10.6 Paediatric Orthopaedics, Growth, Childhood Cancer & Common Chronic Problems
Key Takeaways
A child with a limp and fever needs urgent same-day assessment to exclude septic arthritis; transient synovitis is a diagnosis of exclusion in a well child.
Slipped upper femoral epiphysis typically affects overweight adolescents, causes hip or knee pain with loss of internal rotation, and needs urgent orthopaedic fixation.
NICE NG12 advises a very urgent referral (within 48 hours) for a child with an unexplained palpable abdominal mass, which may be neuroblastoma or Wilms' tumour.
An absent red reflex in a baby or child needs urgent ophthalmology referral to exclude retinoblastoma or congenital cataract.
A unilateral undescended testis still undescended at 3 months is referred to a paediatric surgeon, with orchidopexy usually between 6 and 12 months of age.
Paediatric Orthopaedics, Growth, Childhood Cancer & Common Chronic Problems
Developmental Dysplasia of the Hip (DDH)
- Risk factors: breech presentation at or after 36 weeks or at birth, first-degree family history of hip problems in early childhood, female sex and first-born babies.
- Screening: Barlow (dislocatable hip) and Ortolani (dislocated hip that reduces with a clunk) tests at the newborn and 6–8 week checks. Later signs include limited hip abduction, leg-length difference, asymmetrical skin creases and a waddling gait.
- Imaging: hip ultrasound (within 2 weeks for an abnormal examination; by about 6 weeks for babies with risk factors); X-ray after about 4–6 months, when the femoral head ossifies.
- Treatment: a Pavlik harness for infants under about 6 months; closed or open reduction with casting for older infants. Late diagnosis increases the risk of early arthritis.
The Limping Child
| Condition | Age | Key Features | Management |
|---|---|---|---|
| Septic arthritis | Any, often under 3 | Fever, unwell, refuses to bear weight, hot swollen joint, severely restricted movement; raised CRP and white cell count | Emergency: joint aspiration, IV antibiotics, surgical washout |
| Transient synovitis (irritable hip) | 3–8 years | Follows a viral illness; child is well, low-grade or no fever, mild restriction | Rest and analgesia; review; diagnosis of exclusion |
| Perthes disease | 4–8 years (boys) | Avascular necrosis of the femoral head; gradual limp, hip or knee pain | X-ray shows flattening and fragmentation; observation, physiotherapy or surgery |
| Slipped upper femoral epiphysis (SUFE) | 10–15 years | Overweight adolescent, hip, thigh or knee pain, limp, loss of internal rotation; bilateral in some | Frog-leg lateral X-ray; stop weight-bearing and urgent orthopaedic fixation |
| Osgood-Schlatter disease | Active adolescents | Painful bony lump at the tibial tuberosity | Rest, analgesia; self-limiting |
| Non-accidental injury | Any, especially non-mobile | Inconsistent history, other injuries | Safeguarding (section 10.4) |
Warning
Knee Pain Can Be Hip Disease: Hip pathology (Perthes disease, SUFE) often presents with pain referred to the knee. Always examine the hip in a child or adolescent with knee pain and a normal knee examination. A child under 3 with a new limp or any child with a limp and fever needs same-day assessment.
Juvenile Idiopathic Arthritis (JIA)
Arthritis beginning before 16 and lasting at least 6 weeks with no other cause.
- Oligoarticular JIA (4 or fewer joints, often knees) is the most common type; ANA-positive girls are at high risk of chronic anterior uveitis, which is painless, so they need regular slit-lamp screening.
- Systemic JIA (Still's disease): daily spiking fevers, a salmon-pink evanescent rash, lymphadenopathy and serositis; risk of macrophage activation syndrome.
- Treatment: NSAIDs, intra-articular corticosteroids, methotrexate and biologics under paediatric rheumatology.
