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AIM: To develop and validate an algorithm to rapidly distinguish transient synovitis (TS) of the hip from differential diagnoses without additional tests. METHODS: This retrospective cohort study included all children admitted for non-traumatic limping in the emergency department at Lille University-Hospital between 2016 and 2020. The gold standard was a definitive diagnosis at follow-up visit. All variables associated with acute limping in children were analysed in univariate and multivariable analyses. An algorithm was then developed using recursive partitioning and validated internally on a subset of patients. RESULTS: There were 995 patients included (mean age 5.3 years; males 63%); 337 had a TS including 210 confirmed at follow-up visit and 354 another diagnosis. After multivariable analysis, the relevant variables for distinguishing between TS and differential diagnoses were: age 3-10 years, absence of fever, absence of local inflammation, sudden onset of limping on awakening. An algorithm combining these variables was developed (n = 297) and validated internally (n = 175) for children >12 months with limping for ≤10 days, with a specificity of 98.2% and a positive likelihood ratio of 19.6. No serious differential diagnoses were missed. CONCLUSION: Use of this algorithm enables the diagnosis of TS without additional tests and without missing serious differential diagnoses.

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BACKGROUND: Limping is a common clinical symptom in childhood; different clinical conditions may lead to limping and the diagnosis of the underlying cause may often be a challenge for the pediatrician. CASE PRESENTATION: We describe the clinical manifestations, radiological pictures and disease course of other causes of limping in childhood, through a case series of seven cases and a brief discussion of each disease. CONCLUSIONS: although trauma is the most common cause of acute limping, when there is no history of traumatic events and the limping has a chronic course, Juvenile Idiopathic Arthritis is usually the most likely clinical diagnosis. However, other some rare conditions should be taken into account if JIA is not confirmed or if it presents with atypical clinical picture.

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BACKGROUND: Limping and/or refusal to walk is a common complaint in the setting of the pediatric department, with a widely diverse differential diagnosis. An unusual etiology, is that of a hereditary neuropathy. Hereditary neuropathy with liability to pressure palsies (HNPP) is a recurrent, episodic demyelinating neuropathy, most commonly caused by a 17p11.2 chromosomal deletion encompassing the PMP22 gene. METHODS: We pursued chromosomal microarray analysis (CMA) in multiple affected individuals of a single extended family, manifesting a range of phenotypic features consistent with HNPP. RESULTS: A 4.5 years-old boy presented for in-patient evaluation due to refusal to walk. Initial investigations including spine MRI and bone scan failed to yield a conclusive diagnosis. Following family history, which implied an autosomal dominant mode of inheritance, CMA was pursued and confirmed a 17p11.2 deletion in the proband consistent with HNPP. Importantly, following this diagnosis, four additional affected family members were demonstrated to harbor the deletion. Their variable phenotypic features, ranging from a prenatal diagnosis of a 6 months-old sibling, to recurrent paresthesias manifesting in the fourth decade of life, are discussed. CONCLUSIONS: Our experience with the family reported herein demonstrates how a thorough anamnesis can lead to a rare genetic etiology with a favorable prognosis and prevent unnecessary investigations, and underscores HNPP as an uncommon diagnostic possibility in the limping child.

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Atraumatic limb pain in a child raises concerns in a medical setting. That is how a typical case of Brodie's abscess presents, having pain without any other symptoms of systemic illness. Assessment and investigations might also not reveal anything significant unless adequate imaging is done. Although Brodie's abscess has a very low rate of complications and morbidity/disability, it is important that such a presentation is assessed clinically with a diagnosis of Brodie's abscess in mind to ensure an uneventful and good outcome. We illustrate in this case report a similar presentation of an 11-year-old girl who had multiple visits to primary care. She was then assessed through radiological imaging. By the time of her diagnosis, her abscess had protruded through the skin. Thankfully management was done swiftly after identification and the final outcome was good with complete recovery.

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A limp is a common presentation to pediatricians, emergency centers, and orthopedists. A directed history and physical examination, and the development of a differential diagnosis based on limp type, patient's age, and the anatomic site that is most likely affected, provides a selective approach to diagnostic testing. Laboratory tests are indicated when infection, inflammatory arthritis, or a malignancy is considered. Imaging usually begins with plain radiography. Ultrasonography is valuable in assessing irritable hips. Advanced imaging is done in select cases. Prompt referral to an orthopedist is essential, especially if septic joint, vascular or compartment issues, or open fractures are suspected.

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Limping is a challenging symptom in the pediatric patient as the diagnosis can range from traumatic, malformative, infectious/inflammatory and neoplastic diseases. In this paper, we propose a schematic imaging algorithm to the limping child in three different age groups (Toddler: 1-3years, child: 4-10 years; adolescent: 11-16 years) based on presence of signs of infection, any specific localization of pain, and history of trauma. In this setting, the most common imaging pitfalls are also summarised. Finally, a literature review of the main differential causes of limping in the pediatric patient is reported.

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Imaging plays in important role in the evaluation of the acutely limping child. The decision-making process about initial imaging must consider the level of suspicion for infection and whether symptoms can be localized. The appropriateness of specific imaging examinations in the acutely limping child to age 5 years is discussed with attention in each clinical scenario to the role of radiography, ultrasound, nuclear medicine, computed tomography, and magnetic resonance imaging. Common causes of limping such as toddler's fracture, septic arthritis, transient synovitis, and osteomyelitis are discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

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Limp is described as any deviation from a normal gait pattern for the child's age. Limping takes many forms and is one of the most enigmatic complaints in pediatric medicine. It is never normal, and both benign and life-threatening illnesses can present with limp. The provisional diagnosis can be a challenge to establish even after history, physical, and laboratory examinations.

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Diagnosis of a limping child can be challenging for the clinician given the vast array of conditions that present in this manner. This review article discusses the history, examination and subsequent differential diagnoses that should be considered along with the most appropriate investigations for each diagnosis. The latest evidence regarding choice of investigation to make the clinician's task less onerous is also discussed.

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