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Approach to a child with hip
pain
By
Mohammed Ayad
MRCPCH
Paediatric registrar in YGC
Contents of this presentation
1- Overview.
2- Causes.
3- History.
4- Examination.
5- Laboratory tests.
6- Imaging.
7- Common causes.
8- Common scenarios.
9- Take home messages.
1- Overview
Hip pain in children is not always a
simple pain of a simple pathology as it
may be caused by diseases which can
destruct the joint and cause a life long
disability.
Hip pathology may cause groin pain,
referred thigh or knee pain, refusal to
bear weight or altered gait in the
absence of pain.
The history and examination of the
child with hip pain are focused on
distinguishing between infectious,
inflammatory, orthopedic, and
neoplastic etiologies. This
distinction helps to determine the
appropriate laboratory and
radiographic evaluation.
2- Causes
1- Infections :-
septic arthritis of the hip.
Septic arthritis of the sacroiliac joint.
Lyme disease.
Appendicitis or abdominal abscess.
Psoas abscess.
2- Inflammatory
Transient synovitis.
Juvenile idiopathic arthritis.
3- Mechanical/orthopaedic
Slipped capital femoral epiphysis.
Legg-Calvé-Perthes disease.
Femoral stress fracture.
4- Neoplastic
Osteoid osteoma.
Leukemia.
Solid tumor, primary or metastatic.
5- others
Sickle cell disease crisis.
3- history
Important aspects in the history
1- age
Typical age for:
Bacterial arthritis: 0 to 6 years
Transient synovitis: 3 to 8 years
SCFE: Early adolescence
Idiopathic chondrolysis: 10 to 20 years.
2- sex
More common in males: Legg-Calvé-Perthes disease,
septic arthritis, transient synovitis, SCFE
More common in females: Idiopathic chondrolysis,
chronic recurrent multifocal osteomyelitis
Pain.
3- severity
Refusal to bear weight Septic arthritis,
osteomyelitis, malignancy, trauma, transient
synovitis; also may be due to discitis
Willing to bear weight with limp or antalgic gait:
Transient synovitis, systemic JIA, SCFE, Legg-
Calvé-Perthes disease.
Night time pain  leukaemia.
4- location
Isolated hip pain (which may be localized to the
thigh or knee): Septic arthritis, osteomyelitis,
Legg-Calvé-Perthes disease, SCFE
Pain in other joints (uncommon): Viral/postviral,
JIA.
5- systemic manifestations
*Systemic symptoms increase the likelihood of
infections, systemic arthritis, or neoplasms and
decrease the likelihood of orthopedic
conditions.
*Fever >38.5°C is associated with acute
infections, but also with acute and chronic
inflammatory processes (eg, systemic JIA,
inflammatory bowel disease) and malignancy.
*Recent upper respiratory tract infection
transient synovitis.
However viral infections may coincidentally
precede septic arthritis or trauma.
6- Family history
positive family history of inflammatory arthritis,
psoriasis, inflammatory bowel disease, or uveitis
may be associated with JIA.
4- Examination
1- Systemic examination
*Generally unwell, pale or lethargy  septic
arthritis, Leukaemia.
*looks well  Transient synovitis, post-
infectious arthritis.
*skin rash  lyme disease.
*Obesity  slipped capital femoral epiphysis.
* hepatosplenomegally leukaemia.
2- local examination
PGALS approach is excellent in examination not
only of the hip joint but to exclude any other
pathology in other joints which alter the final
diagnosis.
PGALS approach is very well illustrated in this
video
https://www.youtube.com/watch?v=CYY5fZASz8
4
3- specific hip examination
A- Inspection and palpation
*Position
partial flexion, abduction and external rotation of
the hip  septic arthritis.
*Swelling, heat, and overlying erythema rarely are
identifiable on physical examination.
*hip joint cannot be palpated directly.
*tenderness at the anterior superior iliac spine,
greater trochanter, or elsewhere along the femur
suggests a source of pain external to the hip joint.
