Limp (Pediatric)

Adults who limp generally give a story, but toddlers typically keep the story to themselves. On my last ER shift a mom was sent by her pediatrician because her two year old had a limp. The pediatrician had done a knee X-ray which showed nothing, and he decided to send our way for further evaluation. I stood on one side of the room and put my arms out asking the kid to come toward me. With a big smile she decided to run instead, but tripped a couple steps in. She then sprang up and hop-skipped-limped over to me, laughing the whole way. Her affected knee was entirely non tender. She just didn’t wanna use it. What to do?

Red Flags:

• Fever
• Miserable
• Red swollen joint
• Other findings like belly pain, neck pain or rash
• Trauma history
• Any suspicion for abuse
• History of infected joint
• Multiple affected joints
• Recent tick or other insect bites
• Recent travel
• Days to weeks duration
• Sickle cell disease
• Cancer history

Happy Words

• “Limping for less than a day.”
• “He doesn’t seem to mind.”
• “She has three older siblings and they wrestle all the time.”

Kids with limps from seemingly out of nowhere can be a challenge. We first chase the low hanging fruit with X-rays, but this only reveals fractures. Rarely do we find pathology like bone cysts, cancers, or old healing injuries raising concern for abuse.

Blood work including the “CBC, ESR, CRP +/- blood cultures” may be next in line, but these rarely prove useful as well. Really we do these for general reassurance and to prove we care. If we truly suspect underlying serious pathology, then a bone scan, MRI and/or joint aspiration may be next.

Mom’s eyes got huge when we ran this list with her in the ER the other day. Ultimately she declined the works. I gave her my number and she decided to watch and wait and call me if worse. Three siblings, and no red flags, it was just too tough to chase this happy limping child down with a needle. No calls as yet. Luckily, kids heal quick.

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