21 responses to “Acute limping in children”

  1. A very good article, transient synovitis will be foremost in my differential diagnosis of a limping child now.

  2. good article. ibuprofen likely would help the patient relatively more than the bacterial synovitis but it would be difficult to use this clinically. Perhaps in the case that clinically it strongly appears to be transient synovitis it would be a confirmatory finding.

  3. I have never seen this approach. Is there evidence that using Ibuprofen and observing an immediate response helps distinguish transient synovitis from septic arthritis?

  4. nice and concise

  5. No change in clinical assessment, diagnostic methodogy and treatment

  6. Useful and appropriate

  7. Good clinical exam (and history) is always paramount.

  8. Excellent succinct summary and recommendations….have seen both and always remember the key clinical features.

  9. Nice synopsis – but if in doubt, I would always tap the joint

  10. I wonder: Need the improvement w Ibuprophen be fairly marked?

    I recall a case (23 years ago) of a limping little boy, otherwise well, w a negative hip xray and some improvement w simple analgesia. I referred him 6 hr down the road anyway, where someone proceeded to capture the whole femur on xray, identifying an undisplaced distal hairline #. They then looked for and found various other fractures of different ages and stages. The diagnosis was physical abuse. I’d missed it. Though at least I had referred.

  11. Very interesting and useful. I’ve seen this problem before and know the anxiety that considering the differential diagnosis can produce (in parents and physician). The article mentions testing CRP yet the prediction rule refers to ESR. Many labs won’t do an ESR, so is there an evidence based level of concern for the CRP in helping predict a septic joint? Or is mere elevation enough?

  12. Excellent summary which clarifies in an orderly way what goes through the clinicians mind when presented with a limping child.

  13. agree

  14. Perhaps the ibuprofen approach applies to remote settings – I am in an urban area so would send anything clinically suspicious to the ED – no harm waiting in emerg to rule out something as serious as septic arthritis.

  15. Interesting and helpful–but in urban setting would likely refer to ER

  16. Very interesting & helpful

  17. To Noman, Ryan, Marisa :
    Providing Ibuprofen to children with suspected transient synovitis or septic arthritis is a practice-tip, not an evidence-based approach to differentiate between the two conditions. It will help children with pain management, after about 20 minutes, and will also give a general impression of the severity of the illness. In many cases, it will help much more to alleviate pain in children with transient synovitis.
    To Bruce, EHenshaw, Kathy :
    Levels of ESR and CRP are not good at differentiating between the two conditions, especially in early phases of the illness, so it is back to clinical impression. Whenever based on history and clinical exam a provider suspects septic arthritis, an immediate referral to the appropriate physician is needed.

  18. When clinical differential diagnosis of transient synovitis and septic arthritis is equivocal after ESR WBC FEVER WEIGHT BEARING been done.I feel it is best toto refer to the ER for specialist consultation eg aspiration of the affected joint

  19. Refer to ER when diagnosis is equivocal

  20. Very helpful.
    Infrequently I have faced this dilemma of the limping young child q1-2
    Summary
    Differentiate first with clinical presentation,lethargic,unwell child.
    Non wt bearing
    ESR>40
    WBC>12,000,
    Not responsive to ANSAID. Think septic jt.vs transient synovitis.
    If in doubt refer.

  21. good article and useful to see guidelines on this subject

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