The limping child

includes: Juvenile idiopathic arthritis

Limp is a common presentation in paediatrics and has a range of benign and mores serous causes. Common differentials to consider in a limping child (by age) are shown in the table below:

Causes of limp by age
0-3 years 4-10 years 11-16 years
Most common
  • Trauma (including toddler's fracture)
  • Trauma
  • Transient synovitis
  • Perthes' disease
  • Trauma
  • Osgood-Schlatter disease
Conditions requiring urgent intervention
  • Osteomyelitis
  • Septic arthritis
  • Non accidental injury (NAI)
  • Malignancy (e.g. neuroblastoma)
  • Testicular torsion
  • Inguinal hernia
  • Osteomyelitis
  • Septic arthritis
  • NAI
  • Malignant disease (e.g. acute lymphocytic leukaemia)
  • Testicular torsion
  • Appendicitis
  • Inguinal hernia
  • Osteomyelitis
  • Septic arthritis
  • Slipped upper femoral epiphysis (SUFE)
  • Malignancy (e.g. bone tumours)
  • Testicular torsion
  • Appendicitis
  • Inguinal hernia
Other important conditions to consider
  • Developmental dysplasia of the hip
  • Juvenile Idiopathic Arthritis
  • Juvenile Idiopathic Arthritis
  • Juvenile Idiopathic Arthritis
  • Metabolic (e.g. rickets)
  • Haematological disease (e.g. sickle cell anaemia)
  • Reactive arthritis
  • Lyme arthritis
  • Multisystem diseases (e.g. Juvenile Systemic Lupus Erythematosus, Juvenile Dermatomyositis)

Indications for urgent assessment of a limping child

Investigations will depend on the suspected cause of the limp. Discuss management with seniors and the orthopaedic team.

Juvenile Idiopathic Arthritis (JIA)



Commoner Subtypes (International league of associations for rheumatology, ILAR)

Arthritis Type Diagnostic Features Outlook Other
Systemic (SO-JIA) Arthritis AND fever of at least 2 weeks PLUS AT LEAST ONE OF:
serositis, evanescent rash, hepatosplenomegaly, lymphadenopathy
Variable. Systemic features usually settle but arthritis may continue for several years
Oligoarthritis (OA-JIA) Arthritis in 4 or less joints. If further joints become involved > 6 months later this is called oligo extended JIA Usually good, rarely causes joint damage if treated and usually remits by adulthood (unless it is the extended type) Commonest subtype, high risk for anterior uveitis
Polyarthritis (PA-JIA) Arthritis in 5 or more joints. Can be rheumatoid factor positive or negative Can continue into adulthood or remit Can be associated with fatigue and low grade fever



Important differentials include


in patients without red flag features who have symptoms for > 6 weeks and are presumed to have JIA


For all patients

For some patients (discuss with consultant)

pGALS (paediatric gait, arms, legs, spine) screen-validated for use in school aged children

Screening questions

Then an examination (if all is normal it makes musculoskeletal pathology very unlikely)

BMJ Best practice, Juvenille Idiopathic Arthritis. June 2015 [online]