Hip pain Flashcards
What is the most common cause of a limp in childhood?
The most common cause of limp in childhood is a hip problem.
Children with hip pathology may present with pain, refusal to bear weight, a limp, or decreased movement of the lower extremity
What is the most common cause of hip pain in a child aged 3 years or over?
Transient synovitis is one of the most common causes in children over 3 years of age but it has similar early symptoms to septic arthritis.
What should you ask in the history of a child presenting with hip pain?
History should include pain characteristics (location, character, onset, duration, change with activity or rest, aggravating and alleviating factors, night pain), together with any mechanical symptoms (catching, clicking, snapping, worse during or after activity).
If pain is present it is important to determine the origin:
- Pain in the hip area may originate from any part of the hip joint or from the femur. Intra-articular hip pathology is usually localised to the groin.
- Pain in the hip area may be referred from the knee joint or from structures in the inguinal canal, testis (including torsion) and lower abdomen, or from the lower back.
- Hip pathology often causes referred thigh or knee pain.
History should include previous injury (acute macrotrauma, repetitive microtrauma), surgery, neurological disorder, inflammatory joint disease or bleeding diathesis, as well as conditions associated with arthropathies, including psoriasis, acute uveitis and inflammatory bowel disease.
Any other underlying developmental conditions (eg, Down’s syndrome).
Establish whether there is any possibility of tick exposure.
Ask about developmental history, particularly noting late onset of walking, unusual gait or clumsiness in very young children. These might suggest developmental or degenerative conditions.
Ask about family history of hip problems.
Ask about systemic symptoms (fever, irritability); inflammatory symptoms (morning stiffness); neurological symptoms (weakness, altered sensation); and the current level of function of the child.
Ask about previous treatments and response (including antibiotics, analgesics, anti-inflammatories, physiotherapy, steroid treatment).
What should you examine in a child presenting with hip pain?
Hip examination
Most causes of hip pain are unilateral, allowing comparison to the unaffected side.
The lumbar spine, sacroiliac joint, knee and abdomen should also be examined.
A complete musculoskeletal examination to look for joint swelling should be done if there is a history of inflammatory symptoms.
Examine the corresponding knee, inguinal canal, abdomen and testes.
Systemic examination should include temperature and vital signs.
Which investigations should be done for a child presenting with hip pain?
If infection is suspected, urgent assessment in secondary care is required and FBC, ESR, CRP, blood and joint cultures will form part of the evaluation. Cultures of joint and synovial fluid may be needed.
Arthritis is a clinical diagnosis; anti-nuclear antibody (ANA), rheumatoid factor and HLA-B27 are helpful in classification and treatment.
Radiographs, ultrasound and magnetic resonance imaging (MRI) are the most common imaging tools used to assess the paediatric hip.
Children and adolescents with hip pain, referred pain to the thigh or knee or a limp require visualisation of the proximal femur in two planes. Anterior posterior (AP) plain films of both hips, preferably taken with the patient standing and ‘frog leg’ view are standard.
Technetium bone scan identifies areas of increased osteoblastic activity and can help localise infection and subtle areas of bone injury such as early stress fracture.
What are the common causes of hip pain in children?
The most common and significant causes of hip pain in children are:
- Transient synovitis (irritable hip) peaking at 3-8 years.
- Septic arthritis - any age (peaking at 0-6 years).
- Perthes’ disease (3-12 years peaking at 5-7 years).
- SCFE (early adolescence - usually in obese children).
Why is it possible to diagnose septic arthritis as transient synovitis?
Transient synovitis and septic arthritis have similar early symptoms with spontaneous onset of:
- Progressive hip, groin, or thigh pain.
- Limp or inability to bear weight.
- Fever.
- Irritability.
This significant clinical overlap means that there are no absolute criteria for definitive diagnosis of either condition.
How does transient synovitis present?
Transient synovitis typically has an acute onset, followed by spontaneous recovery with no systemic upset. It is a benign condition with a small amount of fluid in the joint.
It is the most common cause of hip pain in children between the ages of 3-10 years (peaking between 5 years and 6 years) and is more common in boys, often preceded by viral infection.
What is the management of transient synovitis?
It is a self-limited condition with no long-term sequelae. It can be managed with oral analgesics such as ibuprofen/paracetamol and observation.
Transient synovitis recurs in up to 15% of children.
What are the complications of transient synovitis?
It may affect the same or the opposite hip:
- Pain is usually not severe but may prevent weight-bearing.
- Usually there is no pain at rest and passive movements are only painful at the extreme range of movement.
- The child is usually systemically well and the ESR is either normal or slightly raised.
- Management includes rest and analgesia, with mobilisation once the pain has settled.
What is juvenile idiopathic arthritis?
Juvenile idiopathic arthritis (JIA) is defined as joint inflammation presenting in children under the age of 16 years and persisting for at least six weeks, with other causes excluded.
There are seven subsets of JIA with oligoarticular JIA most common.
What is the presentation of JIA?
It affects the hips in 30-50% of cases and is usually bilateral. It is very uncommon for hip monoarthritis to be the initial manifestation.
Children typically present with groin pain but may have referred thigh or knee pain.
There is often morning stiffness, with gradual resolution of pain with activity.
There is painful or decreased range of motion, especially in internal rotation.
What are the differentials of JIA?
Septic arthritis Osteomyelitis Reactive arthritis Trauma Mechanical pain IBD Malignancy Connective tissue disease
What are the investigations of JIA?
It is a clinical diagnosis,
Aspirate the joint if septic arthritis is suspected.
What is the management of JIA?
Treatment includes physiotherapy and anti-inflammatory therapies.
All children suspected of having chronic inflammatory arthritis should be referred to a paediatric rheumatologist.
Patients should be encouraged to participate in physical activity.
NSAIDs provide symptom relief
Methotrexate is the first-line treatment
Etanercept is second-line in polyarticular JIA
Surgery such as joint replacement
What are the complications of JIA?
Joint deformities such as contractures, swan-neck/ boutonniere deformities
Uveitis which can lead to blindness
Osteoporosis
Growth restriction
Restriction of sports
Psychosocial, behavioural and educational difficulties may occur.
What is Perthes disease?
This is an idiopathic avascular necrosis/osteonecrosis of the femoral epiphysis (usually affecting those aged 4-10 years and peaking between 5 and 7 years). It affects more boys for each girl affected and is bilateral in 10%.
