Hip Pain in Children

Transcription

Hip Pain in Children
Aresh Hashemi-Nejad FRCS(Orth)
The Royal National Orthopaedic Hospital
RNOH founded 1837 by
William Little
Aresh Hashemi-Nejad FRCS(Orth) The Royal National Orthopaedic Hospital
Prevalence of Paediatric Orthopaedic
Conditions
• By far the most common conditions
presenting to the primary care clinicians are
assessments of torsion,
• bowlegs, knock knees
• Gait abnormalities
• and flat feet
Gait abnormalities in Children
• Hip Pathology
What is physiological?
• Parental Concern
• perfect children
• Normal Toddlers do not walk like small
adults
• wide bases gait, arm swing, foot drop
• Toddlers proportion are different
• neurological/
developmental
milestones determine
age of sitting, crawling
and walking
Development of a mature gait
• 1 year old with flexed
elbow and plantar
flexed foot
• 3 yr old with arm
swing and heel strike
• 6 yr old with adulttype gait
Tripping and Falling
• Many Toddlers trip and fall
• Immature gait
• wide base, improve by 3
• Variation at each step
• Flexed rotated knee
• less ground clearance
A Causes of limp in 60 young children Data from Choban and Killian (1990).
A cliché is an expression, idea, or element of an artistic
work which has become overused to the point of losing
its original meaning, or effect
• Just Because It’s a Cliché Doesn’t Mean It’s Not
True
• HISTORY
• EXAMINATION
• INVESTIGATION
DIAGNOSIS
Age
Causes of hip pain in children
DIAGNOSIS
Onset
Acute onset injury or a
rapid onset of infection. Acute slips.
Spontaneous movement
septic
arthritis of the hip is a loss of spontaneous
movement of the affected limb.
DIAGNOSIS
Systemic illness
septic arthritis,
less sick with toxic synovitis, rheumatoid spondylitis, and tumours.
Resting position of the limb
Intra-articular hip disorders spontaneous positioning in
slight flexion and externalrotation.
DIAGNOSIS
Tenderness
Hip rotation test
Guarding and a loss of internal rotation
suggest the problem is within the joint
DIAGNOSIS
Night pain
Nocturnal pain suggests the possibility of a
malignancy or infection
Back stiffness
Limitation of forward bending suggests that the
disorder may be referred from the spine.
Kocher’s Criteria for infection
•
•
•
•
non-weight-bearing,
ESR> 40 mm/hr,
fever,
WBC >12,000 mm3
4/4 criteria are met, 99%
when 1/4 criteria are met, there is a 3% chance of septic
arthritis
Hip pain and major diagnostic features
clinical features that differentiate each cause of pain.
Case Discussion
• History
• 2 yr old:
• I never noticed anything, but then grandma
said she walks oddly and then I noticed
The Limping Toddler
• DDH
• painless limp
• short leg, one sided
toe walking
• waddle bilateral
• limited abduction in
flexion
Development Dysplasia of The
hip
Clinical screening
• Infant relaxed and warm
• Nappy removed
• Firm surface
Clinical screening
• Look for thigh asymmetry
•
(Buttock crease)
• Range of movement
•
abduction in flexion
Clinical screening
•Barlow’s Test (1962)
•
attempt to
dislocate the head
posteriorly with the hip
adducted
Clinical screening
•Ortolani’s Test (1937)
•
reduction in
flexion and abduction
pushing with finger on
GT
Differentiation of septic arthritis
• Sick Child
• Non weight bearing
T > 38’C
Raised WCC
Raised CRP
andESR)
The Limping Toddler
• Transient Synovitis
• acute joint pain
• commonest age 3-8 yrs
• not systemically unwell, may be pyrexial
• Exclude infection
• Rx: rest NSAID
Juvenile Idiopathic
Arthritis
• JCA / JRA
• Incidence - 10/100000
• Prevalence – 1/1000
• Arthritis for 6/52 in the
under 16 with no cause
Juvenile Idiopathic
Arthritis
• Systemic – 10-20%
• Oligoarthritis – 50-60%
• Polyarthritis – 20-30%
Case Discussion
• History
• 5 year old:
• He has been limping when he is tired. This
has been occurring on and off for several
weeks
The Limping Child
• Perthes
• Transient interruption
of the blood supply to
the femoral head
which goes through a
cycle of necrosis,
fragmentation and
healing
• Boys 5-10
Differential Diagnosis
•
•
•
•
•
•
Transient synovitis
JIA
Trauma
Septic hip
Discitis
Late presentation dysplasia
Back pain in Children
• Difficulty in walking or
refusal to bend spine to
pick up things may
indicate discitis
• Back pain in athletes
with hyperextension
movements (gymnasts,
cricket) ..
Spondylolisthesis
Case Discussion
• History
• 13year old:
• He limps now and again
walks a little out-toed
and complains of knee
pain
Slip of the Upper Femoral Epiphysis
(SUFE)
• Acute or chronic, boys –
prepubescent, present with
pain in hip or groin or knee
(beware!!)
• Need a good quality AP and
lateral radiograph to make
the diagnosis.
SCFE / SUFE
Differential Diagnosis
• Spine
• Late presentation dysplasia
• Trauma
• Hypermobile joint
• Snapping TFL, labral pathology
Labral tears
Pain and clicking in
groin
Do not like flexion,
adduction and internal
rotation
Hip Pain in children
• Urgent diagnoses
• Infection
• SUFE
• Fracture
• Tumour
•
•
•
•
•
•
•
Soon diagnoses
DDH
Perthes
Discitis
Irritable hip
JIA
Snapping hip
Thank You

Hip Pain in Children

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