We currently use 2 recognised pain scores in our Emergency Department, depending on the age of the patient. The FLACC score (ref) was put together at the end of the 1990’s and has been validated for use in pre-verbal children aged 2 months to 7 years. The Wong Baker (“smiley faces”) score is for use in the over 3’s. We also ask older children to give us a mark out of 10 on their pain with 10 being the worst they have ever felt and 1 being not too bad. Our local pain protocol suggests what the health professional should do with the information gleaned and when the child should be reassessed. I have reproduced that table for you here. The UK Department of Health National Service Framework for young people and maternity services says that the prevention, assessment and control of pain in children should be subject to regular audit.
Limping Child Guideline
(with thanks to Dr Rajashree Ravindran)
Children who have hip pathology may present with a variety of non-specific symptoms. They may present with pain, refusal to bear weight, limp, or decreased movement of the lower extremity. If pain is present it is important to determine where it is coming from, as pelvis and low back pathology may refer pain to the hip region and hip pathology commonly presents with referred thigh or knee pain.
The history should include
- pain characteristics
- trauma (recent/remote)
- mechanical symptoms (catching, clicking, snapping, worse during or after activity)
- systemic symptoms (fever, irritability, weight loss, anorexia)
- inflammatory symptoms (morning stiffness)
- neurological symptoms (weakness, altered sensation)
- gait (limp or not weight bearing)
- effects of previous treatments (including antibiotics, analgesics, anti-inflammatory drugs, physiotherapy)
- The current level of function of the child and development
- Temperature and vital signs.
- Musculoskeletal exam including gait assessment: Look, Feel, Move approach to joint examination can be used. It should be noted that it is exceptionally rare to appreciate swelling of the hip on physical exam as it is a deep joint.
- A CNS examination is also vital to exclude any neurological pathology.
- Look for abdominal masses(Neoplasias in children can present with a simple limp)
- Examine the genitalia(testicular torsion may present simply as a limp) and perform an ENT examination
- Look for rashes, bruises in unusual areas and remember the possibility of a non accidental injury.
Common differential diagnosis of limp by age:
|0-3 years||3-10years||10-15 years|
|Septic arthritis or OsteomyelitisDevelopmental dysplasia of hip(usually does not present with pain)Fracture or soft tissue injury (toddler fractures or non accidental injury)||Transient synovitis (Irritable hip)Septic arthritis or osteomyelitisPerthes’ diseaseFracture or soft tissue injury||Slipped Upper Femoral epiphyses(SUFE)Septic arthritis or OsteomyelitisPerthes’ diseaseFracture or soft tissue injury|
|Also consider:||Neoplasms, Neurological/ neuromuscular causes, Rheumatological disease such as Juvenile idiopathic arthritis|
Limp due to trauma: If a traumatic fracture is suspected perform an x ray of the affected site and involve the orthopaedic team as appropriate. Always consider the possibility of non accidental injury in a younger child presenting with fracture.
Atraumatic limp: The algorithm as below can be used for guidance. You may wish to give the parent information leaflet out as part of your “safety netting” as it reminds the family to seek further help if the limp is still present 1 or 2 weeks later.
1. Frick, S.L., Evaluation of the child who has hip pain. Orthop Clin North Am, 2006. 37(2): p. 133-40, v.
2. Perry, D.C. and C. Bruce, Evaluating the child who presents with an acute limp. BMJ, 2010. 341: p. c4250.
3. Kocher, M.S., D. Zurakowski, and J.R. Kasser, Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am, 1999. 81(12): p. 1662-70.
4. Caird, M.S., et al., Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am, 2006. 88(6): p. 1251-7.
5. Howard, A. and M. Wilson, Septic arthritis in children. BMJ, 2010. 341: p. c4407.
6. Kang, S.N., et al., The management of septic arthritis in children: systematic review of the English language literature. J Bone Joint Surg Br, 2009. 91(9): p. 1127-33.
7. Kocher, M.S., et al., Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am, 2004. 86-A(8): p. 1629-35.
8. Padman, M. and B.W. Scott, (i) Irritable hip and septic arthritis of the hip. 2009. 23(3): p. 153-157.
The March 2011 version is now published. I have covered the new NICE guideline on food allergy and provided a link to the Allergy Academy which runs some really excellent course on all aspects of allergy in children, including one specifically for ED physicians. There’s a bit on how to get foreign bodies out of noses and a text box on the paediatric early warning system or PEWS. I have reminded you all that children under 18 months with a fracture need to be seen by a paediatrician before discharge for a safeguarding assessment. This guideline comes from a new document put together by the NSPCC and the Welsh Child Protection group. The pamphlet, downloadable here, describes when to suspect physical abuse in children with fractures and is useful reading for all ED practitioners. Do leave comments below.
Please find local safeguarding boards contact details below. Lots of information on what the LSCB is, training courses on offer, what to do if worried about a child, relevant local contact details etc.:
Child Protection Handbook produced by Royal College of Paediatrics and Child Health (RCPCH) available to download in full from http://www.rcpch.ac.uk/Policy/Child-Protection/Child-Protection-Publications. Do peruse the continually updated list of downloadable documents at this link. For example the guidelines on when to suspect Fabricated and Induced Illness were updated in 2009 and quite substantially broadened.
NICE quick reference guideline on When to Suspect Child Maltreatment (July 2009) available at www.nice.org.uk/nicemedia/pdf/CG89QuickRefGuide.pdf
Working Together (2013) is a guide to inter-agency working to safeguard and promote the welfare of children https://www.gov.uk/government/publications/working-together-to-safeguard-children
In May 2010, after the election, the Department for Children, Schools and Families became the Department for Education. The safeguarding content is currently split between the 2 websites. Most of the Every Child Matters information is at www.dcsf.gov.uk/everychildmatters but some of the more up to date news on safeguarding issues is at http://www.education.gov.uk/childrenandyoungpeople/safeguardingandsocialworkreform.
A useful document on recognising physical abuse in children with fractures has just been published jointly by the NSPCC and Welsh Child Protection Systematic Review Group. Compulsory reading for GPs and ED physicians I should think. This Cardiff Core Info Group publish a number of excellent pamphlets on bites, head injury, burns, bruises and neglect.
Do use the comments box below to let me know about any other resources you would recommend.