The Limping Child and Hip Pain Patrick J. Maloney, MDDenver Emergency Center for Children Denver Health Medical Center
Evaluation of the LimpingChild or Child w/ Hip pain Clinical History Circumstances surrounding the limp Trauma, pain, associated systemic symptoms/illness Physical Exam Localize source of pain Abdominal and genitourinary exam Laboratory and Radiologic Studies Tailored to findings in history and physical exam
Evaluation of the Limping Child Physical Exam Flexed, abducted, externally rotated hip = fluid in hip joint capsule
Evaluation of the LimpingChild Physical Exam Passive ROM of the hip
Evaluation of the LimpingChild Trauma is the most common cause in all age groups Acute or repetitive Oftentimes, parents will endorse minor trauma as cause of limp Coincidence or Causation?
Differential Diagnosis forNon-Traumatic Limp Transient Synovitis Septic Arthritis Legg-Calve-Perthes disease (Avascular Necrosis of the Capital Femoral Epiphysis) Slipped capital femoral epiphysis (SCFE) Other Peripelvic Pyomyositis Osteomyelitis Tumor/Leukemia Occult Fracture (e.g. Toddler’s Fx)
Case 1 A 5-year-old boy presents with a 4-week history of limp that has worsened progressively. There are no significant findings on the past medical history. He has not been ill recently. There is not history of trauma. Physical examination reveals a decreased range of motion of the left hip and an obvious limp with walking.What is the MOST likely etiology of this child’s limp?
Legg-Calve-Perthes Disease Avascular necrosis of the capital femoral epiphysis Most common between 4-10 years of age. Male:Female is 4:1 Child may complain of pain in hip, thigh or knee. often insidious and can lead to disuse of affected limb Xray findings are pathopnomonic
Legg-Calve-Perthes Disease 4 distinct radiographic stages Synovitis/Necrosis: Initial joint space widening and irregularity of the physis. Ischemia of the epiphysis resulting in dead bone. Ave age 5.6 years Fragmentation: Fracturing of the weakened demineralized epiphysis. Epiphysis may collapse resulting in a shortened limb. Ave age 6.1 years Re-ossification: Begins at the margins of the epiphysis. Ave age 7 years Remodeling: Newly formed head is soft. At risk for poor prognosis if not allowed to heal. Ave age 9.1 years MRI better at detecting early disease
Legg-Calve-Perthes Disease Treatment 50% recover without treatment Goal: maintain femoral head within the acetabulum Abduction splints/casts and non-weight bearing state Surgically with an osteotomy of the proximal femur Prognostic factors Better Prognosis Younger (<6y) <50% epiphyseal necrosis Worse Outcome Obesity
Case 2 A 6 year-old boy presents with a 3-day history of a limp. He has had a URI for 1 week. There is no history of trauma. On physical examination, his temp is 100.4 F (38C), he does not bear weight on the right leg, and there is decreased ROM at the right hip. WBC count is 8,000, and the ESR is 20 mm/hr. What is the MOST likely etiology of this child’s pain?
Transient Synovitis Also called “toxic synovitis” or “irritable hip” Most common cause of non-traumatic hip pain in children Accounts for 30-40% of all non-traumatic limps Occurs in children 2-6 years old typically <4 years old Associated with recent URI in 32-50% of cases Male:Female is > 2:1 Almost always unilateral
Transient Synovitis Benign, self-limited disorder Sterile inflammation of the synovium of the joint With or without a joint effusion Unclear etiology (? Post-viral)
Transient Synovitis Clinical History Acute onset of pain and limited ROM of the hip Limp or refusal to bear weight Physical Exam Hip is flexed and externally rotated mildly decreased ROM Afebrile/low-grade fever (<38.5) Laboratory Normal WBC (<12,000) Normal or mildly elevated CRP (<2) and ESR (<40)
Transient Synovitis X-Ray Most commonly normal Joint space widening (joint effusion) Ultrasound Joint effusion and/or synovial swelling
Transient SynovitisTreatment Rest; weight bear as tolerated Ibuprofen Decreased pain vs Placebo (2d vs. 4.5d) 80% of all patients with resolution by 7 days Prognosis Generally good Recurrence in 4-15% have been reported So why is it important to make the diagnosis of transient synovitis?Annals of Emergency Medicine 2002; 40:3:297
Case 3 A 6-month-old female infant presents to you with fever to 102°F (38.9°C), poor feeding, and decreased activity for 5 days. Her mother has noted that over the last 7 days she cries whenever her diaper is changed, and for the last 2 days she has refused to move her left leg. On physical examination, you note a febrile infant who cries with passive movement of the left leg.What is the MOST likely etiology of this child’s leg pain?
