An 8-year-old has a painful limp with knee pain medially and hip internal rotation pain. How should the NP manage this?

• A. The NP should order a hip X-ray, CBC and ESR
• B. The NP should order a hip and knee X-ray
• C. He should be referred for synovial fluid aspiration
• D. The NP should be immediately referred to orthopedics

Answer: (A)

The important idea is that a child’s limp with knee pain can actually originate from a problem in the hip, so you start by evaluating the hip with appropriate imaging and basic labs. An 8-year-old with hip problems often presents with referred knee pain and limited hip motion, so focusing on the hip helps avoid missing conditions that require specific treatment.

Obtaining a hip radiograph is key to looking for conditions that classically affect school‑age children, such as Perthes disease, slipped capital femoral epiphysis risk, effusion, or fractures. Pairing that with CBC and ESR helps distinguish infectious or inflammatory processes from more benign etiologies. A septic hip, for example, would often raise ESR and possibly the white cell count, and would push you toward faster, more urgent intervention, including possible joint aspiration or orthopedic involvement. But you don’t jump straight to invasive steps without first establishing whether the infection is a concern; initial imaging and labs guide the next move.

So the best first steps are to image the hip and check inflammatory/infectious markers. If there are red flags (fever, inability to bear weight, marked joint intolerance, very high inflammatory markers), you escalate appropriately to aspiration or urgent specialty care.