MSK - Hip Pain in Child Flashcards
A 4 year old boy has been complaining that his right leg hurts. His mother, has noticed that he has been limping, and think it’s his hip that is causing the problem.
When taking a history here, what ‘Red Flags’ might there be and what conditions would they indicate?
- Nocturnal pain, night sweats, weight loss - Acute lymphoblastic leukaemia
- High fever holding leg abducted (not allowing any internal rotation due to pain) - septic arthritis
- High fever, non weight bearing - osteomyelitis of femur-pelvis
- Changeable history/unusual history regarding mechanism of injury – Non accidental injury
How might you determine if a child has weight loss as a symptom?
- Parent observation
- Growth charts - use age, height/length and weight to determine if child is where they should be
In a child patient with hip pain and limping (loss of movement), what part of the pGAL exam is most likely to be abnormal?
Internal rotation of the hip
- Internal rotation is most sensitive for assessing loss of movement and pain of the hip joint
Pain at the hip can be referred - which other areas might you examine that could cause referred hip pain?
- Abdomen:
- Hernial orifices
- Testicles
- Check for enlarged liver or spleen i.e. malignancy
- Knee joint
A 4 year old boy with hip pain and limp on R side when weight-bearing, temp 37.4, not in pain at rest.
Examination shows ↑ pain on hip movements on R side - all other findings normal.
What is the most likely diagnosis?
What other differentials might you consider?
Transient synovitis of the hip
- Also known as irritable hip
- Boys > girls
- Typically between 4-8 yrs
- Often preceded by a viral illness, either URTI or gastroenteritis
- Symptoms:
- Acute onset limp - with or without pain
- Reduced hip movements
- Child is systemically well and it is self limiting
Differentials:
- Septic arthritis
- Fracture
- Perthes disease
- Slipped upper femoral epiphysis (SUFE)
- Developmental dysplasia of the hip (DDH)
- Juvenial idiopathic arthritis (JIA)
- Bone tumour
- Testicular torsion / inguinal hernia / appendicitis
- Haematological malignancy
A 7 year old present with hip symptoms:
- Acute pain
- Fever
- Non-weightbearing + extreme pain on movement
- Inconsolable (child)
- Systemic symptoms
What is the likely diagnosis?
Septic arthritis (red flag condition)
What might you see on X-ray for Perthes disease?
- X-ray:
- Early changes: widening of joint space
- Later changes: ↓ femoral head size/flattening
- Stages:
- 1 - Clinical and histological features only
- 2 - Sclerosis with or without cystic changes and preservation of the articular surface
- 3 - Loss of structural integrity of the femoral head
- 4 - Loss of acetabular integrity
- Pic shows bilateral perthes with deformed acetabula
How is Perthes disease managed?
Most cases resolve with conservative management
- Cast / braces - keep femoral head in acetabulum
- If pt < 6 yrs –> observation
- If > 6 yrs –> surgical management with moderate results
- Operate on severe deformities
Describe slipped upper/capital femoral epiphysis (SUFE)
(Common presentation/risk factors, features, management)
General:
- Pt typically 10-15 yrs old
- More common if: boy, obese, hypothyroidism
- 20% cases bilateral
- Commonly chronic presentation with persistent symptoms but can present acutely (post-trauma)
Features:
- Postero-inferior displacement of femoral head
- Hip, groin, medial thigh or knee pain
- Loss of internal rotation of leg in flexion
- limp
Management:
- Internal fixation - typically single cannulated screw in centre of epiphysis
Describe developmental dysplasia of the hip (DDH)
(Common presentation/risk factors, features, management)
General:
- Used to be called congential dislocation of the hip (CDH)
- Affects 1-3% newborns
- 20% cases bilateral
- Signs: asymmetrical skin folds, leg length discrepancies, buttock flattening, and walking with the affected leg in external rotation
- Older children may have gradual onset of painless limp
Risk Factors:
- Female 6x risk
- Breech presentation
- +ve family history
- Firstborn children
- Oligohydramnios - deficiency of amniotic fluid
- Birth weight > 5 kg
- Congenital calcaneovalgus foot deformity - benign soft tissue contracture of foot (eversion + dorsiflexion)
Tests:
- Barlow test: attempts to dislocate an articulated femoral head (shouldn’t dislocate if normal hip)
- Ortolani test: attempts to relocate a dislocated femoral head (used to confirm hip was dislocated by Barlow test)
- USS
Management:
- Most unstable hips will spontaneously stabilise by 3-6 weeks of age
- Pavlik harness (dynamic flexion-abduction orthosis) in children younger than 4-5 months
- Older children may require surgery
You are in GP and assess a 3-year-old child presenting with an acutely painful knee,. They are pyrexial, very irritable and refusing to weightbear.
Which is the appropriate course of action:
- Administer analgesia and re-assess 2 hours later
- Advise analgesia and ask them to return if no better within 24 hours
- Arrange urgent admission for assessment at hospital
- Do nothing, they will probably get better
- Take a full set of blood tests, arrange an X-ray and review results
Arrange urgent admission for assessment at hospital
- This is an example of a septic child and joint and therefore requires urgent hospital assessment
What is Osgood-Schlatter disease?
Also called Tibial apophysitis
- Is inflammation of the patellar ligament at the tibial tuberosity
- Thought to be caused by repeated avulsion at the insertion of the patellar tendon (i.e. strong pulling of patellar tendon causing
- Characterised by:
- Painful bump over tibial tuberosity
- Enlarged tibial tubercle
- Worse with activity/kneeling + better with rest
- Risk factors:
- Boys (12-15y) > girls (8-12y)
- Jumpers (basketball, volleyball), sprinters
What is the most likely cause of hip pain which has developed gradually over weeks in a 13 year old boy?
- Fractured neck of femur
- Perthes disease
- Septic arthritis
- Slipped upper femoral epiphysis
- Transient synovitis of the hip
Slipped upper femoral epiphysis (SUFE)
An 11 year old girl who is a keen dancer presents with knee and ankle pain after activity.
What is the most likely diagnosis?
- Juvenial idiopathic arthritis (JIA)
- Joint hypermobility
- Septic arthritis
- Perthes disease
- Transient synovitis
Joint hypermobility - can cause pain at active hypermobile joints
Which age/genders do the following most often present at?
- Transient synovitis?
- Perthes disease?
- Developmental dysplasia of hip?
- Slipped Upper Femoral Epiphysis?
- Bone tumours
- Transient synovitis: Boys, 4-8years
- Perthes disease? Boys, 4-8 years
- Developmental dysplasia of hip? Girls, 0-3 years
- Slipped Upper Femoral Epiphysis? Boys, 10+ years
- Bone tumours? 10+ years
