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Approach to hip joint pain in childhood
- 1. Approach to Hip Joint Pain in Childhood
- 2. Hip Joint Anatomy The hip joint is a ball-and-socket synovial joint: the ball is the femoral head, and the socket is the acetabulum. The hip joint is the articulation of the pelvis with the femur, which connects the axial skeleton with the lower extremity
- 3. Hip Bone Anatomy Hip bone, is formed by the fusion of the ilium, the ischium, and the pubis, which occurs by the end of the teenage years.
- 4. Femoral Bone Anatomy The superior end of the femur consists of a head, a neck, and greater and lesser trochanters. The head of the femur is angled superomedially and slightly anteriorly when articulating with the acetabulum.
- 7. Approach to Hip Pain in Childhood Hip pain is common in children and adolescents and has a broad range of causes, ranging from the benign to the potentially devastating. The history and examination of the child with hip pain are focused on distinguishing between infectious, inflammatory, orthopedic, and neoplastic etiologies.
- 8. Infectious – Infectious pain is usually acute, localized, and severe (eg, refuses to bear weight); it is generally accompanied by fever, elevated white blood cell (WBC) count, and elevated erythrocyte sedimentation rate (ESR) and C- reactive protein (CRP) Inflammatory – Inflammatory pain typically is chronic or has insidious onset (with the exception of transient synovitis, which has acute onset); may be accompanied by other findings (eg, rash, nail pits, uveitis), involve joints other than the hip, and recur; refusal to bear weight is uncommon Orthopedic – Pain is usually localized to the hip but may be referred to the thigh or knee; may have acute or insidious onset; pain increases with activity and decreases with rest; systemic symptoms are absent; ESR and CRP are usually normal Neoplastic – Pain is characteristically worse at night and unrelated to activity; may be associated with systemic symptoms and laboratory abnormalities (eg, anemia, leukopenia, thrombocytopenia, elevated lactate dehydrogenase or uric acid)
- 9. Pain from true hip pathology is typically experienced in the groin, though children and even adults may localize the pain to the thigh or knee. Pain that alters function (limp, alteration in activities) should be explored fully, whereas transient or fleeting hip pains are typically of limited significance. Important aspects of the history in the child with hip pain include the age and sex of the child (table 3); the onset, duration, severity, and location of the pain; associated systemic symptoms; past medical history; family history; and social history Acute onset of hip pain, particularly when it is severe, is associated with infectious processes (eg, septic arthritis, Lyme disease, bacterial osteomyelitis), transient synovitis, and trauma. Hip pain of insidious onset is more likely to be caused by slipped capital femoral epiphysis (SCFE), Legg- Calvé-Perthes disease (LCP), or juvenile idiopathic arthritis (JIA, formerly juvenile rheumatoid arthritis).
- 10. Severe pain (eg, refusal to bear weight) typically is caused by acute infections (eg, septic arthritis, osteomyelitis), malignancy (eg, leukemia, osteosarcoma), and trauma (eg, fracture). Less severe pain (eg, limps, but willing to bear weight) is more characteristic of transient synovitis, JIA,LCP, or SCFE. A history of previous episodes of similar symptoms in the same or contralateral hip increases the likelihood of JIA, in particular psoriatic JIA, or transient synovitis, which has a recurrence rate of up to 15 percent Conditions that affect the hip alone (eg, SCFE,LCP) are unlikely if the patient has joint pain at other sites. JIA rarely presents with isolated hip involvement. Recent upper respiratory tract infection may suggest transient synovitis but is nonspecific; viral infections are common in children and also may coincidentally precede septic arthritis or trauma The recent use of antibiotics can alter the presentation of septic arthritis or osteomyelitis.
- 11. A positive family history of inflammatory arthritis, psoriasis, inflammatory bowel disease, or uveitis may be associated with JIA. Avid sports participation, a fall, or other injury suggests traumatic hip pain. However, minor trauma occurs commonly in childhood, and initial symptoms of inflammatory or malignant disease often are attributed to an incidental injury. Sexual activity may suggest infectious (eg, gonococcal) or reactive (eg, Chlamydia trachomatis) arthritis; however involvement of the hip is unusual.
- 12. The examination of the child with hip pain is targeted to determine whether the pain is coming from inside or outside the hip joint and whether it is an isolated problem or a manifestation of a systemic condition. Observation The examiner should look for asymmetry of the pelvis, thighs, and knees. The position in which the femur and pelvis are held should be noted; partial flexion and external rotation of the hip may indicate increased intraarticular pressure. Palpation The hip joint cannot be palpated directly, but tenderness at the anterior superior iliac spine, greater trochanter, or elsewhere along the femur suggests a source of pain external to the hip joint. Range of motion Range of motion should be evaluated in both the supine and prone position. The pelvis should be stabilized as much as possible during examination of range of motion Ability to bear weight The inability to bear weight is a sign of serious pathology until proven otherwise. Children who are unable to bear weight should not be sent home until a diagnosis is made and therapy instituted.
