Synopsis
Localise pain from spine to foot, identify the febrile non-weight-bearing child and safeguarding or malignancy red flags, then order age- and mechanism-appropriate imaging without allowing a normal early radiograph to close the diagnosis.
- A limp is a symptom, not a hip diagnosis. Observe gait if safe, then examine spine, abdomen, pelvis, both hips, thighs, knees, tibiae, ankles and feet because hip disease often presents as knee pain.
- First decide whether the child is systemically unwell, febrile, unable to bear weight, in severe night pain or has trauma, neurological change or safeguarding concern.
- A febrile child who refuses to move or bear weight has septic arthritis or osteomyelitis until urgently assessed; give sepsis care and involve orthopaedics before delays from routine imaging.
- Take onset, exact function, preceding infection, trauma, morning stiffness, night waking, constitutional symptoms, medicines and developmental stage, and compare the account with the child's abilities.
- Transient synovitis is a diagnosis of exclusion in a well child after viral illness; improving function and short follow-up are essential because early infection, Perthes disease and malignancy can resemble it.
- Adolescents with hip or referred knee pain, obesity, endocrine disease or obligatory external rotation need urgent assessment for slipped upper femoral epiphysis and must be kept non-weight-bearing.
- A child aged roughly 4 to 8 years with insidious limp and restricted hip abduction or internal rotation may have Perthes disease even when pain is mild.
- Plain radiographs answer fracture and established bony disease but can be normal in early infection, stress injury, Perthes disease or malignancy; choose ultrasound or MRI when the clinical question remains.
- Pallor, bruising, persistent night pain, weight loss, nodes, hepatosplenomegaly or focal swelling needs urgent blood count, film and malignancy-aware imaging rather than repeated reassurance.
- Discharge only a well child with safe mobility, a plausible diagnosis, adequate analgesia, explicit return criteria and a short review plan if symptoms do not rapidly resolve.
Key red flags
Fever, toxic appearance, severe pain or inability to bear weight requires urgent bone and joint infection assessment.
Adolescent hip or knee pain with external rotation requires immediate non-weight-bearing management for possible SUFE.
Night pain, pallor, bruising, weight loss, lymph nodes or organomegaly suggests malignancy or marrow disease.
Back pain, weakness, bladder or bowel change, saddle symptoms or abnormal reflexes requires urgent spinal and neurological imaging.
Absent pulse, cold limb, severe swelling or pain out of proportion suggests vascular compromise or compartment syndrome.
Injury inconsistent with developmental ability, delayed presentation or multiple injuries requires a safeguarding pathway.
Persistent or worsening symptoms after a transient-synovitis label needs re-examination and repeat or advanced imaging.
Night pain, pallor, bruising, weight loss, mass, nodes or organomegaly requires urgent diagnostic escalation.
Investigation priorities
Localise pain and identify hip referral, neurological, abdominal, vascular and safeguarding causes before imaging.
Assess marrow, cartilage, soft tissue, spine, occult fracture, tumour and multifocal infection with high sensitivity.
Management branches
A child presents with new altered gait, refusal to walk or limb pain.
- Assess physiology, fever, pain, weight-bearing, neurological and vascular function and expose for rash, swelling and injury.
- Keep non-weight-bearing when fracture, SUFE or serious infection is possible and provide age-appropriate analgesia.
- Escalate sepsis, compartment, vascular, spinal, malignant and safeguarding red flags before routine diagnostic pathways.
The child is stable enough for systematic musculoskeletal assessment.
- Observe gait only if safe and compare posture, leg length, muscle bulk and skin on both sides.
- Examine spine, abdomen, pelvis, hips, femora, knees, tibiae, ankles and feet plus pulses and neurological status.
- Select blood tests and imaging from the localised question while remembering hip disease can refer to the knee.