomen, scrotum and inguinal area (masses)
    • Bony tenderness
    • All joints
      • knee pain can be referred from the hip, and thigh pain can be referred from the spine
      • Include sacro-iliac joints and spine in joint assessment - look for pain on flexion and/or midline tenderness which may be present in discitis
      • Exaggerated lordosis (discitis)
      • Hip abduction and internal rotation are often the most restricted movements in hip pathology



    Unless suspecting a specific diagnosis, investigations are usually not required in children with limp <3 days duration.

    Discuss with senior staff, then consider:

    • Bloods:     
      • FBE, CRP, ESR, blood culture
    • Imaging:    
      • plain films
      • Further imaging should be discussed with senior staff:

    Imaging may demonstrate:

    Plain x-rays Ultrasound scan Bone scan CT / MRI
    • Perthes / SUFE
    • Chronic osteomyelitis (bony changes only evident after  14 - 21 days)
    • Tumours
    • Developmental dysplasia of hips (> 6 months of age)
    • septic hip
    • Osteomyelitis
    • Discitis
    • Perthes
    • Occult fracture
    • Only after  orthopaedic consultation


    Specific management depends on diagnosis.

    Ensure adequate analgesia. 

    Discharge and Follow-up: 

    If no specific cause found, or suspected transient synovitis:

    • Bed rest is important for children with transient synovitis.
    • Analgesia; NSAID (eg ibuprofen) +/- paracetamol
    • Review with local doctor within 3 days.
    • Return to hospital if febrile, unwell or getting worse
    • Patients with symptoms for greater than 4 weeks can be referred to rheumatology clinic.

    Consider consultation with local paediatric/orthopaedic team:

    • Suspected cause of limp is infection of bone/joint, SUFE, Perthes or malignancy.
    • Child presenting on multiple occasions.
    • Uncertainty regarding diagnosis.

    When to consider transfer to tertiary centre:

    • Child requiring care beyond the comfort level of the hospital. 

      For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Parent information sheet:

    Information Specific to RCH

    If admission required, admit under Orthopaedics for septic joint, Perthes, SUFE or DDH.

    Patients with discitis or osteomyelitis can be admitted under General Medicine.

    Additional Notes - specific causes of Hip Pain

    Irritable Hip (transient synovitis)

    • Commonest reason for a limp in the pre-school age group.
    • Usually occurs in 3-8 year olds
    • History of recent viral URTI (1-2 weeks)
    • Child usually able to walk but with pain
    • Child otherwise afebrile and well
    • Mild-moderate decrease in range of hip movement - especially internal rotation.
    • Severe limitation of hip movement suggests septic arthritis.

    Transient synovitis is a diagnosis of exclusion. Symptoms overlap with those
    of septic arthritis. If diagnosis in doubt, consult with orthopaedics.

    Perthes disease

    • Avascular necrosis of the capital femoral epiphysis.
    • Age range 2-12 years (majority 4-8yrs)
    • 20% bilateral
    • Present with pain and limp
    • Restricted hip motion on examination

    Slipped Upper Femoral Epiphysis

    • Late childhood/early adolescence.
    • Weight often > 90th centile.
    • Presents with pain in hip or knee and associated limp.
    • The hip appears externally rotated and shortened.
    • There is decreased hip movement - especially internal rotation.
    • May be bilateral.

    Last updated December 2012