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 resistance to 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

  • 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

Examination

  • Thorough gait, orthropaedic & general physical exam
  • 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 / shuffle = beware peritonism, PID or psoas abscess


Note

  • 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 limbs
  • Dipstick urine for blood and protein

Investigating the Painful Hip in Childhood

X-ray paediatric hip with effusion
Hip effusion labelled (hover)
  • Document temperature, pulse rate, and capillary refill time
  • If any doubt check FBC and CRP (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 and should be the first imaging investigation of the irritable hip.[BestBets]

Main diagnostic Groups by Age

Birth to 3 years

  • Septic arthritis
  • Osteomyelitis
  • Fractures
  • Developmental dysplasia of the hip
  • Congenital limb length discrepancy

4 to 10 years

  • Septic arthritis
  • Osteomyelitis
  • Toxic synovitis
  • Fractures
  • Perthes disease
  • Juvenile rheumatoid arthritis
  • Leukemia

11 to 18 years


Children aged under 5 years of age

  • Transient synovitis most likely (no Hx trauma)
  • Exclude sepsis in all unwell children, those who will not wt bear or marked reduced ROM
  • Plain imaging is generally only indicated in trauma
  • Bloods (FBC, CRP, ESR) are generally only indicated in suspected septic arthritis or osteomyelitis i.e. not in transient synovitis
  • Most limping children in this age group have short-duration limp (<2 days), can partially weight-bear, are not systemically unwell and have minor abnormal exam findings at most – these children can be discharged from ED with analgesia and advice to return by day 5 if they are not improved, or sooner if they deteriorate
  • If still symptomatic - US scan hips and bloods (confirm effusion; liaise with Ortho for guided aspiration

Children in the age range 5-10 years of age

Perthes

Perthes
  • Perthes' disease is most likely diagnosis (no trauma Hx)
  • Exclude sepsis in all (vitals, detailed H&P, consider bloods)
  • 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
    • 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 (vitals, detailed H&P, consider bloods)
  • Plain AP and frog lateral x-rays
  • NWB or significant slip = admit orthi
  • PWB = analgesia, crutches, OPD (VTAC via iCM in CUH)
  • Get consultant radiologist report asap - slip can be subtle ('pre-slip') on initial x-rays
  • If x-rays normal admit or home for analgesia
  • If discharged arrange next week follow up
  • Further Ix with bone scan or MRI needed if symptomatic on review. If clinical concerns persist, then arrange ortho review
Slipped Femoral epiphysis

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 EM duty doctor or orthopaedic registrar.


Content by Dr Íomhar O' Sullivan. Reviewed Prof. Ronan O' Sullivan 11/06/2017. Last review Dr ÍOS 21/11/21.