normal x-ray does not exclude septic arthritis or early osteomyelitis.pelvis AP or frog leg view is useful for identifying SUFE, DDH (>6 mo), Perthes disease and common pelvic avulsions.a clear working diagnosis and/or a plan for review within 7 days of onset of limp.ambulating with mild or no discomfort with simple analgesia.no red flags in the history and physical examination.No investigations are indicated if all of the following apply:.Haematological: vaso-occlusive crisis (sickle cell), haemophilia.Intra-abdominal pathology or genitourinary conditions eg appendicitis, ovarian or testicular torsion.Rheumatological/immunological disorders: reactive arthritis, autoimmune arthritis, Henoch Schonlein Purpura, vasculitis, serum sickness, post infectious arthritis, Guillain-Barre syndrome.Malignancy: haematological, bone, soft tissue.Osteomyelitis/septic arthritis, bursitis, discitis, epidural collection Traction apophysitis (Osgood Schlatter – tibial tuberosity, Severs – calcaneus).Petechiae/purpura/ecchymosis (consider HSP, malignancy/haematological cause).Neurovascular assessment of affected limb.A marked reduction in range of motion is suggestive of more serious pathology such as septic arthritis compare both sides, as well as active and passive range of movement.passive: assess for limitations and asymmetry in all planes of motion.active: facilitate by placing toy or parent out of reach.Feel: heat, cold, tenderness (including calf), crepitus, fluctuance.Look: resting limb position, leg length disparity, swelling, deformities, skin changes e.g.Identify location if possible - bone vs joint vs soft tissue.Joint examination using "Look, Feel, and Move" including joints above and below area of pain.Assess gait if possible – walking +/- running.Generalised wasting, pallor, interaction with carer.Recent viral infection (acute myositis, transient synovitis) Examination.Constitutional symptoms eg unplanned weight loss, lethargy/easy fatigue, anorexia (consider malignancy/haematological cause).Systemic symptoms: fever, night sweats, chills, rigors, rash.Functional limitations: complete inability to walk or weight-bear may indicate significant pathology.Pattern and severity of pain and limp: severe localised joint pain should raise suspicion for septic arthritis.Therefore, a thorough assessment of joints above and below (including the spine and other relevant body systems) is essential to accurately localise the source Transient synovitis, acute myositis and minor trauma are common causes of limp in children, but serious pathology should be excluded.Septic arthritis is an orthopaedic emergency and should be considered in all limping children with severe localised joint pain and fever.Acute inability to walk or weight-bear is a red flag.Observing the child's gait may help localise the problem and narrow the differential diagnosis.Most children presenting with a limp do not require investigations.Fractures Bone and joint infections Acutely swollen joint Child abuse Key points
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