Painful Hip in Childhood
Background
Toddlers (aged 1-3 y)
- Immature gait leads to falling (eg, toddler's fracture, stress fractures, puncture wounds, lacerations)
- Infections are prominent as immature bony cortex has limited resustance tp bacterial invasion (septic arthritis, osteomyelitis)
- Other causes include - neoplasia, developmental dysplasia of the hips, neuromuscular disease, cerebral palsy, and congenital hypotonia.
Children (aged 4-10 y)
- Higher velocity trauma leads to fractures, dislocatiions and ligamentous injuries
- Microvascular trauma causes Perthes disease
- Infections still prominent
- Early rheumatoid arthritis
Adolescents (older than 11 y)
- Muscular strength and weight outstrip bony maturity - SUFE
- Arthritis (including STD related arthralgias)
- Neoplasm more common
History and examination
Full physical examination includes
- Head, eyes, ears, nose, and throat (HEENT) exam
- Jaundice (sickle cell)
- Blue sclera (osteogenesis imperfecta)
- Iritis (Rheumatoid).
- Oral lesions may be seen with Crohn disease.
- Facial angiofibromas (tuberosclerosis).
- Brushfield spots/epicanthal folds (trisomy 21)
- A goiter from hyperthyroidism
- Respiratory exam including asthma (steroids)
- CVS exam - murmur of rheumatic fever
- Examint the FEET (FB, warts, athletes foot etc)
- Joint examination
- Check the back for ROM, localizing tenderness, deformity or signs spinal bifida
- NEUROLOGICAL exam particularly of lower limb
- Dipstick urine for blood and protein
Points in the history
- Comprehensive history needed
- Constitutional symptoms, trauma history
- Fever - infection (arthritris/ostepmyelitis), malignancies, HSP arthritis
- Nocturnal pain suggests malignancy or osteoid osteoma
- Early morning stiffness in Still's disease
- Back pain may be discitis
- Referred pain more common
- Pain eased by activity suggests arthritis in this agegroup
- Enquire if child can keep up with their peers (chronic conditions or overuse eg stess fractures)
- Check family history
Points in the examination
- Thorough gait, orthropaedic and general physical exam needed
- NB overall appearance - signs sepsis may be limited
- Antalgic gait = pain
- Pain on weight bearing = v short stance phase on that side
- Shortened swing phase of the contralateral side produces the quickstep or antalgic gait
- Abductor lurch or Trendelenburg gait is observed with hip disease
- Trunk swings over the affected leg on the ground (stance phase)
- Beware Perthes or SUFE
- The steppage gait commonly = peroneal nerve palsy (tibialis anterior)
- Toe walking = real or apparent leg length discrepancy
- Straight leg gait = knee pain or quadraceps pathology
- Waddling gait = neurological problems or bilateral hip disease
- Stooped gait and shuff;le beware peritonism, PID or psoas abscess
Investigating the Painful Hip in Childhood
- Consider the possibility of sepsis in all
- Document temperature, pulse rate, and capillary refill time
- If any doubt check FBC and CRP immediately (ESR alone is not sufficiently sensitive to outrule spesis [BestBets])
- Dipstick urine for blood or protein
- Take a thorough Hx to exclude trauma
- NAI is a common cause of presentation
- Ultrasound is more sensitive than plain x-ray at detecting hip effusions in children.
- It should be the first imaging investigation of the irritable hip.[BestBets]
| Birth to 3 years | Ages 4 to 10 years | Ages 11 to 18 years |
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Children aged under 5 years of age
- Transient synovitis most likely (no Hx trauma)
Exclude sepsis in all
- Ix with plain AP x-ray of hips, FBC and CRP (ESR alone is not sufficiently sensitive to outrule spesis [BestBets])
- If x-rays and all bloods normal - discharge to ED or fracture clinic next day (Referral form).
- If still symptomatic - US scan (confirm effusion +/- guided aspiration)
- Many patients may need admission for analgesia.
Children in the age range 5-10 years of age
- Perthes' disease is most likely diagnosis (no
trauma Hx)
- exclude sepsis in all (vitals, FBC, CRP)
- AP x-ray of hips (demonstrate the capital physis of the femur)
- Request frog leg lateral view if AP normal (only if epiphysis open as Perthes' not seen after epiphysis closed)
- If Perthes' disease is demonstrated
- Analgesia
- Non-weight-bearing crutches
- ? admit for bed rest analgesia and skin traction (analgesia)
- Fracture clinic CUH (Referral form)
- If the x-ray is normal early Perthes' disease is not excluded - arrange orthopaedic OPD follow up.
- Return stat SOS (any septic symptoms or more pain)
Children greater than 10 years of age
- Exclude slipped upper femoral epiphysis "SUFE"
- Exclude sepsis in all (ESR alone is not sufficiently sensitive to outrule spesis [BestBets])
- Plain AP and frog lateral x-rays
- Dx slip - refer orthopaedic immediately (Referral form CUH fracture clinic)
- Get consultant radiologist report asap
- If x-rays normal admit or home for analgesia
- If discharged arrange next day follow up (ED clinic)
- Further Ix with bone scan or MRI needed if symptomatic on review
In all cases consideration should be given to any relevant history of previous episodes of arthropathy. If doubt concerning other clinical conditions exists then discussion with the senior ED duty doctor or orthopaedic registrar at CUH is recommended.
