Risk stratification of atraumatic limp. Before and after: a retrospective cohort study.
TITLE:
Risk stratification of atraumatic limp. Before and after: a retrospective cohort study.
AIMS:
To review the investigation and outcomes of children presenting with atraumatic limp to a tertiary Paediatric Emergency Department (PED) over a 12-month period (May 2016 - April 2017) following introduction of a revised guideline advocating targeted investigations where red flags exist.
To compare the data to that from the 12 months preceding introduction of the revised guideline to ensure safety and efficacy.
To assess adherence to the guideline by local doctors and emergency nurse practitioners (ENP).
METHODS:
All patients who attended the PED clinic from May 2016-April 2017 with limp/lower limb pain in the absence of clear trauma were manually identified and the following information gathered: age, sex, presenting complaint, duration of symptoms, examination findings (including ability to weight bear), pyrexia preceding/during PED attendance, blood results (white cell count, neutrophil count, C-reactive protein, erythrocyte sedimentation rate), X-ray and ultrasound (USS) results, clinical diagnoses and final outcomes (including those diagnosed at a later date by other specialists). This was compared with results from the 12 months preceding the new guideline when all patients regardless of clinical findings had blood tests and USS.
RESULTS:
386 patients attended the PED review clinic with atraumatic limp after introduction of the revised protocol. Of these 226 patients (59%) had investigations on their first PED attendance, and of those investigated, 93.6% had a documented appropriate “red flag” justification for doing so. All febrile patients had investigations. Five patients (1.2%) had duration of history that merited investigation but did not have them performed at first PED attendance.
30 patients (8%) had a significant pathology including seven patients with juvenile idiopathic arthritis (JIA), four with osteitis/osteomyelitis, two with Perthes’ disease, two with acute lymphoblastic leukaemia (ALL), one with Langerhans Cell Histiocytosis (LCH) and one with metachromatic leukodystrophy. 23/30 had investigations appropriately at first presentation. Of the 7 that did not, one ought to have had for duration of symptoms and subsequently had a diagnosis of JIA.
The remaining 92% had insignificant pathology, predominantly transient synovitis (73%) with a small number of soft tissue injuries and unexpected minor fractures.
Compared to the 498 patients attending in 2014-15 who all had investigations (with significant pathology diagnosed in 10%) we are doing 62% fewer blood tests and 72% fewer USS.
CONCLUSIONS:
Children presenting with atraumatic limp in the absence of red flags can be safely managed at first presentation without blood and radiological investigations. Prevalence of significant pathology in those who do have investigations remains low but it is pertinent to follow these patients up until symptom resolution or the underlying pathology declares itself given the serious nature of the conditions we may find.
