| < 3 years |
- Fracture or soft tissue injury (may be due to 'toddler's fracture', or child maltreatment)
- A fracture will present with point tenderness over bone, redness, or bruising and swelling in the affected area.
- A 'toddler's fracture' is a subtle undisplaced spiral fracture of the tibia typically seen in pre-school children. It is usually caused by a sudden twist, often after an unwitnessed fall. Affected toddlers (often new walkers) present with difficulty or refusal to bear weight.
- A sprain is a stretch and/or tear of a ligament. A strain (or 'pull') is a stretch and/or tear of muscle fibres and/or tendon. Children have growth plates that are more susceptible to injury than ligaments. An apparent sprain in a child should raise suspicion of an injury to the growth plate.
- Always be aware of the possibility of child maltreatment. The presence of unusual skin marks, multiple bruises of varying ages, recurrent instances of 'unexplained' injury, delayed presentation, and certain types of injuries (such as fractures) should raise suspicion of child maltreatment.
- Developmental dysplasia of the hip (DDH)
- DDH is a congenital condition where the ball and socket hip joint fails to develop normally.
- Risk factors include being a firstborn child, female sex, family history of DDH, breech presentation at birth, and oligohydramnios.
- A physical exam may reveal asymmetric skin folds, extremity shortening, and limited hip abduction.
- Untreated, DDH may lead to hip pain and/or osteoarthritis in older children.
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| 3 - 10 years |
- Fracture or soft tissue injury (may be due to stress fracture or child maltreatment)
- Transient synovitis
- A self-limiting inflammatory disorder of the hip. It is more common in boys than in girls and is rare in children aged younger than 3 years.
- It presents acutely with mild to moderate hip pain and limp, and there is no (or only mild) restriction of hip movements, especially abduction and internal rotation. Children are otherwise well and afebrile. There is usually a history of viral illness, but the absence of a viral illness does not rule out the possibility of synovitis.
- The diagnosis of transient synovitis is one of exclusion, after other causes of hip pain and limp have been ruled out. The Kocher criteria is a tool useful in the differentiation of septic arthritis from transient synovitis in the child with a painful hip. A point is given for each of the four following criteria:
- Kocher’s criteria:
- History or presence of fever > 38.5°C
- Child not weight-bearing on the affected side
- ESR > 40 mm/h
- WCC > 12 x 10⁹/L
- Score interpretation:
- Score 1 - 3% likelihood of septic arthritis
- Score 2 - 40% likelihood of septic arthritis
- Score 3 - 93% likelihood of septic arthritis
- Score 4 - 99% likelihood of septic arthritis
- Perthes' disease (also called Legg-Calve-Perthes' disease)
- An idiopathic avascular necrosis of the developing femoral head. It is more common in boys than in girls.
- Onset is usually over weeks, and the child will typically present with limitation of hip rotation and a subacute limp sometimes with referred pain to the groin, thigh, or knee. It is typically unilateral, though bilateral involvement is present in 10% of cases. The child is systemically well with no other joint involvement and no evidence of joint inflammation.
- X-ray changes are progressive; early imaging may show widening of the joint space (the best view is frog-leg lateral). Later there is a decrease in size of the femoral head with patchy density and and later still, there may be collapse and deformity of the femoral head with new bone formation.
- Most children with Perthes' disease have good outcomes, but long-term complications may include chronic pain and osteoarthritis.
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| 10 -18 years |
- Fracture or soft tissue injury (may be due to stress fracture or child maltreatment)
- Slipped upper femoral epiphysis (SUFE)
- A displacement of the proximal femoral epiphysis from the metaphysis.
- SUFE is slightly more common in boys than girls and in children who are overweight. It is sometimes associated with endocrine abnormalities, such as hypothyroidism, and in children being treated for growth hormone deficiency or with a history of radiotherapy treatment.
- When there is sudden displacement of the epiphysis, the child presents with sudden onset of severe hip pain with the leg held in external rotation. Gradual displacement of the epiphysis may cause only mild discomfort of the hip or only referred knee pain. The child may walk with an antalgic gait out-toeing, with shortening of the affected limb.
- Anteroposterior and frog-leg lateral X-rays show widening of epiphyseal line or displacement of the femoral head. The lateral x-ray is the best way to identify a subtle slip. Trethowan’s sign seen on the AP view describes where a line (line of Klein/Klein's line) drawn along the superior border of the femoral neck passes above the femoral head, instead of intersecting the femoral epiphysis as in the normal hip.
- Prompt diagnosis and management is crucial to avoiding further displacement and the development of avascular necrosis.
- Perthes' disease
- Osgood-Schlatter disease
- An overuse injury with multiple small avulsion fractures within the ossification centre (apophysis) of the tibial tuberosity at the inferior attachment of the patellar ligament caused by forceful contractions of the quadriceps muscles.
- It is a usually self-limiting disorder causing anterior knee pain during adolescence, particularly in children active in sport. Symptoms typically settle over weeks or months but occasionally may persist for 1–2 years, before resolving completely in 90% of people.
- Knee pain is typically unilateral (but may be bilateral in up to 30% of people), gradual in onset (initially mild and intermittent progressing to severe and continuous), relieved by rest and made worse by kneeling and activity. On examination there may be tenderness over the tibial tuberosity and firm or bony enlargement of the tibial tuberosity.
