History Taking of a Limping Child

Easy memory rule: LIMP

• L - Location and limb affected
• I - Illness symptoms
• M - Mode of onset and mechanism
• P - Past, personal, and family history

1. Start with the main complaint

• “When was the limp first noticed?”
• “Is the child limping, refusing to walk, or unable to bear weight?”
• “Which side is affected?”
• “Was the child walking normally before this?”

In a young child, parents may notice the limp before the child complains of pain.

2. Ask about onset and course

3. Ask about pain carefully

A. Site of pain

• Groin
• Hip
• Buttock
• Thigh
• Knee
• Leg, ankle, heel, or foot
• Back

B. Character and severity

• “Is the pain sharp, aching, severe, or mild?”
• “Does pain wake the child from sleep?”
• “Can the child stand or take four steps?”
• “Does the child cry when the hip or limb is moved?”

• Severe pain with refusal to move a joint suggests septic arthritis until proved otherwise.
• Pain waking the child at night, especially if persistent and progressive, raises concern for tumour or infection.
• Inability to bear weight is a major warning sign.

4. Ask about fever and illness symptoms

• “Has the child had fever, chills, or looked unwell?”
• “Any recent cold, sore throat, diarrhoea, vomiting, or skin infection?”
• “Any recent viral illness?”
• “Any loss of appetite, tiredness, weight loss, or night sweats?”

• Fever, severe pain, and inability to bear weight suggest septic arthritis or osteomyelitis.
• A recent viral upper respiratory infection can occur before transient synovitis of the hip.
• Weight loss, pallor, fatigue, night sweats, or persistent night pain may indicate malignancy, chronic infection, or systemic disease.

5. Ask about trauma, but do not stop there

• “Was there a fall, collision, twisting injury, or sports injury?”
• “Was the event witnessed?”
• “Did the child walk normally immediately after the injury?”
• “Has there been repeated injury or unexplained bruising?”
• “Is the story consistent with the child’s age and development?”

• Toddlers may sustain a toddler’s fracture of the tibia after trivial or unnoticed trauma.
• A history of trauma can coexist with another problem and should not automatically explain persistent symptoms.
• Inconsistent history, delay in seeking care, unexplained injuries, or injuries incompatible with developmental age should raise concern for non-accidental injury.

6. Ask about associated symptoms outside the limb

Joint and skin symptoms

• Joint swelling, redness, warmth
• Morning stiffness
• Rash or purpura
• Heel pain or multiple painful joints

• Suggests septic arthritis, juvenile idiopathic arthritis, reactive arthritis, acute rheumatic fever, or vasculitis such as IgA vasculitis.

Neurological symptoms

• Weakness, frequent falls, altered sensation
• Back pain
• Bowel or bladder disturbance
• Loss of previously achieved walking ability

• Consider spinal disease, nerve disease, cerebral palsy, muscular dystrophy, Guillain-Barré syndrome, or spinal cord compression.

Abdominal and genitourinary symptoms

• Abdominal pain, vomiting
• Testicular/scrotal pain or swelling
• Urinary symptoms

• Appendicitis, psoas pathology, testicular torsion, or pelvic pathology can occasionally present with altered gait or hip pain.

7. Past history

• “Any previous similar episodes?”
• “Any known hip disease, arthritis, bone disease, or fractures?”
• “Any previous operations or hospital admissions?”
• “Any recent injection, infection, or antibiotic treatment?”
• “Does the child have sickle-cell disease, haemophilia, immunodeficiency, or cancer?”
• “Any long-term medicines, especially steroids?”
• “Are vaccinations up to date?”

• Recurrent episodes can occur in inflammatory conditions, haemarthrosis in haemophilia, sickle-cell bone crisis, or recurrent transient synovitis.
• Immunosuppression and recent infections increase the risk of bone and joint infection.
• Steroid use may predispose to bone disease.

8. Birth, development, and gait history

• “Was the birth difficult, breech, or was there a family history of hip problems?”
• “When did the child sit, stand, and walk?”
• “Did the child ever walk normally?”
• “Has the child always walked on toes, waddled, or fallen frequently?”
• “Has there been loss of walking ability?”

• Breech birth and family history are risk factors for developmental dysplasia of the hip (DDH).
• Delayed walking, toe walking, frequent falls, or a long-standing abnormal gait can suggest cerebral palsy, muscular dystrophy, limb-length discrepancy, or other neuromuscular disease.
• Loss of a previously acquired skill is never normal and needs urgent assessment.

9. Family and social history

• Family history of DDH, Perthes disease, SCFE/SUFE, arthritis, autoimmune disease, bleeding disorders, or neuromuscular disorders
• School and sports activity
• Obesity or rapid growth in adolescents
• Diet, especially very restricted diet
• Safeguarding concerns or possible injury at home

• SCFE/SUFE is more likely in an overweight adolescent during rapid growth.
• Family history may support DDH, inflammatory disease, or neuromuscular disorders.
• Restricted diet can rarely lead to nutritional bone disease.
• Social history helps detect possible non-accidental injury.

Key Differentials by Age

Red Flags: Think “Fever, Failure to bear weight, Feeling unwell, and Funny pain pattern”

1. Fever with severe joint pain, painful restricted movement, or swelling
   • Think septic arthritis.
2. Acute inability or refusal to walk / bear weight
   • Could be septic arthritis, osteomyelitis, fracture, or serious neurological disease.
3. Toxic or very unwell child
   • Think sepsis or severe infection.
4. Severe, persistent, progressive, or night pain
   • Consider infection, tumour, or osteoid osteoma.
5. Weight loss, anorexia, pallor, bruising, night sweats, or fatigue
   • Consider malignancy or chronic systemic illness.
6. Back pain, weakness, altered sensation, bowel or bladder symptoms
   • Consider spinal cord or neurological pathology.
7. Inconsistent trauma history, delayed presentation, unexplained bruises
   • Consider non-accidental injury.
8. Adolescent with groin, thigh, or knee pain and limp, especially if overweight
   • Think SCFE/SUFE until excluded.
9. Loss of previously achieved walking ability
   • Consider neurological, muscular, or spinal disease.

History-Based Algorithm

CHILD PRESENTS WITH LIMP
            |
            v
1. Is the child systemically unwell, febrile, or unable to bear weight?
            |
      Yes ------------------> URGENT: suspect septic arthritis,
      |                      osteomyelitis, fracture, or sepsis
      |                      (urgent orthopaedic/paediatric assessment)
      |
      No
      |
      v
2. Sudden onset after trauma or activity?
            |
      Yes ------------------> Consider fracture, toddler’s fracture,
      |                      sprain, stress injury, non-accidental injury
      |
      No
      |
      v
3. Recent viral illness, mild pain, child otherwise well?
            |
      Yes ------------------> Consider transient synovitis
      |                      but exclude septic arthritis if fever/severe pain
      |
      No
      |
      v
4. Gradual limp or persistent pain?
            |
            v
5. Use age and pain site:
   - 4-10 yr + hip/thigh/knee pain --> Perthes disease
   - Adolescent + groin/thigh/knee pain --> SCFE/SUFE
   - Morning stiffness/multiple joints --> inflammatory arthritis
   - Night pain/weight loss/pallor --> tumour or infection
   - Weakness/delayed milestones --> neuromuscular/spinal cause

One-line MBBS exam summary