- 13. Septic Arthritis Children with septic arthritis generally present with an acute onset of joint pain, limited movement and fever. Limping or non-weight bearing is typical in lower limb joints. Male Ill-appearing Irritability and Pseudoparalysis Weight-bearing and motion of the affected hip are quite painful and strongly resisted in all patients Fever > 38.5°C Refusal to bear weight within the week before presentation (ESR) > 40 mm/h C-reactive protein (CRP) >2 mg/dL (20 mg/L) Peripheral white blood cell (WBC) count > 12,000 cells/microL
- 14. Diagnosis Diagnosis is confirmed by ultrasound-guided aspiration of inflammatory hip fluid with identification of a causative organism by blood or synovial fluid culture. Treatment Therapy consists of urgent and, in some cases, repeated drainage to avoid buildup of intraarticular pressure that may impede local blood flow, and administration of parenteral antibiotics.
- 15. Congenital Coxa Vara Coxa vara includes all forms of decrease of the femoral neck-shaft angle to less than 120-135° The term congenital coxa vara has been applied to two types of coxa vara seen in infancy and childhood. The first type is present at birth, is rare, and is associated with other congenital anomalies, such as proximal femoral focal deficiency. The second type, usually not discovered until the child is walking, is more common than the first and is associated with no other abnormality. Coxa vara, often bilateral, is characterized by a progressive decrease in the angle between the femoral neck and shaft, a progressive shortening of the limb. CCV has characteristic clinical and radiographic features that help differentiate it from other forms of coxa vara. It is commonly associated with a significant limb-length discrepancy.
- 17. Presentation Patients who have congenital coxa vara (CCV) usually present with gait abnormalities. Affected children generally present between the time they begin ambulation and age 6 years. In most patients, the gait abnormality is progressive and, notably, pain free. Unilateral involvement with an associated relative limb-length discrepancy and Trendelenburg limp may be noted. This discrepancy in limb lengths usually is mild, ranging from 1.5 to 4.0 cm.
- 18. Treatment A large percentage of patients with congenital coxa vara (CCV) will require surgical intervention. Treatment of CCV is contraindicated in children who demonstrate any of the following: Lack of symptoms on clinical assessment Radiographs showing a Hilgenreiner epiphyseal angle (HEA) of less than 45° Radiographs showing an HEA of 45-60° with no documented progression In such situations, close clinical and radiographic follow-up is warranted.
- 19. Medical therapy Many forms of nonoperative treatment have been proposed for CCV, including spica cast immobilization and skeletal pin traction with bed rest, with generally unsatisfactory results. It is generally accepted that no place remains for conservative nonoperative measures for individuals who require treatment of either symptomatic or progressive CCV.
- 20. Hilgenreiner Epiphyseal angle Weinstein et al proposed a radiologic means of quantifying CCV. [16] This measure, the HEA, is the angle subtended by the horizontal Hilgenreiner line through the triradiate cartilages and an oblique line through the proximal femoral capital physes (see the image below). A study of normal values of the HEA found that the angle in children younger than 7 years averages 20°, with a wide variation of 4-35°. The mean value for those aged 8 years to maturity is 23°.
- 22. Surgical Therapy The treatment of choice for correction of developmental coxa vara is subtrochanteric osteotomy to place the femoral neck and head in an appropriate valgus position with the shaft of the femur. Surgery can be delayed until the child is 4 or 5 years old to make internal fixation easier. Surgical treatment is indicated when coxa vara deformity is progressive, painful, unilateral, or associated with leg-length discrepancy or when the Hilgenreiner-epiphyseal (H-E) angle is greater than 60 degrees. Surgery also is indicated when the neck-shaft angle is 110 degrees or less. Regardless of the method of osteotomy, the deformity can recur, so children should be examined periodically after surgery until their growth is complete.
- 23. Transient Synovitis Transient synovitis (TS) is the most common cause of acute hip pain in children aged 3-10 years. The disease causes arthralgia and arthritis secondary to a transient inflammation of the synovium of the hip.
- 24. Presentation Unilateral hip or groin pain is the most common symptom reported; however, some patients with transient synovitis (TS) may report medial thigh or knee pain. Very young children with transient synovitis may have no symptoms other than crying at night Recent history of an upper respiratory tract infection, pharyngitis, bronchitis, or otitis media is elicited from approximately half of patients with transient synovitis. A prospective study from the University of Edinburgh Medical School reported that the symptoms of vomiting, diarrhea, or common cold/runny nose were more likely to precede transient synovitis. Other symptoms suggestive of either viral or bacterial infections were not significantly prominent. Children with transient synovitis are usually afebrile or have a mildly elevated temperature; high fever is rare. Some patients with transient synovitis may not report pain and may present with only a limp. Male to Female Ratio is 2:1
- 25. Treatment The management of transient synovitis is conservative, with the use of nonsteroidal anti-inflammatory drugs and return to full activity as tolerated Recurrence rates from 4 to 15 percent have been reported
- 26. Juvenile Idiopathic Arthritis Juvenile rheumatoid arthritis (JRA) is the most common chronic rheumatologic disease in children and is one of the most common chronic diseases of childhood.