Childhood Cancer Red Flags (NICE NG12)
| Cancer | Red Flag | Action |
|---|---|---|
| Leukaemia | Pallor, fatigue, unexplained bruising or bleeding, bone pain, hepatosplenomegaly, lymphadenopathy, petechiae | Very urgent full blood count (within 48 hours); immediate referral for unexplained petechiae or hepatosplenomegaly |
| Neuroblastoma / Wilms' tumour | Unexplained palpable abdominal mass or enlarged abdominal organ | Very urgent referral (within 48 hours) |
| Bone sarcoma (osteosarcoma, Ewing's) | Unexplained bone swelling or pain, especially around the knee in teenagers | Very urgent X-ray (within 48 hours) |
| Retinoblastoma | Absent red reflex (leukocoria), new squint | Urgent ophthalmology referral |
| Brain tumours | New abnormal cerebellar or central neurological function | Very urgent referral (within 48 hours) |
Growth
- Faltering growth (NICE NG75): a fall across 1 or more centile spaces if birthweight was below the 9th centile, 2 or more if between the 9th and 91st, or 3 or more if above the 91st; or a weight below the 2nd centile. Newborns commonly lose up to 10% of birthweight, regaining it by about 3 weeks; a loss of 10% or more needs feeding assessment.
- Causes: inadequate intake (feeding difficulties, neglect), malabsorption (coeliac disease, cystic fibrosis), increased requirements (congenital heart disease) and chronic illness.
- Short stature: compare with the mid-parental height. Most children are familial short stature or constitutional delay of growth and puberty (delayed bone age, family history of late puberty). Pathological causes include hypothyroidism, growth hormone deficiency, Turner syndrome (karyotype every short girl with unexplained short stature), coeliac or Crohn's disease, long-term corticosteroids and psychosocial deprivation.
- Precocious puberty: signs of puberty before 8 in girls or 9 in boys need specialist assessment.
Common Genital, Bowel & Bladder Problems
- Undescended testis (cryptorchidism): bilateral impalpable testes at birth need same-day senior review (to exclude disorders of sex development such as congenital adrenal hyperplasia). A unilateral undescended testis is re-examined, and if still undescended at 3 months, refer to a paediatric surgeon; orchidopexy is usually done between 6 and 12 months. It reduces (but does not remove) the risks of subfertility and testicular cancer. A retractile testis that can be brought into the scrotum is normal.
- Hypospadias: the urethral opening is on the underside of the penis; do not circumcise, because the foreskin may be needed for repair.
- Constipation (NICE CG99): red flags include symptoms from birth, delayed passage of meconium (more than 48 hours in a term baby) suggesting Hirschsprung disease, ribbon stools, abdominal distension with vomiting, faltering growth and abnormal leg neurology. Idiopathic constipation is treated with macrogol (a disimpaction regimen if impacted, then maintenance for weeks to months), diet and toileting routines.
- Bedwetting (nocturnal enuresis, NICE CG111): reassure under 5. For children 5 and over, advise fluids and toileting, then an enuresis alarm first-line for motivated families, or desmopressin if an alarm is unsuitable or rapid short-term control is needed (sleepovers). Daytime wetting or new-onset bedwetting needs assessment for UTI, diabetes, constipation and safeguarding concerns.
A 13-year-old boy with a BMI above the 98th centile has had 3 weeks of left knee pain and a limp. Knee examination is normal. Internal rotation of the left hip is painful and reduced. What is the most likely diagnosis?
Legg-Calvé-Perthes disease
Osgood-Schlatter disease of the knee
Transient synovitis of the hip
Slipped upper femoral epiphysis
A 2-year-old girl is brought to her GP because her mother noticed a firm mass in her abdomen while bathing her. She is otherwise well. According to NICE NG12, what is the most appropriate action?
Reassure and review in 4 weeks
Request an abdominal X-ray and review the result
Refer very urgently to be seen within 48 hours
Arrange a routine paediatric outpatient appointment
At the 6–8 week check, a baby boy's right testis cannot be felt in the scrotum or brought down; the left testis is normal. What is the most appropriate plan?
Refer for same-day surgical exploration of the inguinal canal
Re-examine at 3 months, then refer to a surgeon if still undescended
Arrange urgent karyotyping and endocrine tests for a sex development disorder
Reassure the parents that it will descend naturally by school age
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