Approach to a child with hip pain
B- Range of movement
Honestly this video is amazing and I believe it is
the second to none in showing how to do hip
joint examination.
https://www.youtube.com/watch?v=zxk6OJhsxC
g
C- Specific tests
1- FABER test ( Patrick’s test)
Approach to a child with hip pain
Approach to a child with hip pain
2- Gelazzi sign
Positive in
Legg-Calvé-Perthes disease
The child is placed in the supine position with
the hips and knees flexed. In a positive test, the
knee on the affected side is lower than the
normal side.
Approach to a child with hip pain
3-Modified Trendelenburg test
*The patient stands with feet shoulder width
apart and lifts one leg. The examiner observes
for a drop in the level of the iliac crest on the
side of the lifted le.
*2-cm drop in the level of the iliac crest,
indicating weakness on the contralateral side.
*Positive intransient synovitis, Legg-Calvé-
Perthes disease, SCFE
Approach to a child with hip pain
5- Laboratory tests
When to ask for blood tests?
It is not indicated in all patients.
It depends on the history and examination but
generally required in
Unwell children
Hip pain with high temperature
Suspecting leukaemia
Basic investigations
Needed in all children need investigations :-
Full Blood Count.
CRP and ESR.
Blood culture is needed in suspected arthritis.
RF and Anti-DNA antibodies are not routinely
recommended.
6- Imaging
Two main points
Imaging is necessary in all patients in whom
septic arthritis, skeletal injury, or tumor remains
in the differential diagnosis after history,
examination, and initial laboratory evaluation.
The need for imaging in children who present
with mild hip pain and have a normal physical
examination, normal laboratory values, and
reliable follow-up is controversial.
So conclusion is
Imaging of all children with hip pain is strongly
advisable.
The choice of the imaging study again depends on
the suspected pathology.
Common imaging study
1- Plain X Ray.
2- Ultrasound scan.
3- MRI.
4- bone scan.
1- plain x ray
Very helpful in diagnosis of
1- fractures.
2- tumors.
3- SCFE.
anteroposterior and frog-leg views are
recommended.
Approach to a child with hip pain
Osteoid osteoma
2- Ultrasound
Extremely valuable imaging study.
N.B
*Both hips should be evaluated.
*septic arthritis is almost always unilateral.
*Bilateral effusions suggest a systemic arthritic
disorder or transient synovitis.
*Ultrasonography also may be used to guide
aspiration of the hip when assaying joint fluid is
deemed appropriate.
3- MRI
MRI provides the highest resolution imaging of
the painful hip. MRI can identify marrow
changes suggestive of osteomyelitis and early
SCFE.
MRI should be ordered with gadolinium contrast
to distinguish synovitis from joint effusion.
7- COMMON CAUSES
1- Septic arthritis of the hip
Septic arthritis is a "diagnosis not to miss" in
the evaluation of a child with hip pain, given the
potential for rapid joint destruction and long-
term morbidity that can accompany delay in
diagnosis and treatment.
An early peak appears to occur in the first
months of infancy, with an overall average age
of three to six years.
Fever
Unwell
Refusal to bear weight.
N.B
Neonates and infants may present with
irritability and pseudoparalysis of the affected
limb, even without fever.
The presentation of septic arthritis may be
altered by recent use of antibiotics.
CRP and ESR .
FBC WBCs
Blood culture should be done.
Ultrasound with aspirate is crucial and usually
diagnostic.
MRI may be needed.
Antibiotics should be started as early as possible
( eg, flucloxacillin).
2- Septic arthritis of the sacroiliac
joint
presents with pain in the region of the hip.
Examination reveals that gentle hip motion is
not painful, whereas maneuvers as the FABERE
test reproduce the patient's symptoms.
3- Osteomyelitis
The diagnosis of osteomyelitis should be made
as soon as possible, because delay in treatment
increases the likelihood of a poor outcome.