Septic Arthritis True Orthopedic emergency Single most important prognostic factor for a good outcome is early treatment!!! Results from bacterial invasion into the joint space Most commonly hematogenous spread Contiguous spread from neighboring osteomyelitis Direct inoculation from penetrating wound Can occur at any age but >50% of cases are in children <3 years old Hip is most commonly affected joint in children
Septic Arthritis Organisms Staphycoccus aureus (most common) Streptococcus species Strep pneumoniae Strep pyogenes Group B Strep (neonates) Haemophilus Influenzae Neisseria gonorrhea (adolescents) Salmonella (sickle cell disease) Gran negative bacilli (neonates) Acute inflammatory response (TNF-α, IL-1, proteases destroy the articular cartilage Continues after eradication of the bacteria
Diagnosis may be very difficultSeptic Arthritis occur in children Usually previously healthy children <5 years (>50% of cases <3 years) Early peak in the first months of infancy 1/3 w/ URI’s within the past month Usually temp > 38.5
Septic Arthritis Physical Exam DOES NOT present with erythema, warmth or swelling (hip) Hip is usually held in flexion, external rotation, abduction Usually very painful ROM
Septic Arthritis Joint Aspiration is definitive diagnosis Cloudy, turbid WBC count >50,000; predominantly PMNs Glucose levels < ½ of serum 50% positive gram stain 50-70% with positive culture
Septic Arthritis Joint Aspiration Performed under ultrasound guidance Usually needs procedural sedation Complications iatrogenic infection Bleeding neurovascular injury
Septic Arthritis Other Diagnostic Tests WBC: elevated with left shift (>12,000) ESR: elevated (>40) CRP: elevated (>2) Xray: may show wide joint space (effusion) late findings (10 days): osteopenia, joint narrowing, soft tissue swelling Ultrasound: may demonstrate joint effusion early in disease MRI: helps evaluate for abscess and/or osteomyelitis
Septic Arthritis vs TransientSynovitis Kocher et al. Journal Caird et al. Journal of of Bone and Joint Bone and Joint Surgery. 1999 Surgery. 2006 Boston Children’s CHOP Prospective study Retrospective study 53 patients who all had hip Risk Factors aspiration WBC >12,000/mm3 Risk Factors ESR >40 mm/hr WBC >12,000/mm3 Temp >38.5 Oral ESR >40 mm/hr Refusal to bear weight CRP >2 mg/dL Temp >38.5 Oral Refusal to bear weight
Septic Arthritis vs Transient Synovitis PPV of Septic Arthritis # of Caird et al Kocher et alfactors Fever (>38.5 C) was best 0 16.9 0.2 predictive factor 1 36.7 3 CRP >2mg/dL was only other independent risk factor 2 62.4 40 Caveat: 3 82.6 93.1 studies evaluated children 4 93.1 99.6 with high clinical suspicion for septic arthritis 5 97.5 N/A
Septic Arthritis Treatment Joint drainage (“wash-out”) IV antibiotics for 2-4 weeks <2 months: Nafcillin + Gentamicin >2 months: Ceftriaxone +/- Vancomycin• Prognosis: risk of avascular necrosis • Good outcome Initiation of treatment within 4 days of symptom onset • Poor outcome Initiation of treatment after 5 or more days Severe joint destruction: osteonecrosis
Case 4• A 14 year-old boy presents to your office for evaluation of low-grade, diffuse knee pain on the right. On exam you have the child stand on the right leg and notice that he has a mild downward tilt of the pelvis to the left. What is the most likely etiology of his knee pain?
Slipped Capital Femoral Epiphysis (SCFE) An acquired growth plate injury (Salter-Harris I) Separation of the proximal femoral epiphysis from the metaphysis Most commonly occurs in adolescents and preadolescents 81% BMI >95th Percentile Peak age is 10-13y in females and 12-16y in males Overweight boys Rare after menarche African Americans and Pacific Islanders >> Caucasian and Hispanics Associated with endocrinopathies (growth hormone deficiency) in 8%
Slipped Capital FemoralEpiphysis Clinical History Preceding history of trauma with acute pain/limp common Subacute or chronic pain with insidious onset that can be referred to the hip or knee Pain increased with physical activity May be able to bear weight if stable Examination Hips is slightly flexed and externally rotated Often unable to fully flex hip Limited internal rotation and abduction of the hip Limited passive ROM secondary to pain Bilateral in up to 30%
Slipped Capital FemoralEpiphysis Radiography X-ray of both hips AP, Lateral, and Frog-Leg Views “Ice Cream falling off Cone”
Slipped Capital FemoralEpiphysis
Slipped Capital FemoralEpiphysis Klein’s Line Line drawn along the posterior aspect of the femoral neck Normal Abnormal
Slipped Capital FemoralEpiphysis Treatment Strict non-weight bearing to prevent further slip Occasionally may discharge on crutches Surgical fixation Screw fixation under flouroscopy Some prophylactically fix contralateral hip as well Osteotomy may be necessary for advanced slippage
Slipped Capital Femoral Epiphysis 25-40% have bilateral SCFEs Contralateral slip usually occurs within 6-12 months of index side Prognosis Usually good prognosis (stable and chronic slips) Increased risk of subsequent acute chondrolysis, avascular necrosis, and premature hip arthritis
Other Etiologies of Limp Peripelvic Pyomyositis Osteomyelitis Occult Fractures (Toddler’s Fx) Tumors Leukemia Deep Muscle Hematomas/Abscesses Abdominal and Genitourinary Dx