Children often have musculoskeletal symptoms. Most are benign and many occur after trauma. The GP’s duty is to distinguish these from more serious conditions.
Here are just some conditions that affect children. They are included because they are common, or because primary care has a pivotal role in prevention and/or management.
- Children may deny pain, or claim to have pain when they don’t.
- Observe the child’s relationship with the parent. Benign pains are more common if the child gains attention from them.
- Your careful history and examination must take into account the child’s developmental progress for his or her age.
- A child’s job is to play.
The child who does not play is ill until proven otherwise.
Developmental Dysplasia of the Hip
Formerly known as congenital dislocation of the hip, this affects around 1% of infants. In developmental dysplasia of the hip (DDH), the acetabulum is too shallow for the femoral head, which can sublux or dislocate. The aim is to diagnose it as early as possible.
DDH is more common in:
- Girls
- Breech deliveries
Spina bifida
Families with a history of DDH (ask about hip problems).Look for:
Asymmetric skin creases in the thigh
Any leg length discrepancy.Tests for DDH can be performed from birth. In both tests, flex the knees:
- Barlow’s test – feel for a clunk as you abduct the hip and push it backwards.
- Ortolani’s test (rarely positive) – feel for a clunk as the abducted and dislocated hip slips back into place when you push the femur forwards.
Refer promptly for assessment if you suspect DDH as splinting (or occasionally surgery) can be curative. Uncorrected DDH rarely delays walking, but it can cause a limp and lifelong problems.
Limping
A limp is always significant. Causes include:
- Transient synovitis of the hip (common and benign)
- Septic arthritis or osteomyelitis (rare but serious)
- Perthes’ disease
- Slipped upper femoral epiphysis
- Rickets
- Acute lymphoblastic leukaemia
- Trauma, including non-accidental injury (see Chapter 11).
Always assess the whole child, and remember that hip pain can be referred to the knee (and vice versa).
Look for sepsis.
Check for signs of injury, especially injuries of varying ages.Consider full blood count (FBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and X-rays. Refer if there are red flags or the limp persists.
Growing Pains
While a convenient shorthand term for benign limb pain in childhood, ‘growing pains’ may not be caused by growth.
History
- The child is usually aged 3–12 years, and may be athletic.
- Pain is usually symmetrical, in the lower limbs below the knees.
- It often occurs at night, especially after an active day, but never in the morning.
- Ask about limping. Growing pains do not cause a limp.
- Ask about limitation of activities.
Persistent night pain or asymmetrical pain can be caused by osteosarcoma.
Examination
Assess the child carefully, including general health and developmental milestones.
Can you see a limp?
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