Emerg Med J 29:969-971 doi:10.1136/emermed-2011-201037
  • Original articles

C reactive protein, erythrocyte sedimentation rate, or both, in the diagnosis of atraumatic paediatric limb pain?

  1. Paul Leonard2
  1. 1Emergency Department, Edinburgh Royal Infirmary, Edinburgh, UK
  2. 2Emergency Department, Royal Hospital for Sick Children, Edinburgh, UK
  1. Correspondence to Dr S Robinson, Emergency Department, Edinburgh Royal Infirmary, 51 Little France Crescent, Edinburgh, EH16 4SA UK; psrobinson{at}
  1. Contributors SR collected the data and wrote the manuscript. PL performed the statistical analysis and reviewed the manuscript.

  • Accepted 10 January 2012
  • Published Online First 14 February 2012


Objective To assess if measurement of either C reactive protein (CRP) or erythrocyte sedimentation rate (ESR) individually has an equivalent diagnostic value to measurement of both in identifying orthopaedic infection as the cause of paediatric atraumatic limb pain.

Setting Emergency department of a paediatric teaching hospital.

Study design Retrospective study of case notes for patients attending the emergency department with a complaint of atraumatic limb pain and in whom both ESR and CRP were measured at the time of presentation. Laboratory results at the time of presentation were recorded along with the final diagnosis. Receiver operating characteristic (ROC) curves were created using the data and the optimum cut-off values for each of ESR and CRP were derived using the point of best trade off between sensitivity and specificity. Likelihood ratios for ESR and CRP individually and in combination were calculated.

Results 259 patients were included in the study, of whom 17 were considered to have an orthopaedic infection. ROC curves revealed the best results were obtained using cut-off values of CRP >7 and ESR >12. The combination of a CRP >7 and an ESR >12 gave the best positive likelihood ratio at 6.26 (likelihood ratio 5.34 (CRP >7) vs 2.57 (ESR >12)). For ruling out disease, the combination of CRP ≤7 and ESR ≤12 also outperformed either variable individually (negative likelihood ratio 0.09 (CRP ≤7 and ESR ≤12) vs 0.34 (CRP ≤7) vs 0.18 (ESR ≤12)).

Conclusion Measurement of both CRP and ESR should be considered an important aid in the investigation of atraumatic limb pain.


  • Competing interests None.

  • Ethics approval This was a service evaluation and therefore ethics board approval was not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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