Diagnostic Imaging Pathways - Paediatric, Limp
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Population Covered By The Guidance
This pathway provides guidance on imaging a child with a newly developed limp.
Date reviewed: July 2014
Date of next review: 2017/2018
Published: July 2014
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1a |  |
Perthes Disease Image 1a and 1b (Plain Radiography): Frontal views in a neutral position and abduction with external rotation. The left hip shows marked fragmentation and resorption of bone and broadening of the femoral head and neck in keeping with advanced Perthes Disease. |
| 1b |  |
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| 2a |  |
Slipped Capital Femoral Epiphysis (SCFE) Image 2a and 2b (Plain Radiography): SCFE is demonstrated in the left hip. |
| 2b |  |
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Teaching Points
Teaching Points
- Depending on the age of the child and his/her ability to localize pain, as well as a thorough clinical history and examination, the choice of investigation is dictated by the most likely cause
- Initially, plain films and ultrasonography are recommended
- If further investigations are required, consideration should be given to a radionuclide scan, CT or MRI
bonescan
Radionuclide Bone Scan
- Is an excellent test for evaluating the limping child where the history and examination have failed to localise an area of abnormality 1
- A bone scan was effective in localising an area of abnormality in 54% of limping children with normal initial x-rays 5
- Has a high sensitivity and specificity for the detection of osteomyelitis 5,6,7
- Particularly useful for identifying infections around the pelvis and spine 8
- Limitations
ctmri
Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)
- These imaging modalities have no role in the initial workup of children with a limp but may be useful in later investigation for suspected causes of limp
- Computed Tomography (CT)
- Useful in selective clinical circumstances including imaging of suspected cortical abnormalities 1
- More widely available and less expensive than MRI but does involve exposure to radiation
- Magnetic Resonance Imaging (MRI)
- Imaging modality of choice if symptoms are believed secondary to spinal pathology such as vertebral osteomyelitis 13
us
Ultrasound
- Is generally the preferred first line imaging modality for the investigation of hip symptoms in the young child (<8 years) in the absence of trauma 1
- Is the preferred first line investigation when a patient presents with limp and is unable to localise symptoms, and for the diagnosis of transient synovitis 12
- Advantages
- Non-invasive
- Requires no sedation
- Widely available
- Inexpensive
- Sensitive for detection of a hip joint effusion and if necessary can guide aspiration 9,10,11
xray
Plain Radiography
- Usually the most appropriate initial imaging modality for the investigation of the limping child 1
- In children who can localise a region of tenderness, radiographs should visualise the joint above and below the point of maximal tenderness 1
- If the child is too young to localise pain options include imaging the entire lower extremity or radionuclide bone scan 1
- Plain radiographs are frequently normal in the limping child 2,3
- If clinical symptoms persist despite a normal initial xray, repeat radiography in 7-10 days may reveal an undisplaced fracture
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Flynn JM, Widmann RF. The limping child: evaluation and diagnosis. J Am Acad Orthop Surg. 2001;9:89-98. (Review article)
- Englaro EE, Gelfand MJ, Paltiel HJ. Bone scintigraphy in preschool children with lower extremity pain of unknown origin. J Nucl Med. 1992;33:351-4. (Level IV evidence)
- Blatt SD, Rosenthal BM, Barnhart DC. Diagnostic utility of lower extremity radiographs of young children with gait disturbance. Pediatrics. 1991;87:138-40. (Level IV evidence)
- McConnochie KM, Roghmann KJ, Pasternack J, Monroe DJ, Monaco LP. Prediction rules for selective radiographic assessment of extremity injuries in children and adolescents. Pediatrics. 1990;86:45-57. (Level III evidence)
- Aronson J, Garvin K, Seibert J, Glasier C, Tursky EA. Efficiency of the bone scan for occult limping toddlers. J Pediatr Orthop. 1992;12:38-44. (Level III evidence)
- Myers MT, Thompson GH. Imaging the child with a limp. Pediatr Clin North Am. 1997;44:637-58. (Review article)
- Scott RJ, Christogersen MR, Robertson WW Jr, et al. Acute osteomyelitis in children: a review of 116 cases. J Pediatr Orthop. 1990;10:649-52. (Level III evidence)
- McCoy JR, Morrissy RT, Seibert J. Clinical experience with the technetium-99 scan in children. Clin Orthop. 1981;154:175-80. (Level III evidence)
- Royal SG. Investigation of the irritable hip. J Pediatr Orthop. 1992;12:396-7. (Level III evidence)
- Alexander JE, Seibert JJ, Glasier CM, et al. High-resolution hip ultrasound in the limping child. J Clin Ultrasound. 1989;17:19-24. (Level IV evidence)
- Zawin JK, Hoffer FA, Rand FF, Teele RL. Joint effusion in children with an irritable hip: US diagnosis and aspiration. Radiology. 1993;187:459-63. (Level II evidence). View the reference
- Terjesen T, Osthus P. Ultrasound in the diagnosis and follow-up of transient synovitis of the hip. J Pediatr Orthop. 1991;11:608-13. (Level III evidence)
- Fernandez M, Carrol CL, Baker CJ. Discitis and vertebral osteomyelitis in children: an 18-year review. Pediatrics. 2000;105:1299-304. (Level III evidence)
Information for Consumers
Information for Consumers
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Consent to Procedure or Treatment Radiation Risks of X-rays and Scans Magnetic Resonance Imaging (MRI) |
Magnetic Resonance Imaging (MRI) Radiation Risk of Medical Imaging for Adults and Children Making Your Child's Test or Procedure Less Stressful |
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