Limping: Evaluation, Diagnosis, and Management in the Pediatric ED

A 6 year-old male is brought to the pediatric ED for evaluation of limping that has worsened over the last month. He has complained of intermittent right-sided hip pain with occasional limping over the last 6 months. The parents do not recall any history of trauma. They report that he had a cold during the last 6 months, but nothing out of the ordinary. He has had no fever and no weight loss. He has been seen by his physician several times for the pain and limping. He was previously diagnosed with transient synovitis and muscle strain. Treatment consisted of rest and ibuprofen. He reported temporary relief of the pain with ibuprofen. However, the parents are concerned that the limping is more noticeable, and the child is unable to play like he used to. They want to know when he will walk normally again. As you evaluate this child, several questions run through your head: How do I make a diagnosis in a problem that has been ongoing for 6 months? Will lab tests help me? Should I bother with plain films or get an MRI? What part of the leg do I image? Is this a tumor?