Hip pain in children

Ferbile

Afebrile

Septic arthritis

Perthes disease

Reactive arthritis

Slipped femoral epiphysis

Osteomyelitis

Transient synovitis

Juvenile idiopathic arthritis

DDH
Mechanical: trauma, sports injury

1-3 yo

Infection-septic srthritis, osteomyelitis

Transient synovitis
Trauma
Malignancy-leukemia, neuroblastoma

3-10 yo

Transient synovitis
Septic arthritis, osteomyelitis
Trauma
Perthes disease
JIA
Malignancy

11-16yo

Mechanical-trauma, sports injury

Slipped capital femoral epiphysis
Reactive arthritis
JIA
Avascular necrosis of femoral head
Septic arthritis, osteomyelitis
Malignancy

Septic arthritis

<2 yo
Staphylococcus aureus, by haematogenous spread/ local
spread from osteomyelitis
Involve 1 joint (hip)
Clinical features: erythematous, tender joint, hip held in
flexion, abduction, external rotation, pseudoparalysis,
unwell, febrile child

 Investigation:
FBC: raised WCC
ESR, CRP: raised
Blood culture: may be positive
X ray of affected joint: soft tissue swelling,
widening of joint space, evidence of osteomyelitis
US: effusion. Positive echogenic-septic arthritis,
echo free-transient synovitis
Joint aspiration (definitive IX): gross and
microscopic examination, culture and sensitivity.
Purulent, raised WCC, low glucose, low viscosity,
bacteria present

Kocher criteria

Treatment
Symptomatic :
Analgesia and IV fluid
Antibiotic: ex: cloxacilin
Hip joint on traction/splinting in abduction

Surgical:
Surgical drainage
Arthrotomy (arthroscopic debridement and copious
irrigation with normal saline)
Indication:

Joint does not respond to serial aspiration

Frank pus aspirated
No improvement in 48hrs of RX
Loculation noted on US/MRI

Complication : articular cartilage destruction,

growth arrest, septicemia

Transient synovitis

Most common cause of acute hip pain in

children (2-12yo)
Self limited inflammatory condition with hip
joint effusion
Associated with viral infection
Mild fever/afebrile, non toxic
Acute limp, non weight bearing, pain on
movement, no rest pain, limited internal
rotation
Ix: normal WCC, normal/slightly raised ESR,
US-fluid in joint, X-ray-normal
Rx: bed rest and analgesia

Slipped capital femoral

epiphysis

10-15yo-adolescent growth spurt, more common in

boys, obese/extremely tall and thin
Followed minor trauma/insidous
Limp/hip pain referred to knee, external rotated hip,
shortened 1-2cm
Limited abduction and internal rotation of hip joint
Complications: avascular necrosis, coxa vara,
secondary OA, contralateral SCFE
Treatment:
mild (displacement<1/3 epiphysis width- accept
position, fix epiphysis with 2 thin threaded pin
Moderate (displacement of 1/3-1/2 epiphysis widthepiphysis fixation with pin, femoral remodelling
Severe (>1/2 epiphysis width)-corrective surgery

Klein lines are drawn

along the superior
cortex of the femoral
neck. A normal Klein
line will intersect the
epiphysis. An abnormal
Klein line does not
intersect the epiphysis,
as the femoral neck has
moved proximally and
anteriorly relative to
the epiphysis

Perthes disease

Idiopathic avascular necrosis of femoral head

4-8yo, boys x4 more common than girls
Pain and limp, limitation of all movement
Treatment (based on prognosis assessment):
Symptomatic: bed rest with skin traction for pain relief (3
weeks)
Containment: hip abducted in plaster/removable splint
until end of bone change (1year)
Varus osteotomy of femur/innominate osteotomy of pelvis

Favourable prognostic signs: onset<6yo, partial

involvement of femoral head, absence of
metaphyseal rarefaction, normal femoral head
shape

Lateral epiphyseal
vessel in retinacula
susceptible to stretching
by effusion and pressure