Diagnostic Imaging Pathways - Paediatric, Limp
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This pathway provides guidance on imaging a child with a newly developed limp.
Date reviewed: July 2014
Date of next review: July 2016
Published: July 2014
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|SYMBOL||RRL||EFFECTIVE DOSE RANGE|
|Minimal||< 1 millisieverts|
- 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
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
- A bone scan was effective in localising an area of abnormality in 54% of limping children with normal initial x-rays
- Has a high sensitivity and specificity for the detection of osteomyelitis ,,
- Particularly useful for identifying infections around the pelvis and spine
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)
- Magnetic Resonance Imaging (MRI)
- 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
- 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
- Requires no sedation
- Widely available
- Sensitive for detection of a hip joint effusion and if necessary can guide aspiration ,,
- Usually the most appropriate initial imaging modality for the investigation of the limping child
- In children who can localise a region of tenderness, radiographs should visualise the joint above and below the point of maximal tenderness
- If the child is too young to localise pain options include imaging the entire lower extremity or radionuclide bone scan
- Plain radiographs are frequently normal in the limping child ,
- If clinical symptoms persist despite a normal initial xray, repeat radiography in 7-10 days may reveal an undisplaced fracture
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)
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