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Editor,— As Mattick et al1 explain, the irritable hip is a common presentation that requires the exclusion of serious pathology. The protocol described allows appropriate outpatient management of many children. The text describes how no one single investigation or examination finding is predictive of septic arthritis. We were however disappointed to see a “blanket” approach to investigations with all children undergoing blood tests.
History and examination are more useful than any investigation. If a child has been unwell, whether feverish or not, septic arthritis should be considered and appropriate investigation and treatment instituted.
Furthermore, in a well child with an isolated painful hip, structural problems need to be excluded with imaging but we have not found blood tests helpful. These are the factors that we use in the individual evaluation of a child with a painful hip in our emergency department.
We appreciate that the comprehensive approach by Mattick et al is aimed at detecting serious disorders but do not agree that blood tests are necessary for every limping child.
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The authors reply
We welcome the interest shown by Bridges et al in our paper.1 They state that a history and clinical examination are sufficient to select those children, presenting with atraumatic limp, who require further inpatient investigations They suggest that the routine screening of blood is unnecessary for such children who are discharged, and imply that we are subjecting children to needless venepuncture. However, no objective evidence is offered to substantiate their statement.
In addition, Bridges et al misquote our paper. Our paper states “no one clinical finding or investigation can be used in managing the limping child who attends the A&E department”. Our protocol was not aimed at identifying “septic arthritis”, but identifying children who may be safely discharged home. Our paper demonstrates that this protocol does not appear to miss significant pathology in those children who are discharged. While we accept that our protocol has the potential to be refined, making it more sensitive and specific, we are unaware of any robust published evidence demonstrating history and clinical examination alone as being reliable at excluding significant pathology in children presenting with hip pathology.
However, there is evidence demonstrating the pitfalls of relying on history and clinical examination alone. Taylor et al2 reported in a series of 509 cases of “irritable hip” that history is unreliable in this condition. A recent study3 identified four cases of occult osteomyelitis, at various sites in the distal limb, presenting to a paediatric A&E department with atraumatic limp. Clinical findings were unreliable with further investigation and the subsequent diagnosis resulting from the identification of a markedly increased erythrocyte sedimentation rate. Finally, Aston4 reported identification of neuroblastoma by detection of anaemia on investigation of the limping child.
Therefore, we would advise caution in discharging children presenting to A&E departments with atraumatic limp based on history, clinical examination and imaging alone.