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 Post subject: HIP PAIN IN CHILDREN.
PostPosted: 31 Jul 2015 03:35 
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Hip pain in children is always potentially serious and needs urgent assessment.
The main immediate concern is to distinguish infection of the hip joint or pelvic bones from irritable hip.
If examination shows a restriction of hip movement or there are X-ray abnormalities, many will have a serious disorder requiring long-term management.

Differential diagnosis.
At any age:
Transient synovitis (irritable hip); commonest cause of hip pain in a child aged between 4 and 10 years.
Trauma
Septic arthritis of the hip - always consider this diagnosis, especially in a younger, febrile or unwell child (it can destroy a hip joint within hours and is therefore a surgical emergency)

Acute osteomyelitis of the proximal femur
Tuberculous arthritis
Juvenile idiopathic arthritis
Bone malignancy
Non-accidental injury

Age 0-3 years:
Septic arthritis
Osteomyelitis
Developmental hip dysplasia
Infantile cox vera
Fracture or soft tissue injury (including non-accidental injury)

3-10 years:
Transient synovitis or irritable hip
Septic arthritis
Osteomyelitis
Perthes’ disease
Fracture or soft tissue injury (stress fracture)

10-15 years:
Slipped upper femoral epiphysis
Septic arthritis
Osteomyelitis
Perthes’ disease
Fracture (including stress fracture) or soft tissue injury.

Assessment of a child with a limp.
A hip problem is the most common cause of a limp in a child. Pain in the hip is often referred to the knee.
Apart from an isolated hip problem other possible causes of a limp include haematological (eg, sickle cell anaemia), infection (eg, pyomyositis or discitis), metabolic disease (eg, rickets), acute lymphoblastic leukaemia, neuromuscular disease (eg, cerebral palsy, muscular dystrophy), primary anatomical abnormalities (eg, limb length inequality) and juvenile idiopathic arthritis.

Intra-abdominal pathology and testicular torsion may occasionally present as a limp.

Meticulous examination of the hips is crucial. Restricted internal rotation is the most sensitive marker of hip pathology in children, followed by a lack of abduction.
Loss of hip abduction can be difficult to assess because children often tilt their pelvis to give a false impression of hip abduction.
Because of the serious nature of many of the underlying causes and the importance of early diagnosis and treatment, urgent referral for specialist assessment is often required.

Investigations
An initial diagnosis can usually be based on clinical presentation. Imaging is then used to confirm the diagnosis.

Plain X-ray of the hips (always do both for comparison - and include AP and lateral "frog leg" view).

Ultrasound - the best method of showing hip joint effusion, and may guide the needle if aspiration is appropriate.
MRI and bone scintigraphy may be useful but CT has a limited role because of the risks associated with ionising radiation.

Transient Synovitis
This usually has acute onset.
It is a self-limiting condition thought to be due to viral infection or an autoimmune process.
It is often preceded by a viral upper respiratory tract infection.
It is twice as common in boys.

Presentation:
Pain is usually not severe but may prevent weight-bearing on the affected leg.
Usually there is no pain at rest and passive movements are only painful at the extreme range of movement.
The child is usually well and the ESR is either normal or slightly raised.

Management:
Includes rest and analgesia, with mobilisation once the pain has settled.
Symptoms usually resolve within two weeks but may recur.
There is no evidence of any long-term complications.

G Mohan.


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