- X-ray is not required routinely but if undertaken, knee X-ray may be normal or may demonstrate anterior soft tissue swelling, fragmentation of the tibial tubercle, or rarely a persistent bony ossicle may be visible after fusion of the tibial epiphysis.
- Sever's disease
- An overuse injury thought to be caused by repetitive microtrauma from the pull of the Achilles tendon on the unossified apophysis.
- It is most common in boys aged 10–12 years who are active in sports, such as running and football, and produces heel pain as a result of inflammation of the calcaneal apophysis.
- It often resolves within 2 weeks to 2 months, but a child may have recurrent symptoms until skeletal maturity.
- Osteochondritis dissecans
- Occurs when a small piece of subchondral bone begins to separate from its surrounding area due to a disturbance of the local blood supply. This bone and the cartilage covering it may break loose, causing pain and possibly hindering joint motion.
- It is the most common cause of a loose body in the joint space, typically affecting the knee between the ages of 10–19 years. The aetiology is uncertain but trauma, vascular abnormalities, defects in ossification, and genetics have all been suggested as possible causes.
- Clinical findings are subtle and a small effusion or limited range of joint movement may be the only sign. Locking or instability suggest a loose body in the joint.
- Chondromalacia patellae
- Describes anterior knee pain typically felt when walking up or down stairs.
- Affects children between the ages of 10–19 years in a ratio of three girls to two boys.
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| At any age |
- Septic arthritis and osteomyelitis
- Septic arthritis is an infection of the synovium and joint space. It can present in any joint but most commonly affects the lower limbs, and can lead to joint destruction, permanent loss of joint function, and sepsis. Clinical features include refusal to bear weight and fever. There may be evidence of joint inflammation.
- Osteomyelitis is an infection of the bone. It usually involves a single bone but may rarely affect multiple sites, and can lead to inflammation and bone destruction. The most common presenting signs are pain with palpation and decreased limb use. Osteomyelitis of the proximal femur can be difficult to distinguish from septic arthritis on physical examination.
- The clinical presentation of osteomyelitis and septic arthritis may mimic that of transient synovitis. However, transient synovitis is rare in children younger than 3 years of age.
- Other infection e.g. discitis
- Discitis is an inflammation of the disc space and adjacent vertebral endplates that typically affects the lumbar spine. It is more common in neonates and young children.
- Presentation can be very non-specific, and a high index of suspicion is required for diagnosis. Clinical presentation ranges from refusal to walk or bear weight to irritability on spine immobility. Point tenderness over the spine can aid in the diagnosis. It may also present with unusual symptoms, such as abdominal pain, limp, hip or leg pain. Limited spinal flexion, stiff posture, and local tenderness on spine examination are also suggestive of discitis.
- Malignancy e.g. primary bone tumours, soft tissue sarcoma, leukaemia, lymphoma
- The most common bone tumour in children is osteosarcoma, which peaks in incidence after 10 years of age. Leukaemia and neuroblastoma are the most common non-bone tumours in children.
- Clinical findings that may indicate malignancy include night pain, hepatosplenomegaly, lymphadenopathy, or pathological fractures.
- Non-malignant haematological disease e.g. sickle cell disease, haemophilia
- Sickle cell disease can cause a limp through avascular necrosis of the hip, increased susceptibility to infections (including osteomyelitis), and stroke (about 10% of children with sickle cell disease are at risk of stroke, which may present as sudden onset of a limp).
- Haemophilia may result in easy bruising, bleeding after dental procedures, haemarthrosis, soft-tissue/muscle haematomas in toddlers, and swollen joints in active toddlers (usually boys). May be related to family history of bleeding disorders.
- Metabolic disease e.g. rickets and osteomalacia
- Osteomalacia is due to a lack of vitamin D or problems with its metabolism. When osteomalacia affects the growing skeleton, it is referred to as rickets.
- Clinical features of rickets include bone pain and tenderness, skeletal deformity (such as bowing of the legs) and kyphoscoliosis, and proximal muscle weakness.
- Inflammatory muscle or joint disease e.g. juvenile idiopathic arthritis (JIA), Lyme arthritis
- JIA encompasses a group of disorders presenting with inflammatory joint disease in children. It is characterised by joint pain, swelling without a large effusion, and morning stiffness that persists for longer than 6 weeks, and has no known cause. It can affect single or multiple joints. Systemic symptoms of lethargy and anorexia may be present. Eye involvement in the form of uveitis is also commonly noted. Often children with JIA are otherwise well and blood tests and X-rays may be normal.
- Lyme arthritis is the second most common symptom to the classic rash associated with Lyme disease. In cases where the erythema migrans rash (commonly called the bull’s eye rash) does not appear or goes unnoticed, Lyme arthritis may be the first clinical sign. It typically presents without a fever. The child will bear partial weight and present with a limp.
- Neuromuscular disease e.g. spina bifida, muscular dystrophy, cerebral palsy
- Primary anatomical abnormality e.g. limb length discrepancy
- Non-musculoskeletal causes e.g. inguinal hernia, appendicitis, testicular torsion
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