This document discusses the evaluation and differential diagnosis of hip pain in children. It outlines the key steps as obtaining a thorough history, conducting a physical exam, ordering relevant lab tests and imaging studies, and providing follow up care. The differential diagnosis for hip pain in children can include traumatic injuries, infections like septic arthritis, inflammatory conditions such as Legg-Calve-Perthes disease, and vascular causes like osteonecrosis. Joint aspiration is an important diagnostic tool to differentiate between potential infectious and non-infectious causes.

1. Evaluation
of Hip Pain in Children
Dr. Rashed AL Qudhaya

2. Educational Objectives
• Differential diagnosis.
• Evidence-based work up.
• Initial management steps for various causes.

3. Case Presentation
• 8y/F.
• 2d worsening hip & thigh pain, 1st time.
• No trauma.
• Stopped playing e friends.
• Walks few steps then sits down.

4. Case Presentation
• No fever now.
• 10d ago streptococcal pharyngitis e fever.
• No insect bite or rashes.
• No other joint C/O.
• Normal milestones & immunizations.

5. Differential Diagnosis

6. Differential Diagnosis

7. How do you approach the Clinical evaluation of this
patient?
History.
Clinical Examination
Laboratory work up.
Radiological studies
follow up

8. History
Obtaining a thorough history can be
the most important part of the evaluation.

9. History
History of PAIN includes the 10
characters.

10. History
• S Site
R Radiation
M Mode of onset
S Severity
N Nature
D Duration
A Aggravating
R Relieving
AS Associated Symptoms

11. History
Always remember the fact
‘‘Knee pain equals hip pain’’
This referred pain is thought to be
a consequence of Hilton’s Law.

12. History
Hilton’s Law
Any nerve that passes over a joint sends some nerve
fibers to innervate that joint.

13. History
• Pain in the opposite hip or any other joints.
• Trauma
• Previous attempts of Hip aspirations

14. History
• constitutional symptoms;
– Fever,
– Sweating,
– Weight loss.
• Any recent infections.
• Any antibiotic usage.

15. Physical Examination
Vital signs
Walking.
sitting or crawling.

16. Physical Examination
Foot progression angle,
Pelvic and trunk balance,
Presence or absence of a limping
Trendelenburg sign
Antalgic gaits.

17. Physical Examination
Ability to bear weight through the knees proximally
when crawling can localize the problem to the legs
or feet.
Inability to sit comfortably may point to spinal pathology,
What about the child who refuses to bear weight ??

18. Physical Examination
what is the Resting Position of the hip ?
• Flexion, abduction, and outward rotation
• Febrile infant holding the hip in this position at rest
likely needs an aspiration and arthrogram to rule out
pyarthrosis.

19. How can you differentiate between Acute and Chronic
Pathology….!!
• Thigh atrophy (measured at a standard distance above
the patella)

20. Laboratory studies
• Most frequently ordered are
(CBC) with differential,
(ESR),
(CRP),
Rheumatoid Panel (RF, ANA).
Blood culture
Synovial fluid analysis

21. The ESR and CRP …
• are acute phase reactants, and either infectious, inflammatory,
or neoplastic causes can result in elevation above normal
levels.
• The CRP will increase and decrease faster than the ESR
ESR and CRP are better negative predictors

23. Traumatic and mechanical causes of hip pain

24. Slipped capital femoral epiphysis
• SCFE is a disorder of the physis of the proximal femur.
• Age 10 -16 years old
• Boys > Girls
• It is bilateral in 20% of patients at the time of initial presentation,and another 20%
to 30% will develop a contralateral slip within 12 to 18 months of the initial slip.

25. • Acute slip
• Sudden onset of pain,
severe enough to prevent
weight bearing
• Normal WBC, CRP, and
ESR
Chronic slip;
• Most common presentation
• Pain referred to hip, distal
medial thigh, or knee
• Loss of internal rotation and
abduction
• May have limped for months

26. the goal of evaluation of ambulatory patients who have SCFE??
• Treat them (better life)
• Prevent progression of stable to an unstable SCFE.
• Prevent developing osteoarthrosis.

27. Legg Calv !e Perthes’
disease

29. Inflammatory or infectious causes of hip pain

30. Transient synovitis
Hip pain, muscle spasm, restriction of
motion, refusal to walk
• Onset acute or insidious
• Usually appear healthy
• Diagnosis of exclusion
• Age 2-8 years
• septic Arthritis ;
exaggerated clinical picture of
Transient Synovitis

32. Pyomyositis
Similar clinical presentation for septic arthritis !!
Typically ESR and CRP are elevated.
Keep it in mind if hip aspiration or arthrogram is negative and
the patient continues to manifest signs of infection (fever, positive
blood cultures).
MRI is the best imaging study to assess for both of them

33. Joint Aspiration
Should be sent for;
Cytology (in regular tubes)
Microbiology (in blood culture tubes)
Biochemistry (in green tubes)
Histology (in Formaline saline)

34. Joint aspiration is essential for the diagnosis.
WBC >50,000 with 75% nuetrophils.
Gram stains of the aspirate are positive in 30% to 50% of cases
cultures are positive in 50% to 80%.
Synovial protein levels that are 40 mg/dL and are less than the
serum protein levels
Lactate levels are typically elevated and the glucose level in the
aspirate is lower than the level in the serum.

35. Vascular causes
Idiopathic osteonecrosis of the proximal femoral epiphysis.
Age 4 - 8 years old
Boys > Girls
Develop pain, typically in concert with femoral head collapse.

36. • History of pain in the hip, thigh, or knee.
• On Examination pain at the end range of motion, especially
abduction and internal rotation, with less painful mid range
motion.
• Symptoms and limp severity are usually
• worse at the end of the day.

38. sickle cell disease , Thalessemia,leukemia, lymphoma,
and hemophilia.

39. Summery
• High index of suspicion
• Clinical presentation in infantile is not classical.
• Never let the sun set on pus under pressure.
• Aspirated samples ?? what we want to know?
• Knee pain equals hip pain
• Hilton’s low
• Heamoglobinopathies might be the cause.

40. transient synovitis or septic arthritis?
History of trauma and through history of pain is
important.
Never start antibiotics before sending for cultures.

41. ?