See also

Fractures
Bone and joint infections
Acutely swollen joint
Child abuse

Key points

1. Most children presenting with a limp do not require investigation
2. Observing the child's gait may help localise the problem and narrow the differential diagnosis
3. Acute inability to walk or weight bear is a red flag
4. Septic arthritis is an orthopaedic emergency and should be suspected in any child presenting with limp, swelling and reduced range of motion (especially with fever)

Background

• Transient synovitis, acute myositis and minor trauma are common causes of limp in children, but serious pathology should always be considered
• Pain causing limp can be referred. Assess the joints above and below (including spine) and abdomen to accurately localise the source

Causes of limp or difficulty weight bearing

Assessment

History

• Duration of symptoms, >7 days, repeated presentations in same illness
• History of trauma
• Pattern and severity of pain and limp, severe localised joint pain, pain waking from sleep
• Change to urinary or bowel habit
• Functional limitations, inability to walk or weight bear
• Symptoms of infection: fever, night sweats, chills, rigors, rash
• Constitutional symptoms: unexplained weight loss, lethargy, anorexia (consider malignancy/haematological cause)
• Recent viral infection (acute myositis, transient synovitis) or Streptococcal infection (throat and skin)
• Dietary history
• High-risk group for ARF
  

Examination

• Fever (absence does not exclude infection)
• Pallor or petechiae/purpura/ecchymosis (consider HSP, malignancy/haematological or inflicted injury)
• Assess gait if able to weight bear – antalgic, waddling gait, etc or changes in mobility eg from walking to crawling
• Identify location if possible — bone vs joint vs soft tissue
• Identify joint(s) involved (note that hip pain may localise to knee)
• Joint examination using "Look, Feel, and Move" including joints above and below area of pain
  • Look: resting limb position, symmetry, leg length disparity, swelling, deformities, skin changes eg rash, wound, bruising, erythema
  • Feel: heat, cold, tenderness (including calf), crepitus, fluctuance
  • Move:
    • Active: facilitate by placing toy or parent out of reach
    • Passive: assess for limitations and asymmetry in all planes of motion
    • Compare active and passive range of movement on both sides. A marked reduction in range of motion suggests significant pathology eg septic arthritis
  • The paediatric gait, arms leg and spine (pGALS) assessment can be used to screen for other abnormal joints
• Neurological exam including tone, power, and reflexes and neurovascular assessment of affected limb
• Cardiac examination where ARF is a possibility
• Other systems: Abdomen, scrotum, back/spine and hips, features of systemic disease eg rash, organomegaly

Management

Investigations

No investigations are indicated if all the following apply:

• no red flags in the history and physical examination
• ambulating with mild or no discomfort with simple analgesia
• a working diagnosis and/or a plan for review within 7 days of onset of limp if persists

Imaging

• X-ray (area of suspicion)
  • pelvis AP or frog leg view is useful for identifying SUFE, DDH (>6 mths), Perthes disease and common pelvic avulsions
  • normal x-ray does not exclude septic arthritis or early osteomyelitis
  • signs of inflicted injury may be subtle
• Ultrasound (hip)
  • assess for presence of an effusion when septic arthritis of the hip is suspected
  • presence of an effusion often does not differentiate between septic arthritis and transient hip synovitis
• Other eg bone scan or localised MRI if ongoing at 7 days or if features of osteomyelitis. Consult local paediatric, orthopaedic or radiology services

Laboratory

• Raised inflammatory markers (platelets, WCC, CRP, ESR) suggest infective or inflammatory cause. May be normal in contained or chronic infection
• Blood cultures (pre-antibiotics if possible) if osteomyelitis, septic arthritis or septic bursitis suspected
• FBE and film if concern for haematological malignancy
• Vitamin C level (restricted diet)
• Streptococcal serology (and ECG) if ARF suspected

Treatment

• Definitive management is determined by the working diagnosis
• Simple analgesia (paracetamol and NSAID) and child-directed limitation of activity. Need for escalation of analgesia should prompt reassessment
• If concern for infection, see bone and joint infection
  • Septic arthritis is an orthopaedic emergency - consult local orthopaedic specialist ASAP
  • Refer to appropriate sub-specialist team and consult local antibiotic guidelines

Assessment of the limping or non-weight bearing child

Consider consultation with local paediatric team when

• Symptoms last more than 7 days or child unable to weight bear or permit movement after analgesia
• Systemically unwell
• Clinical or laboratory features of malignancy
• Concern for child abuse or inflicted injury
• Suspecting septic arthritis - consult with orthopaedic team
• Suspecting inflammatory arthritis

Consider transfer when

Child requires care above the level of comfort of the local hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

• The cause of the limp has been identified and managed

OR

• Child is ambulating comfortably with or without analgesia AND
• High risk diagnoses are considered unlikely AND
• Follow up plan in place

Parent information

Transient synovitis of the hip

The febrile child

Last updated October 2025