Hip pain in children with normal radiographs

Year 2012, Volume: 4 Issue: 2, 2 - 6, 26.05.2012

Pravin Padalkar , Benjamine Tow Kevin Lim

Abstract

Abstract:

Introduction:An acutely painful hip in a child can be the presenting symptom in a number of conditions. One of the most important conditions of which is septic arthritis of the hip for which early diagnosis and treatment is essential. The focus of management in acute hip pain in a child is to rule out septic arthritis as the penalty for missing a diagnosis of septic arthritis of the hip in a child has serious consequences .The purpose of our study is to add to the available pool of data on hip pain, validate the predictive values published by preceding authors. We also hope that by presenting the breadth and scope of patients presenting with an acutely painful hip with normal radiographs, we can assist the physician in decision-making when confronted with this common diagnostic challenge.

Methods: Retrospective review of all the patients who were admitted to our tertiary referral pediatric hospital with complains of hip pain and pain referable to the hip between January 1997 and December 2003. A total of 207 patients 162 patients with normal x-ray were reviewed retrospectively with evaluation of history, physical examination, laboratory studies. Patients whose diagnoses were defined as transient synovitis were made by the attending physician based on result of a combination of some or all of the Laboratory tests.( presence of fever, full blood count, Erythrocyte Sedimentation Rate (ESR) and C-reactive protein (CRP) levels, negative blood culture, and effusion on ultrasound, and clinical picture of early resolution. Patients whose diagnoses were defined as septic arthritis or probable septic arthritis were made based on the findings of elevated ESR, CRP, positive blood culture or hip aspiration culture.

Results: The 162 patients included 42 females and 120 males, with an age range from 6 months to 14 years. Of our cohort of patients admitted for hip pain, 111 patients were diagnosed as transient synovitis. 56 patients who were diagnosed as transient synovitis underwent ultrasound examination of the affected hip. 89.3% (50/56) had an effusion with a mean joint space thickness of 6.6mm. 10.7% (6/56) of the patients who underwent ultrasound examination had no demonstrable effusion.

Conclusions: In patients with septic with hip pain and normal radiograph, the commonest diagnosis was transient synovitis comprising 67.9% of patients.Septic arthritis is the most important diagnosis to exclude and should be suspected if there is fever, inability weight bear and highly elevated levels of ESR and CRP needed

Keywords

Keywords: Septic arthritis, Transient synovitis, hip pain in children, hip pain with normal radiograph

References

• Hollingworth P. Differential management of hip pain in childhood.Br J Rheumatol. 1995; 34:78-82. diagnosis and
• Del Beccaro MA,Champoux AN, Bockers T, Mendelman PM. Septic arthritis versus transient synovitis of the hip: the value of screening laboratory tests. Ann Emerg Med. 1992; 21:1418-22.
• Eich GF, Superti-Furga A, Umbricht FS, Willi UV. The painful hip: evaluation of criteria for clinical decision-making. Eur J Pediatr 1999; 158:923-8.
• Beach R. Minimally invasive approach to management of irritable hip in children. Lancet. 2000; 355:1202-3.
• Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical Prediction algorithm. J Bone Joint Surg. Am. 1999; 81:1662-70.
• Luhmann SJ, Jones A, Schootman M, Gordon JE, Schoenecker PL, Luhmann JD. Differentiation between septic arthritis and transient synovitis of the hip in children with clinical prediction algorithms JBJS (American) 2004; 86:956-962.
• Jung ST, Rowe SM, Moon ES, Song EK, Yoon TR, Seo HY. Significance of laboratory and radiologic findings for differentiating between septic arthritis and transient synovitis of the hip. J Pediatr Orthop 2003; 23:368–372.
• Do TT. Transient synovitis as a cause of painful limps in children.Curr Opin Pediatr. 2000; 12: 48-51
• Miralles M, Gonzalez G, Pulpeiro JR, et al. Sonography of the painful hip in children: 500 consecutive cases. Am J Roentgenol. 1989; 152: 579- 82
• Dorr U, Zieger M, Hauke H. Ultrasonography of the painful hip. Prospective studies in 204 patients. Pediatr Radiol. 1988; 19(1): 36-40.
• AYC Siu, TW Wong, CC Lau, AKC Poon, CK Lam, FK lp. assessment for paediatric patients with hip pain in the emergency department. Hong Kong J Emerg Med. 2001;8:146-149. of ultrasonographic
• Bialik V, Volpin G, Jerushalmi J, Stein H. Sonography in the diagnosis of painful hips. Int Orthop. 1991;15:155-9.
• Eich GF, Superti-Furga A, Umbricht FS, Willi UV. The painful hip: evaluation of criteria for clinical decision-making. Eur J Pediatr. 1999;158:923-8.
• Lee SK, Suh KJ, Kim YW, et al. Septic arthritis versus transient synovitis at MR imaging: preliminary assessment with signal intensity alterations in bone marrow. Radiology 1999; 211:459–465.
• Kyu-Sung Kwack ,Jae Hyun Cho, Jei Hee Lee, Jae Ho Cho, Ki Keun Oh, Sun Yong Kim. Septic Arthritis Versus Transient Synovitis of the Hip: Gadolinium- Enhanced MRI Finding of Decreased Perfusion at the Femoral Epiphysis. AJR:189, August 2007, 437-444.
• Mitchell DG, Rao V, Dalinka M, et al. MRI of joint fluid in the normal and ischemic hip. AJR 1986; 146:1215–121.
• Caird MS, Flynn JM, Leung YL, Millman JE, D’Italia JG, Dormans JP. Factors distinguishing septic arthritis from transient synovitis of the hip in children: a prospective study. J Bone Joint Surg Am 2006; 88:1251–1257
• Greenspan A, Tehranzadeh J. Imaging of infectious arthritis. Radiol Clin North Am. Mar 2001;39:267-76.
• Jaramillo D, Treves ST, Kasser JR, et al. Osteomyelitis and septic arthritis in children: appropriate use of imaging to guide treatment. AJR Am J Roentgenol. Aug 1995;165:399-403.