Browse categories and answer follow-up questions to refine your symptom profile.
History
Presenting problem
Limp phenotype
Refusal to bear weight
Antalgic gait
Non antalgic gait
Intermittent limp
OPQRST
Onset
Sudden
Gradual
After viral illness
After minor trauma
Provocation and palliation
Worse with weight bearing
Worse with hip rotation
Worse at night
Relief with rest
Quality
Painful
Painless
Stiffness
Weakness
Region and radiation
Hip
Groin
Thigh
Knee referred pain
Ankle or foot
Back
Severity
Unable to take 4 steps
Able to bear weight with limp
Pain limits ROM
Timing
Constant
Episodic
Morning predominance
Activity related
Associated symptoms
Systemic features
Fever
Chills
Malaise
Weight loss
Localizing features
Joint swelling
Warmth
Erythema
Pain with passive motion
Infection exposures
Recent skin infection
Recent pharyngitis
Recent GI illness
Tick exposure
Context and baseline
Trajectory and function
Progressive worsening over hours
Progressive worsening over days
Baseline mobility and assistive devices
Sports and overuse
Prior episodes
Similar limp episodes
Prior hip effusion
Prior fractures
Prior septic joint or osteomyelitis
Alarm Features
Immediate escalation triggers
Time critical red flags
Toxic appearance
Altered mental status
Hypotension
Respiratory distress
Limb threat red flags
Severe pain out of proportion
Pain with passive stretch
Rapidly increasing swelling
Absent or diminished pulses
Infection red flags
Suspected bone or joint infection
Fever plus refusal to bear weight
Inability to tolerate passive ROM of hip
Immunocompromised state
Sickle cell disease
Malignancy red flags
Cancer warning features
Night pain waking from sleep
Weight loss
Persistent symptoms longer than 7 days
Unexplained bruising or petechiae
Non accidental trauma red flags
Sentinel features
Inconsistent history and exam
Delay in seeking care
Multiple injuries or different healing stages
Non ambulatory child with fracture
Medications
Current and recent meds
Medication exposure
Recent antibiotics
Recent systemic steroids
Anticoagulants
Immunosuppressants
Analgesics and antipyretics
Home symptom treatment
Acetaminophen
NSAIDs
Opioids
High risk medication considerations
Contraindications and interactions
NSAID avoidance in significant renal disease
Bleeding risk with anticoagulation
Masking fever after antipyretics
Diet
Intake and hydration
Volume status context
Poor oral intake
Vomiting
Diarrhea
Dehydration symptoms
Exposure history
Relevant exposures
Energy drinks and caffeine excess
Alcohol exposure
Nutritional deficiency risk
Review of Systems
Constitutional and infection
Systemic symptoms
Fever
Night sweats
Fatigue
Weight loss
Musculoskeletal
MSK symptoms
Joint pain
Joint swelling
Morning stiffness
Back pain
Skin and soft tissue
Skin findings
Rash
Purpura
Cellulitis
Recent wounds
Neurologic
Neuro symptoms
Weakness
Numbness
Bowel or bladder dysfunction
Headache with fever
Collateral History and Family History
Collateral and reliability
Source
Parent or guardian
Daycare or school
EMS
Reliability concerns
Family history
Inherited and rheumatologic
Sickle cell disease
Hemophilia and bleeding disorders
Autoimmune disease
Early inflammatory arthritis
Household and social context
Exposure and supervision
Sick contacts
Recent travel
TB exposure
Ability to supervise non weight bearing plan
Risk Factors
Infection risk
Predisposition to bacterial infection
Recent bacteremia risk
Indwelling lines
Immunocompromised state
Incomplete vaccination
Mechanical and orthopedic risk
Age linked diagnoses
Toddler age for occult tibial fracture
School age for transient synovitis
Adolescent for SCFE
Athletic overuse and stress fracture
Hematologic and bleeding risk
Bleeding and infarction risk
Anticoagulation
Hemophilia
Sickle cell disease
Platelet dysfunction
Environmental and regional risk
Tick borne and travel related
Lyme endemic exposure
Farm animal exposure
Water exposure with wounds
Differential Diagnosis
Life threatening
Cannot miss diagnoses
Septic arthritis (M00.9)
Fever plus inability to bear weight
Pain with passive ROM
Osteomyelitis (M86.9)
Focal bony tenderness
Elevated inflammatory markers
SCFE (M93.0)
Adolescent with hip or knee pain
Limited internal rotation
Acute fracture and dislocation
Guarding after trauma
Point tenderness
Compartment syndrome
Pain out of proportion
Pain with passive stretch
Malignancy including leukemia and bone tumors
Night pain
Systemic symptoms
Non accidental trauma
Inconsistent mechanism
Sentinel bruising
Common
Frequent etiologies
Transient synovitis (M67.3)
Recent viral illness
Able to bear weight or improving with NSAIDs
Sprain and strain
Normal vitals
Focal soft tissue tenderness
Toddler fracture (tibia)
Minor trauma history
Refusal to bear weight with minimal exam findings
Viral myositis
Calf tenderness
Recent influenza like illness
Reactive arthritis (M02.9)
Recent GI or GU infection