Fever, pain and limited movement.
MRI is the imaging study of choice.
4- Transient synovitis
pain and limitation of motion in the hip, arising
without clear precipitant and resolving gradually
with conservative therapy.
In up to 3% of children.
Mostly in children between 3-8 years.
The male-to-female ratio is greater than 2:1.
Etiology is unclear.
Symptoms affect both hips in as many as 5
percent of cases. Even in symptomatically
unilateral disease, ultrasound can detect
bilateral effusions in 25 percent of children.
At presentation most of children have this pain
for a week.
children usually look very well however high
temperature and lethargy may be present.
Hip infection must be excluded so FBC, CRP and
ESR are needed, specially in those who are
unwell or refuse to weight bear.
If blood tests are reassuring follow up
clinically.
If abnormal blood test  ultrasound.
Management is usually conservative with NSAID
and follow up.
Prognosis is excellent.
Recurrence is in nearly 10%.
A small percentage (1 to 2 percent in most
series) may go on to develop Legg-Calvé-Perthes
disease (LCP) with avascular necrosis of the
ipsilateral femoral head.
5- Slipped capital femoral epiphysis
The mean age of presentation is 12 years in girls
and 13.5 years in boys.
Genetic predisposition.
The typical patient is an obese child in early
adolescence.
The male-to-female ratio is approximately 1.5:1.
SCFE is bilateral in 20 to 40 percent of cases.
Acute, sub acute and chronic presentation.
acute hip pain.
inability to walk.
Usually preceded by minor trauma.
months of ill-defined hip or knee symptoms and
limp, with or without an acute exacerbation.
The absence of pain, or pain localized to the
knee or thigh instead of the hip, can lead
clinicians to overlook the diagnosis.
Plain X ray ( frog position ) is diagnostic in most
cases however MRI is very sensitive in early
SCFE.
Management is operative stabilization.
6-Legg-Calvé-Perthes
peak incidence at five to seven years of age.
However common age between 3 and 12 years.
The male-to-female ratio is 3 to 4:1.
Associations with obesity, skeletal immaturity,
and lower socioeconomic status have been
reported.
Acute onset of hip pain and limping is the main
presentation.
MRI is highly sensitive.
Treatment focuses on containing the femoral
head within the acetabulum through the use of
splints or occasionally surgery.
Approach to a child with hip pain
Approach to a child with hip pain
8- Approach
1- hip pain with fever or unwell child
In this scenario septic arthritis should be the
working diagnosis until proved otherwise.
So plan should be
1- admission.
2- FBC, CRP, ESR and blood culture.
3- start IV antibiotics.
4- ultrasound.
2- well afebrile child with hip pain
If the history and examination strongly suggest
reactive arthritis or synovitis
Plain X Ray to exclude SCFE.
Discharge home with close follow up and review
after 1-2 weeks with an advice if pain worsens
or been unwell to contact.
3- Febrile but generally well child with
hip pain
**FBC, CRP and ESR.
*If abnormal results arrange urgent ultrasound
scan and treat as unwell child with hip pain.
*If results are reassuring  discharge home and
arrange non urgent ultrasound and follow up.
Choice of the best imaging study
There is a nice approach on how to choose the
imaging study you are going to ask for and how
urgent will it be
Approach to a child with hip pain
9- summary
Hip pain in children has a broad range of causes,
ranging from the benign to the potentially
devastating.
The history and examination of the child with hip
pain is focused on distinguishing between
infectious, inflammatory, orthopedic/mechanical,
and neoplastic causes. This distinction helps to
determine the appropriate laboratory and
radiographic evaluation.
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, such as
inflammatory arthritis. Abnormal findings in
other joints, in the skin, or in growth parameters
may suggest systemic disease.
The laboratory evaluation of the child with hip
pain is directed by the findings from the history
and physical examination.
Imaging is necessary in all patients in whom
septic arthritis, skeletal injury, or tumor remains
in the differential diagnosis after history,
examination, and initial laboratory evaluation.
