3. APPROACH
• History: Age, Sex, Pain(SOCRATES): site, onset, severity, preceeding ,
associated symptoms, limp, inability to bear weight
• Past medical hx, family social history
4. Physical examination
• Do complete examination depending on the presentation
• pGALS(if suspecting rheumatological disorders)
• Limb length discrepancy
• Look
• Feel
• Move
5. SPECIAL TESTS
• FABER test: principle- position with maximum articular contact thus
the most stable. Opposite is FADIR
10. Approach to specific disorder
• Definition
• Epidemiology
• Risk factors
• Pathophysiology
• Signs and symptoms
• Investigations
• Management
• Complications
11. TRANSIENT SYNOVITIS
• Self limiting inflammation of the synovium.
• Common cause of hip pain in pediatric patients
• Must be differentiated from septic arthritis of the hip.
• Diagnosis of exclusion
• Epidemiology: 4-8 yrs, recurrence rate(20%), M:F-2:1, most commonly affects the hip joint
• Risk factors: may be related to viral infection (upper respiratory), bacterial infection
(poststreptococcal toxic synovitis), trauma, higher interferon concentration, allergic reaction
• Pathophysiology: idiopathic/immune: non-specific inflammation and hypertrophy of the synovial
lining/membrane
12. Signs and symptoms
• History: recent upper respiratory infection or trauma, mild or absent fever, acute or insidious
onset of groin/thigh pain, refusal to bear weight usually improves during the day, muscle spasms
• Physical exam:
• hip presents in flexion, abduction, and external rotation (position with least amount of
intracapsular pressure)
• mild to moderate restriction of hip internal rotation is the most sensitive range-of-motion
restriction
• a painless arc of motion is more likely synovitis rather than septic arthritis
• neurovascular
• toe-walking, cavus foot, or clawing of the toes may suggest a neurological cause of limp
• provocative tests
• log-rolling leg can detect involuntary muscle guarding
• non-tender motion of lumbar spine and ipsilateral knee
13. Investigations
1. Radiographs: AP, lateral or frog leg hip views - usually normal
2. Ultrasonography: indications
• history and physical examination suspicious for septic arthritis -
accurate for detecting intracapsular fluid/effusion ; may show synovial
membrane thickening
3. MRI
• Indications: suspicion for myositis or osteomyelitis
14. Management
• Nonoperative
1. NSAIDS and close observation
• Self limiting
• observe over 24 hours
• minimize walking for 24 hours
• consider traction to enforce rest
Outcomes
• if symptoms improve with NSAIDS, more likely to be transient synovitis
• symptom resolution in under 1 week from the date of presentation
16. LEGG-CALVE-PERTHES DISEASE
AVN of the femoral head epiphysis
• Epi: 4-10yrs, M:F 4:1, bilateral in 10%
• Risk factors: Family hx, 2nd hand smoking, LBW, Abnormal birth
presentation, Asian, Thrombophilias, SCD
17. Pathophysiology: 3 stages
1. Ischemia(Death) due to an insult that alters blood supply
2. Revascularization and repair
3. Remodelling and distortion
18. Signs and Symptoms
• +/-Pain, limp
• Limited range of movement
• gait disturbance-antalgic limp, trendelenberg
• limb length discrepancy-late finding
19. Investigations
• early findings include
1. medial joint space widening: less ossification of head
2. irregularity of femoral head ossification
3. decreased size of ossification center
4. sclerotic appearance
5. cresent sign (represents a subchondral fracture)
20.
21. 2. Bone scan
• decreased uptake (cold lesion provides information on extent of femoral
head involvement
3. MRI
• early diagnosis - more sensitive than radiograph
4. Perfusion studies predict maximum extent
5. Arthrogram
• a dynamic arthrogram can demonstrate coverage and containment of the
femoral head
22. Management
• Initial therapy : bed rest till pain free allows revascularization
• minimal weight bearing and protection of the joint - femur abducted
and externally rotated so that the femoral head is held well inside the
rounded portion of the acetabulum.
• Studies prove braces not useful.
• Reserved for less severe dx
• Role of radiologic surveillance
