6522 Enhancing management practices of atraumatic limp- an audit of the sandwell and west Birmingham limping child guideline

Objectives Causes of atraumatic limp in children range from benign conditions such as 'Transient synovitis' (TS), to emergencies like 'Septic arthritis'.¹ Timely assessment necessitates the exclusion of red flag symptoms and early involvement of the trauma and orthopaedic (T&O) team. The Sandwell and West Birmingham Hospital (SWBH) Trust Limping Child guidelines provide an algorithm with a focus on early referrals to senior teams (figure 1). This audit aimed to assess adherence to this guideline. Methods Data was collected retrospectively from the general hospital database, UNITY. Paediatric admissions from March 2020 to March 2023 labeled as 'child limp' were compiled in an Excel spreadsheet. We included: children under 18, presenting via any admission route, with limping/lower limb pain and no history of trauma. The analysis focused on diagnoses at discharge and the appropriateness of the management undertaken. Results A total of 213 patients were identified, with 75 meeting the inclusion criteria. The most prevalent diagnosis on discharge was TS (52%), with other diagnoses including SUFE, Perthes, Septic arthritis, viral myositis and osteomyelitis. 49 patients received inappropriate X-RAYs which were not clinically indicated. 6 patients had inappropriate/not arranged blood tests. Blood cultures were indicated in 11 cases but only performed in one patient. There was no appropriate follow-up initiated for TS patients following discharge. Conclusion This audit reveals an overutilization of X-rays in cases of atraumatic limp in pediatric patients. Orthopaedic registrars often incorrectly await blood and X-ray results prior to reviews. Also highlighted, were cases of blood cultures and even FBC + CRP not being performed despite children presenting with fever. The results ultimately show a lack of knowledge and use of the guideline, potentially stemming from differing clinical opinion. The risks associated with radiation exposure should be clearly balanced with the benefits to the child.²Whilst unknown history of trauma does not exclude its possibility, X-rays should be used when clinically indicated, after less invasive and more effective investigations have been employed. With specific consideration to better use of blood tests and follow up guidance, the guidelines have been updated in consulta tion with the orthopaedic, paediatric and radiology team at SWBH (figure 2). Roll out during T&O and A&E handovers, coupled with digital and print distribution, aims to enhance guidelines awareness and support professionals in delivering standardised and safe patient care. A future audit will be undertaken to monitor its use. References Swarup I, et al. Septic Arthritis of the hip in children: a critical analysis review. 2020. Baysson, et al. Diagnostic radiation exposure in children and cancer risk: current knowledge and perspectives, 2012.