Limp in Childhood: Are we Missing Significant Diagnoses?

Background: Limp is a common presentation and accounts for up to 5% of emergency department visits in children. It is difficult to clinically differentiate benign, self-limiting conditions like transient synovitis, from more serious conditions such as septic arthritis and osteomyelitis. It is therefore imperative to investigate and manage appropriately. Currently, there are no national guidelines for the investigation and management of limp in children in the UK.

Objective: The aim of this audit was to see how many children presenting with limp to the Children’s Clinical Decision Unit were being correctly investigated and managed according to local guidelines. Additional aims were to see if any significant diagnoses were missed and to update the guidelines as appropriate.

Methods: A search was done for patients presenting with limp to our Children’s Clinical Decision Unit, within the last 6 months. Their electronic medical records were then reviewed for details of their admission, investigations, diagnosis and any missed diagnoses. These were compared to local guidelines at Oxford University Hospitals Trust.

Results: The search found 106 patients. All patient should have had bloods and an x-ray, according to our guidelines. 33 of the 106 patients had the correct initial investigations. Those with 2 or more risk factors for septic arthritis should have had an ultrasound and this occurred in 10 of 15 patients. The most common diagnosis was transient synovitis (45 out of 106) and there were 2 cases of osteomyelitis and 1 case of septic arthritis. There were 4 missed diagnoses including 1 case of osteomyelitis.

Conclusion: Adherence to limp guidelines was poor and as a result significant pathology was missed. Recommendations included increased education of doctors about the limp management guidelines, creation of limp proforma and reinforcing mandatory telephone reviews after discharge. Further ongoing work includes reviewing and updating the limp guidelines.