The imaging strategy depends upon the
suspected etiology.
References
https://www.aafp.org/afp/2014/0101/p27.html
#afp20140101p27-f1
https://www.uptodate.com/contents/approach-
to-hip-pain-in-childhood
BEST WISHES
Mohammed Ayad

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Approach to a child with hip pain

  • 1. Approach to a child with hip pain By Mohammed Ayad MRCPCH Paediatric registrar in YGC
  • 2. Contents of this presentation 1- Overview. 2- Causes. 3- History. 4- Examination. 5- Laboratory tests. 6- Imaging. 7- Common causes. 8- Common scenarios. 9- Take home messages.
  • 4. Hip pain in children is not always a simple pain of a simple pathology as it may be caused by diseases which can destruct the joint and cause a life long disability. Hip pathology may cause groin pain, referred thigh or knee pain, refusal to bear weight or altered gait in the absence of pain.
  • 5. The history and examination of the child with hip pain are focused on distinguishing between infectious, inflammatory, orthopedic, and neoplastic etiologies. This distinction helps to determine the appropriate laboratory and radiographic evaluation.
  • 7. 1- Infections :- septic arthritis of the hip. Septic arthritis of the sacroiliac joint. Lyme disease. Appendicitis or abdominal abscess. Psoas abscess.
  • 8. 2- Inflammatory Transient synovitis. Juvenile idiopathic arthritis. 3- Mechanical/orthopaedic Slipped capital femoral epiphysis. Legg-Calvé-Perthes disease. Femoral stress fracture.
  • 9. 4- Neoplastic Osteoid osteoma. Leukemia. Solid tumor, primary or metastatic. 5- others Sickle cell disease crisis.
  • 11. 1- age Typical age for: Bacterial arthritis: 0 to 6 years Transient synovitis: 3 to 8 years SCFE: Early adolescence Idiopathic chondrolysis: 10 to 20 years. 2- sex More common in males: Legg-Calvé-Perthes disease, septic arthritis, transient synovitis, SCFE More common in females: Idiopathic chondrolysis, chronic recurrent multifocal osteomyelitis Pain.
  • 12. 3- severity Refusal to bear weight Septic arthritis, osteomyelitis, malignancy, trauma, transient synovitis; also may be due to discitis Willing to bear weight with limp or antalgic gait: Transient synovitis, systemic JIA, SCFE, Legg- Calvé-Perthes disease. Night time pain  leukaemia.
  • 13. 4- location Isolated hip pain (which may be localized to the thigh or knee): Septic arthritis, osteomyelitis, Legg-Calvé-Perthes disease, SCFE Pain in other joints (uncommon): Viral/postviral, JIA.
  • 14. 5- systemic manifestations *Systemic symptoms increase the likelihood of infections, systemic arthritis, or neoplasms and decrease the likelihood of orthopedic conditions. *Fever >38.5°C is associated with acute infections, but also with acute and chronic inflammatory processes (eg, systemic JIA, inflammatory bowel disease) and malignancy.
  • 15. *Recent upper respiratory tract infection transient synovitis. However viral infections may coincidentally precede septic arthritis or trauma. 6- Family history positive family history of inflammatory arthritis, psoriasis, inflammatory bowel disease, or uveitis may be associated with JIA.
  • 17. 1- Systemic examination *Generally unwell, pale or lethargy  septic arthritis, Leukaemia. *looks well  Transient synovitis, post- infectious arthritis. *skin rash  lyme disease. *Obesity  slipped capital femoral epiphysis. * hepatosplenomegally leukaemia.
