In a limping child with noncontributory history and no focal exam findings, what is the first step in workup?

In a limping child with noncontributory history and no focal exam findings, what is the first step in workup?

• A. MRI of the leg
• B. Ultrasound of the hip
• C. Radiographs of both lower extremities
• D. Bone scan

Answer: (C)

When a child limps but the history isn’t revealing and the exam has no focal findings, the priority is to look for bone or joint problems that could be causing the limp. Plain radiographs are the most accessible and quickest way to detect a broad range of conditions, from fractures to early bone diseases. Imaging both lower extremities (including the hips) provides a comprehensive screen and reduces the chance of missing pathology in either limb or in the pelvic region that could be contributing to the limp. This approach can reveal occult fractures, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis, osteomyelitis, or even tumors, which guides timely management. If the radiographs are normal but concern remains, the next steps typically involve targeted imaging such as hip ultrasound to assess for effusion (which can help differentiate transient synovitis from septic arthritis) or MRI for occult pathology. Bone scan is reserved for specific scenarios like occult infection or metastasis when other imaging is inconclusive.

When a child limps but the history isn’t revealing and the exam has no focal findings, the priority is to look for bone or joint problems that could be causing the limp. Plain radiographs are the most accessible and quickest way to detect a broad range of conditions, from fractures to early bone diseases. Imaging both lower extremities (including the hips) provides a comprehensive screen and reduces the chance of missing pathology in either limb or in the pelvic region that could be contributing to the limp. This approach can reveal occult fractures, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis, osteomyelitis, or even tumors, which guides timely management.

If the radiographs are normal but concern remains, the next steps typically involve targeted imaging such as hip ultrasound to assess for effusion (which can help differentiate transient synovitis from septic arthritis) or MRI for occult pathology. Bone scan is reserved for specific scenarios like occult infection or metastasis when other imaging is inconclusive.