Hip Pain

Hip pain encompasses a broad differential that relies on a focused and detailed history to determine the acute and emergent diagnoses from the less urgent hip problems. The most urgent diagnosis to make is septic arthritis, and the most challenging etiologies to manage are those that mimic septic arthritis.

Differential Diagnosis

• Septic arthitis
  –Surgical emergency due to irreversible chondrolysis and epiphyseal injury
  –Acute process leading to decreased hip range of motion, severe pain with passive range of motion
• Slipped capital femoral epiphysis (SCFE)
  –Typically in obese, adolescent males with aching groin, hip, or knee
  –May have externally rotated hip position and gait
• Legg-Calvé-Perthes
  –Presents at younger age than SCFE (3–8 years old)
  –Five times greater incidence in boys than girls
  –Pain in hip or knee, decreased active and passive ROM, and Trendelenburg gait
• Developmental dysplasia of the hip (DDH)
  –Early diagnosis with newborn exam finding of easily dislocatable hip
  –Older infants have limited hip abduction
• Osteomyelitis
  –Vague symptoms may make this a difficult diagnosis
  –Limp, fever, pain in the proximal thigh or pseudoparalysis of an extremity in an infant may be the only sign
• Fracture
  –Consider accidental and nonaccidental trauma
  –Pain, limited ambulation, limited active and passive ROM, or inability to bear weight
• Transient monoarticular synovitis
  –Often preceded 1–2 weeks by upper respiratory infection
  –Antalgic gait, moderate pain in hip, groin, or knee, and uncomfortable range of motion
• Neoplasia
  –Although primary bone disorders do not generally present with hip pain, other malignancies such as acute leukemia may initially present with bone or joint pain
• Vertebral osteomyelitis/diskitis
  –Referred pain from lumbrosacral region may present as hip pain

Workup and Diagnosis

• Despite urgency of surgical emergencies, a thorough history is essential
  –Onset and duration of symptoms, location, and character of pain
  –Previous trauma, preceding illness, or associated symptoms
  –Past medical history/family history: Bone, hematologic, and metabolic disorders
• Labs
  –CBC with differential, platelets, PT/INR, ESR, CRP

• Radiographic evaluation
  –Plain X-ray: AP pelvis and frog-leg lateral of the pelvis, full length femur, and knee films
  –CT scan: Helps define bony anatomy especially with 3D reconstruction images
  –MRI may demonstate joint effusion in synovitis and infection, marrow edema in osteomyelitis, physeal widening in SCFE, or occult fracture such as femoral neck stress fracture
  –Ultrasound for newborn DDH

• Nuclear medicine
  –Triple-phase bone scan may be helpful when the diagnosis is questionable, or if differentiating between bone and joint infections
• Interventional radiology
  –Joint aspiration to evaluate for septic arthritis

Treatment

• Septic arthritis, femoral neck fracture, and irreducible traumatic hip dislocation require immediate surgical intervention
• Infectious disease consult for septic joint
• Once surgical emergencies are ruled out, keeping the patient non-weight bearing on the affected extremity will allow continued investigation without further injury
• SCFE: Prevent further slippage by percutaneous pinning or screw fixation
• Legg-Calvé-Perthes: Treatment goals include restoring ROM, improving symptoms, and containing the femoral epiphysis during reossification phase; accomplished by limiting activity, traction, Petrie casting, and surgical procedures for containment
• DDH: Pavlik harness, closed reduction and casting, open reduction for irreducible hip dislocation, or femoral and/or pelvic osteotomy depending on status and age of developing hip

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Groin symptoms: Introduction (review 43 causes)
• Next Book Extract About Groin symptoms: GROIN MASS (Differential Diagnosis in Primary Care)
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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: GROIN MASS (Differential Diagnosis in Primary Care)

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• Hip Pain (Field Guide to Bedside Diagnosis)

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