Limp Or Refusal to Bear WeightAPPROACH

MUSCULOSKELETAL AND EXTREMITIES · 19 SECTIONS

⚲

442 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Shoulder Pain Elbow Pain Wrist Pain Hand Pain Hip Pain Knee Pain Ankle Pain Foot Pain Cast Or Splint Complication Symptoms Wound Check And Suture Related Visits Joint Swelling And Monoarthritis Suspected Septic Joint Presentation Suspected Tendon Rupture Presentation Limp Or Refusal To Bear Weight

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx61

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

02Alarm Features/alarm25

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

03Medications/meds13

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

04Diet/diet9

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

05Review of Systems/ros20

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

06Collateral History and Family History/chafh15

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

07Risk Factors/rf19

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

08Differential Diagnosis/ddx61

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

09Past Medical History/pmh17

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

10Physical Exam/exam35

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

11Lab Studies/labs16

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

12Imaging/img42

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 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

13Special Tests/spec14

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

14ECG/ecg6

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

15Assessment/ax17

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

16Plan/plan25

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

17Disposition/dispo22

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

18Discharge Instructions/di7

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

19References/r18

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

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Limp Or Refusal to Bear WeightAPPROACH

MUSCULOSKELETAL AND EXTREMITIES · 19 SECTIONS

⚲

442 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx61

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

02Alarm Features/alarm25

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

03Medications/meds13

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

04Diet/diet9

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

05Review of Systems/ros20

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

06Collateral History and Family History/chafh15

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

07Risk Factors/rf19

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

08Differential Diagnosis/ddx61

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

09Past Medical History/pmh17

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

10Physical Exam/exam35

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

11Lab Studies/labs16

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

12Imaging/img42

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 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

13Special Tests/spec14

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

14ECG/ecg6

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

15Assessment/ax17

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

16Plan/plan25

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

17Disposition/dispo22

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

18Discharge Instructions/di7

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

19References/r18

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

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.