  • 18. 2- local examination PGALS approach is excellent in examination not only of the hip joint but to exclude any other pathology in other joints which alter the final diagnosis. PGALS approach is very well illustrated in this video https://www.youtube.com/watch?v=CYY5fZASz8 4
  • 19. 3- specific hip examination A- Inspection and palpation *Position partial flexion, abduction and external rotation of the hip  septic arthritis. *Swelling, heat, and overlying erythema rarely are identifiable on physical examination. *hip joint cannot be palpated directly. *tenderness at the anterior superior iliac spine, greater trochanter, or elsewhere along the femur suggests a source of pain external to the hip joint.
  • 21. B- Range of movement Honestly this video is amazing and I believe it is the second to none in showing how to do hip joint examination. https://www.youtube.com/watch?v=zxk6OJhsxC g
  • 22. C- Specific tests 1- FABER test ( Patrick’s test)
  • 25. 2- Gelazzi sign Positive in Legg-Calvé-Perthes disease The child is placed in the supine position with the hips and knees flexed. In a positive test, the knee on the affected side is lower than the normal side.
  • 27. 3-Modified Trendelenburg test *The patient stands with feet shoulder width apart and lifts one leg. The examiner observes for a drop in the level of the iliac crest on the side of the lifted le. *2-cm drop in the level of the iliac crest, indicating weakness on the contralateral side. *Positive intransient synovitis, Legg-Calvé- Perthes disease, SCFE
  • 30. When to ask for blood tests? It is not indicated in all patients. It depends on the history and examination but generally required in Unwell children Hip pain with high temperature Suspecting leukaemia
  • 31. Basic investigations Needed in all children need investigations :- Full Blood Count. CRP and ESR. Blood culture is needed in suspected arthritis. RF and Anti-DNA antibodies are not routinely recommended.
  • 33. Two main points Imaging is necessary in all patients in whom septic arthritis, skeletal injury, or tumor remains in the differential diagnosis after history, examination, and initial laboratory evaluation. The need for imaging in children who present with mild hip pain and have a normal physical examination, normal laboratory values, and reliable follow-up is controversial.
  • 34. So conclusion is Imaging of all children with hip pain is strongly advisable. The choice of the imaging study again depends on the suspected pathology. Common imaging study 1- Plain X Ray. 2- Ultrasound scan. 3- MRI. 4- bone scan.
  • 35. 1- plain x ray Very helpful in diagnosis of 1- fractures. 2- tumors. 3- SCFE. anteroposterior and frog-leg views are recommended.
  • 38. 2- Ultrasound Extremely valuable imaging study. N.B *Both hips should be evaluated. *septic arthritis is almost always unilateral. *Bilateral effusions suggest a systemic arthritic disorder or transient synovitis. *Ultrasonography also may be used to guide aspiration of the hip when assaying joint fluid is deemed appropriate.
  • 39. 3- MRI MRI provides the highest resolution imaging of the painful hip. MRI can identify marrow changes suggestive of osteomyelitis and early SCFE. MRI should be ordered with gadolinium contrast to distinguish synovitis from joint effusion.
  • 41. 1- Septic arthritis of the hip Septic arthritis is a "diagnosis not to miss" in the evaluation of a child with hip pain, given the potential for rapid joint destruction and long- term morbidity that can accompany delay in diagnosis and treatment. An early peak appears to occur in the first months of infancy, with an overall average age of three to six years.
  • 42. Fever Unwell Refusal to bear weight. N.B Neonates and infants may present with irritability and pseudoparalysis of the affected limb, even without fever. The presentation of septic arthritis may be altered by recent use of antibiotics.
  • 43. CRP and ESR . FBC WBCs Blood culture should be done. Ultrasound with aspirate is crucial and usually diagnostic. MRI may be needed. Antibiotics should be started as early as possible ( eg, flucloxacillin).
  • 44. 2- Septic arthritis of the sacroiliac joint presents with pain in the region of the hip. Examination reveals that gentle hip motion is not painful, whereas maneuvers as the FABERE test reproduce the patient's symptoms.
  • 45. 3- Osteomyelitis The diagnosis of osteomyelitis should be made as soon as possible, because delay in treatment increases the likelihood of a poor outcome. Fever, pain and limited movement. MRI is the imaging study of choice.