- 27. Sign and Symptoms Arthritis present for at least 6 weeks before diagnosis Either insidious or abrupt disease onset, often with morning stiffness or gelling phenomenon and arthralgia during the day Complaints of joint pain or abnormal joint use History of school absences or limited ability to participate in physical education classes Spiking fevers occurring once or twice each day at about the same time of day Evanescent rash on the trunk and extremities Psoriasis or more subtle dermatologic manifestations
- 28. Treatment Because of the success of medical therapy in the treatment of juvenile idiopathic arthritis, surgical treatment is infrequently needed. Pharmacologic therapy with nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), biologic agents, or intra-articular and oral corticosteroids Psychosocial interventions including counseling for patients and parents Measures to enhance school performance Improved nutrition Physical therapy to relieve pain and to address range of motion, muscle strengthening, activities of daily living, and conditioning exercises Occupational therapy including joint protection, a program to relieve pain, range of motion, and attention to activities of daily living
- 29. Legg-Calvé-Perthes disease Legg-Calvé-Perthes disease (LCPD) is avascular necrosis (AVN) of the proximal femoral head resulting from compromise of the tenuous blood supply to this area. LCPD usually occurs in children aged 4-10 years. The disease has an insidious onset and may occur after an injury to the hip. Differentiating an irritable hip with transient synovitis from the acute symptoms of Legg-Calvé-Perthes disease can be difficult. Distinguishing characteristics involve the sex and age of the patient and the duration of symptoms. Irritable hip syndrome occurs twice as frequently in boys as in girls, whereas Legg-Calvé-Perthes disease occurs three times more frequently in boys than in girls. The average age of patients with irritable hips is 3 years, and the average age of patients with Legg-Calvé-Perthes disease is 7 years. Children with irritable hips have an average duration of symptoms of 6 days, whereas children with Legg-Calvé-Perthes disease have symptoms present for an average of 6 weeks.
- 30. Presentation Clinical features of LCP includes insidious onset of hip pain with limp and activity-related pain Pain may be present with passive range of motion and limited hip movement, especially internal rotation and abduction. Children with LCPD can have a Trendelenburg gait resulting from pain in the gluteus medius.
- 31. Treatment Consultation with an orthopedist is recommended. Goals in the treatment of Legg-Calvé-Perthes disease (LCPD) include the following: Eliminating hip irritability Restoring and maintaining good range of motion in the hip Preventing femoral epiphyseal collapse Attaining a spherical femoral head when the hip heals Initial therapy includes minimal weightbearing and protection of the joint, which is accomplished by maintaining the femur abducted and internally rotated so that the femoral head is held well inside the rounded portion of the acetabulum. Abduction and rotation of the femur are accomplished by means of either the use of orthotic devices (bracing) or surgery (osteotomy). The Scottish Rite brace achieves containment by abduction while allowing free knee motion.
- 33. Slipped Capital Femoral Epiphysis In Slipped Capital Femoral Epiphysis(SCFE) the femoral epiphysis slips posteriorly, resulting in a limp and impaired internal rotation.
- 34. Presentation The typical patient is an obese child in early adolescence. The mean age of presentation is 12 years in girls and 13.5 years in boys. The Male to Female Ratio is 1.5:1 SCFE is bilateral in 20 to 40 percent of cases. Acute hip pain Inability to walk Patients often hold their affected hip in passive external rotation. Simultaneous external rotation and abduction of the hip during hip flexion.
- 35. Treatment The ideal treatment of SCFE would restore the biomechanics of the hip, prevent additional slipping of the epiphysis, and stimulate early physeal closure while avoiding the complications of osteonecrosis, chondrolysis, and osteoarthritis. Stabilization of the slip and closure of the physis are relatively easy to obtain by a variety of methods; however, restoration of hip biomechanics and prevention of complications has proved more difficult. Methods of operative treatment of SCFE have included percutaneous and open in situ pinning, ORIF, epiphysiodesis, osteotomy, and reconstruction by arthroplasty, arthrodesis, or cheilectomy. Each technique has its proponents and opponents, and the choice of treatment must be individualized for each child, depending on age, type of slip, and severity of displacement.
- 36. Osteoid Osteoma Osteoid Osteoma is a relatively common benign bone tumor. The proximal femur is the most common site of occurrence. Osteoid Osteoma may occur in all age groups, however most patients present in the teenage years.
- 37. Presentation The typical patient with an osteoid osteoma has pain that is worse at night and is relieved by aspirin or other nonsteroidal anti inflammatory medications. Increased levels of cyclooxygenases and prostaglandins have been demonstrated in the lesions. When the lesion is near a joint, swelling, stiffness, and contracture may occur. The pain is typically nocturnal and aching.
- 38. Treatment Medical therapy Initial treatment of osteoid osteoma remains nonoperative, with medications consisting of aspirin or other NSAIDs. Surgical therapy Surgical intervention is generally indicated for patients whose pain is unresponsive to medical therapy, those who cannot tolerate prolonged use of nonsteroidal anti- inflammatory drugs (NSAIDs), and those who are not amenable to activity restrictions.