Enthesitis pattern
Less common
Important alternatives
Legg Calve Perthes disease (M91.1)
Age 4 to 10
Limited abduction and internal rotation
Juvenile idiopathic arthritis (M08.9)
Morning stiffness
Chronic course
Discitis and vertebral osteomyelitis
Back pain
Refusal to sit or bend
Psoas abscess
Hip flexion posture
Fever plus abdominal pain
Lyme arthritis (A69.23)
Large joint effusion
Minimal pain with weight bearing
Hemarthrosis
Bleeding disorder history
Large atraumatic effusion
Mimics and pitfalls
Common traps
Hip pathology presenting as knee pain
Early septic arthritis with normal initial labs
Occult fracture with normal initial radiographs
Past Medical History
Prior orthopedic history
Prior MSK conditions
Prior fractures
Prior hip dysplasia or surgery
Prior gait abnormalities
Chronic disease
Comorbidities influencing risk
Sickle cell disease
Diabetes mellitus (E11.9)
Chronic kidney disease (N18.9)
Malignancy history
Procedures and devices
Relevant interventions
Recent dental work
Recent surgery
Indwelling vascular access
Baseline function
Functional status
Independent ambulation baseline
Developmental delay affecting gait
Sports participation level
Physical Exam
General and vitals
Stability and appearance
Toxic appearance
Hydration status
Fever pattern
Tachycardia out of proportion to fever
Gait and functional assessment
Mobility phenotype
Ability to take 4 steps
Toe walking
Heel walking
Trendelenburg gait
Hip focused exam
Hip localization
Passive ROM pain
Internal rotation limitation
Abduction limitation
Log roll pain
Knee ankle foot exam
Distal joint evaluation
Effusion
Point tenderness
Ligament laxity
Pain with tibial torsion
Long bone and spine exam
Proximal sources
Femur tenderness
Tibia tenderness
Back tenderness
Sacroiliac tenderness
Skin and soft tissue
Overlying findings
Cellulitis
Abscess
Petechiae or purpura
Bruising pattern concerning for NAT
Neurovascular
Limb perfusion and nerve function
Pulses and cap refill
Sensation
Motor strength
Compartment firmness
Lab Studies
Core labs for infection concern
Inflammatory markers and blood
CBC with differential
CRP
ESR
Blood cultures before antibiotics when febrile
Targeted labs by phenotype
Condition directed testing
CK for suspected myositis or rhabdomyolysis
CMP for systemic illness and renal function
Urinalysis for hematuria or referred pain
Hematology and malignancy screening
When cancer or bleeding concern
Peripheral smear if cytopenias
LDH and uric acid if leukemia concern
PT INR and aPTT if hemarthrosis concern
Pregnancy and STI related considerations
Adolescent considerations
Urine pregnancy test
STI testing if reactive arthritis concern
Imaging
Scoring Systems
Kocher criteria for septic arthritis of the hip
Fever greater than 38.5 C
Non weight bearing
ESR greater than 40 mm/hour
WBC greater than 12 x 10 to the 9 per L
Increasing probability with more criteria present
Limited performance in settings with Lyme or early infection
Modified Kocher including CRP
CRP greater than 20 mg/L
Useful for risk stratification not rule out
MRI
MRI indications
Suspected osteomyelitis with negative radiographs
Suspected septic arthritis complications
Concern for malignancy or occult fracture
MRI precautions
Sedation needs in younger children
Implanted device compatibility
MRI pearls
Detects marrow edema early in osteomyelitis
Defines abscess and adjacent soft tissue involvement
CT
CT indications
Complex fracture characterization
Suspected pelvic or acetabular injury when radiographs limited
CT limitations
Ionizing radiation
Contrast nephrotoxicity risk when used
CT alternatives
Prefer MRI for infection and malignancy workup
Prefer ultrasound for hip effusion screening
Ultrasound
Hip ultrasound
Detects effusion
Cannot distinguish septic arthritis from transient synovitis alone
POCUS adjuncts
Guidance for arthrocentesis when expertise available
Soft tissue abscess identification
Plain radiographs
Radiograph strategy
Joint above and below the suspected site
Pelvis AP plus lateral hip view when hip pathology possible
Tibia and fibula views for toddler fracture phenotype
SCFE safety
Avoid frog leg lateral if unstable SCFE suspected
Use cross table lateral if SCFE concern
Special Tests
Bedside maneuvers
Localization maneuvers
Log roll for hip irritability
FABER for hip and SI joint pain
Passive internal rotation limitation for SCFE or Perthes
Arthrocentesis and synovial analysis
Joint aspiration when septic arthritis suspected
Synovial WBC count and differential
Gram stain and culture
Crystal analysis when appropriate
Infection source evaluation
Focused workup additions
Throat testing when streptococcal trigger suspected
Stool testing in severe post infectious arthritis phenotype
Orthopedic measurements
Limb and hip measurements
Leg length discrepancy
Galeazzi sign for hip pathology
ECG
Indications uncommon
When considered
