Paediatric Hip Conditions

Paediatric Hip Conditions: 

Paediatric Hip Conditions Adam Marnell

8 yr old boy: 

8 yr old boy PC - Left hip joint pain HPC – Came home from school 2 days ago with pain, worse on walking, no bumps trips or falls, no strain, no sports, no event. Rested and went to school following day, was uncomfortable and pain worsened that evening. Had trouble sleeping that night so went to GP the following morning, who admitted the patient.

Pain: 

Pain 5/10 severity Worse on walking, unable to fully weight bear causing antalgic gait Worse when externally rotated and tenderness on anterior medial aspect of hip joint No pain at rest No relieving factors No other painful joints No referred or movement of pain

History of presenting complaint continued ...: 

History of presenting complaint continued ... No previous infection No deep cuts or grazes Apyrexial No coryzal symptoms No rash No diarrhoea or vomiting Never had joint pain before Otherwise feeling well

Past medical history: 

Past medical history Intermittent toe walking, can walk on heels but forgets. Noticed when first began to walk, physiotherapy exercises 4 times a day. Tight calf muscles and resistance to fully dorsiflex Ventouse birth @ 41/40 8lb 11oz, no complications Normal development and imms up to date

Family History: 

Family History Father had toe walking but grew out age 10 Father also had transient synovitis at age 12 and 35 No rheumatic or other joint disorders in the family None other relevant

Social History: 

Social History Lives in house in Aughton with Mum and Dad and sister (age 6) Enjoys school Active and plays football, sometimes with discomfort due to toe walking, can ’ t run as fast as other children but still has fun

Drug History: 

Drug History Not on regular medication Paracetamol 650 mg QDS Ibuprofen 220 mg TDS No over the counter medication No herbal remedies NKDA

Examination: 

Examination Looked comfortable at rest Chest clear, abdo soft not tender, HS I+II+O Temp 36 C, HR 101 , Resp 20 Had full degree of movement in both hip joints active and passive Pain on external rotation, and tenderness on anterior medial aspect of hip joint Resistance on dorsiflexion of both ankles

Examination continued ...: 

Examination continued ... Did not allow exposure of hips but mum stated no obvious deformity, swelling, redness or heat over joint Nothing to note in upper limb joints, knees or spine Antalgic gait Preferred to toe walk

Investigations: 

Investigations FBC Hb 12.5 (11.5 15.5) WBC 7.5 (4.5-14.5) Plt 521 (140-440) Inflammatory markers ESR 8 (0-20) CRP 9.7 (0.0-10.0) U&E Sodium 132 (133-146) Potassium 4.1 (3.5-5.2) Urea 5.9 (2.3-7.5) Creatinine 52 (0-135) Bone profile Calcium 2.39 (2.20-2.60) Phosphate 1.51 (0.80-1.50) ALP 315 (27-350) Total Protein 64 (55-80) Serum Albumin 36 (31-47) Globulin 28 Coagulation screen INR 1.3 APTT ratio 1.06 (0.84-1.16) X-ray no abnormalities USS no abnormalities

What did we do?: 

What did we do? Pt was sent home for weekend leave Came back for review from orthopaedic specialist Discharged and appointment organised for orthopaedic clinic

Differential Diagnosis: 

Differential Diagnosis Transient synovitis (irritable hip) Perthes disease Slipped upper femoral epiphysis Ligament or muscle strain Septic arthritis NAI Juvenile idiopathic arthritis

Transient synovitis (irritable hip): 

Transient synovitis (irritable hip) Most common cause of acute hip pain Occurs in children aged 2-12 years old Sudden onset, no pain at rest Often followed or accompanied by a viral infection Children not unwell and can move hip although degree of stiffness particularly external rotation

Transient synovitis (irritable hip): 

Transient synovitis (irritable hip) WCC and acute phase reactants are normal or slightly raised Blood cultures negative X-ray normal USS small joint effusion may be seen Manage with bed rest and usually resolves spontaneously within few days

Transient synovitis (irritable hip): 

Transient synovitis (irritable hip )

Perthes disease : 

Perthes disease Ischaemia of the femoral epiphysis, resulting in avascular necrosis, followed by revascularisation and reossification over 18-36 months. Usually affects boys aged 5-10 years Bilateral in 10-20% Insidious onset of limp or hip pain or knee pain

Perthes disease: 

Perthes disease Slight restriction of movement of the hip, especially internal rotation Damage to femoral head can be seen on X ray

Perthes disease: 

Perthes disease

Perthes disease: 

Perthes disease Avoid deformity of femoral head and metaphyseal damage If identified early bed rest and traction Severe cases need to keep hip in internal rotation and abduction with frames, plasters or brace Femoral osteotomy

Perthes disease: 

Perthes disease

Perthes disease: 

Perthes disease

Slipped upper femoral epiphysis: 

Slipped upper femoral epiphysis Displacement of the epiphysis of the femoral head postero-inferiorly

Slipped upper femoral epiphysis: 

Slipped upper femoral epiphysis Most common at 10-15 years particularly in obese boys Presents with limp or hip pain, which may be referred to the knee Restricted abduction and internal rotation of the hip Onset may be acute following minor trauma or progressive due to increased mechanical stress

Slipped upper femoral epiphysis: 

Slipped upper femoral epiphysis Classified as stable and unstable

Slipped upper femoral epiphysis: 

Slipped upper femoral epiphysis Diagnosis confirmed on X-ray Management is surgery usually with pin fixation Severe slips may require corrective realignment osteotomy once epiphysis has fused High risk of bilateral

Thank you: 

Thank you Any questions?