  • 46. 4- Transient synovitis pain and limitation of motion in the hip, arising without clear precipitant and resolving gradually with conservative therapy. In up to 3% of children. Mostly in children between 3-8 years. The male-to-female ratio is greater than 2:1. Etiology is unclear.
  • 47. Symptoms affect both hips in as many as 5 percent of cases. Even in symptomatically unilateral disease, ultrasound can detect bilateral effusions in 25 percent of children. At presentation most of children have this pain for a week. children usually look very well however high temperature and lethargy may be present.
  • 48. Hip infection must be excluded so FBC, CRP and ESR are needed, specially in those who are unwell or refuse to weight bear. If blood tests are reassuring follow up clinically. If abnormal blood test  ultrasound. Management is usually conservative with NSAID and follow up.
  • 49. Prognosis is excellent. Recurrence is in nearly 10%. A small percentage (1 to 2 percent in most series) may go on to develop Legg-Calvé-Perthes disease (LCP) with avascular necrosis of the ipsilateral femoral head.
  • 50. 5- Slipped capital femoral epiphysis The mean age of presentation is 12 years in girls and 13.5 years in boys. Genetic predisposition. The typical patient is an obese child in early adolescence. The male-to-female ratio is approximately 1.5:1. SCFE is bilateral in 20 to 40 percent of cases.
  • 51. Acute, sub acute and chronic presentation. acute hip pain. inability to walk. Usually preceded by minor trauma. months of ill-defined hip or knee symptoms and limp, with or without an acute exacerbation. The absence of pain, or pain localized to the knee or thigh instead of the hip, can lead clinicians to overlook the diagnosis.
  • 52. Plain X ray ( frog position ) is diagnostic in most cases however MRI is very sensitive in early SCFE. Management is operative stabilization.
  • 53. 6-Legg-Calvé-Perthes peak incidence at five to seven years of age. However common age between 3 and 12 years. The male-to-female ratio is 3 to 4:1. Associations with obesity, skeletal immaturity, and lower socioeconomic status have been reported.
  • 54. Acute onset of hip pain and limping is the main presentation. MRI is highly sensitive. Treatment focuses on containing the femoral head within the acetabulum through the use of splints or occasionally surgery.
  • 58. 1- hip pain with fever or unwell child In this scenario septic arthritis should be the working diagnosis until proved otherwise. So plan should be 1- admission. 2- FBC, CRP, ESR and blood culture. 3- start IV antibiotics. 4- ultrasound.
  • 59. 2- well afebrile child with hip pain If the history and examination strongly suggest reactive arthritis or synovitis Plain X Ray to exclude SCFE. Discharge home with close follow up and review after 1-2 weeks with an advice if pain worsens or been unwell to contact.
  • 60. 3- Febrile but generally well child with hip pain **FBC, CRP and ESR. *If abnormal results arrange urgent ultrasound scan and treat as unwell child with hip pain. *If results are reassuring  discharge home and arrange non urgent ultrasound and follow up.
  • 61. Choice of the best imaging study There is a nice approach on how to choose the imaging study you are going to ask for and how urgent will it be
  • 64. Hip pain in children has a broad range of causes, ranging from the benign to the potentially devastating. The history and examination of the child with hip pain is focused on distinguishing between infectious, inflammatory, orthopedic/mechanical, and neoplastic causes. This distinction helps to determine the appropriate laboratory and radiographic evaluation.
  • 65. 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, such as inflammatory arthritis. Abnormal findings in other joints, in the skin, or in growth parameters may suggest systemic disease.
  • 66. The laboratory evaluation of the child with hip pain is directed by the findings from the history and physical examination. Imaging is necessary in all patients in whom septic arthritis, skeletal injury, or tumor remains in the differential diagnosis after history, examination, and initial laboratory evaluation. The imaging strategy depends upon the suspected etiology.