Chest pain or syncope plus limp
Suspected myocarditis with myositis
Interpretation focus
High risk patterns
Tachyarrhythmia with hemodynamic instability
Conduction delay in systemic illness
Assessment
Severity and risk stratification
Infection likelihood
High risk when fever plus non weight bearing plus painful passive ROM
Intermediate risk when inflammatory markers elevated without clear source
Lower risk when afebrile and improving and normal exam
Working diagnosis framing
Problem representation
Age group and location pattern
Traumatic versus atraumatic
Ability to bear weight
Presence of systemic illness
Complications to exclude
Must rule out
Septic arthritis
Osteomyelitis
SCFE
Occult fracture
Diagnostic uncertainty
Alternative pathways
If no localization then full limb exam and imaging strategy
If persistent symptoms then advanced imaging and specialty input
Plan
First 5 minutes
Critical workflow
Escalate to resuscitation bay if toxic or unstable
Continuous monitoring if systemic illness
IV access if febrile and unable to bear weight or concern for sepsis
Analgesia early to enable exam
Analgesia and comfort
Pain control
Acetaminophen PO 15 mg/kg per dose
Ibuprofen PO 10 mg/kg per dose if no contraindication
Opioid analgesia for severe pain per local protocol
Diagnostic sequencing
Test ordering logic
If septic arthritis suspected then blood cultures then antibiotics after aspiration when feasible
If trauma phenotype then radiographs first
If atraumatic and hip irritability then ultrasound plus inflammatory markers
Antibiotics when indicated
Suspected septic arthritis or osteomyelitis
Start antibiotics after cultures and aspiration when feasible without delay
Coverage guided by age and local resistance
MRSA risk adjustment per local protocol dependent
Consultation plan
Specialty escalation
Orthopedics urgent for suspected septic arthritis or SCFE
Pediatrics or hospital medicine for systemic illness
Hematology oncology for malignancy concern
Reassessment loop
Interval reassessment
Pain and ability to bear weight every 30 to 60 minutes in ED
Repeat focused ROM and neurovascular exam after analgesia
Escalate imaging if worsening or persistent non weight bearing
Disposition
ICU and high acuity criteria
Higher level of care
Hemodynamic instability
Sepsis requiring vasoactive support
Rapidly progressive limb threat
Inpatient admission criteria
Admit indications
Suspected septic arthritis or osteomyelitis
Persistent inability to bear weight
Uncontrolled pain
Unreliable follow up
Observation pathway criteria
Observation candidates
Intermediate risk infection with pending labs and imaging
Pain improved but gait not normal
Need serial exams
Discharge criteria
Safe discharge features
Afebrile or improving and well appearing
Able to bear weight or clearly improving
Normal neurovascular exam
Clear follow up within 24 to 72 hours
Follow up timing
Outpatient plan
Primary care or urgent reassessment in 24 to 48 hours if uncertain diagnosis
Orthopedics within 1 week for suspected Perthes or persistent limp
Same day ortho for SCFE concern
Discharge Instructions
Copy discharge instructions
Patient instructions
Your child has been evaluated for a limp and no emergency cause was found today
Use pain medicine as directed and limit painful activity
Encourage gentle walking only as tolerated
Return to the emergency department right away for fever or worsening pain
Return right away if unable to bear weight or new swelling or redness
Follow up with your clinician within 1 to 2 days or sooner if symptoms worsen
References
Guidelines and key evidence
Pediatric Infectious Diseases Society and Infectious Diseases Society of America guideline for acute hematogenous osteomyelitis in pediatrics 2021
Diagnostic and treatment framework for pediatric bone infection
Emphasizes MRI and culture directed therapy
Kocher MS septic arthritis of the hip clinical prediction algorithm J Bone Joint Surg Am 1999
Four variable risk stratification tool
Designed to distinguish septic arthritis from transient synovitis
Caird MS addition of CRP to prediction for septic arthritis J Bone Joint Surg Am 2006
CRP improves discrimination in suspected septic hip
Supports modified Kocher approaches
American Academy of Pediatrics Red Book Report of the Committee on Infectious Diseases 2024
Pathogen specific guidance for pediatric septic arthritis and osteomyelitis
Immunization and risk context
Slipped capital femoral epiphysis recognition and urgent management review in orthopedic literature 2019
Emphasizes prompt non weight bearing and orthopedic consultation
Radiograph technique considerations for unstable slips
Local protocol dependent pediatric sepsis pathway and empiric antibiotic recommendations 2024
Antibiotic choices based on local resistance and MRSA prevalence
Time critical escalation triggers
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.