Hip Pain―Provider Track Tim Schrader, M.D.

Transcription

2014 Pediatric Orthopaedic & Sports Medicine Seminar
Saturday, November 8, 2014
Hip Pain―Provider Track
Tim Schrader, M.D.
♦ All handouts are the property of the presenters and are not to be reproduced without permission. If
handouts are not included for the session, they were not provided by the presenter.
Hip Pain:
Elementary to High School
Tim Schrader, MD
Medical Director, CHOA Hip Program
Differential diagnosis
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Trauma/mechanical
Congenital
Inflammatory
Infectious
Neoplastic
Metabolic
Vascular
Other
Referred
Children’s Healthcare of Atlanta
Differential diagnosis
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Trauma/mechanical
Congenital
Inflammatory
Infectious
Neoplastic
Metabolic
Vascular
Other
Referred
• Slipped capital femoral
epiphysis (SCFE)
• Apophysitis
• Avulsion fracture
• Snapping hip
• FAI
• DDH
• Legg-Calvé-Perthes
disease
• Fractures
Hip pain by age
Children <8 y.o.
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Adolescent >10 y.o.
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Toxic synovitis
Septic arthritis
Osteomyelitis
Perthes
SCFE
Apophysitis
Avulsion fractures
FAI
Stress fractures
DDH
Tumor, Trauma
History
• Pain
– Location, timing, severity,
quality, duration,
aggravating/alleviating
factors
• Trauma, limp, weight
bearing?
• Fever, chills, constitutional
symptoms
– Prior URI
• Similar prior symptoms
• Missed activities
• Prior treatments
History
• Pain
– Location, timing, severity,
quality, duration,
aggravating/alleviating
factors
• Trauma, limp, weight
bearing?
• Fever, chills, constitutional
symptoms
– Prior URI
• Similar prior symptoms
• Missed activities
• Prior treatments
Physical examination
• Observation
– Asymmetry
– Resting position
• “log-rolling”
– Isolated hip rotation
• Heel tap
• Impingement test (FADIR)
– Compare to contralateral side
• Patrick’s test (FABER)
– Flexion-Abduction-ER
– SI vs. hip
• Ober’s test
– IT band
• ROM
– Supine, sitting and/or prone
– Stabilize the pelvis to assess
true “hip” motion
– Drehmann’s sign
• Point of maximal tenderness
– Iliac crest, ischial tuberosity,
greater trochanter, pubic
symphysis
• Obligate ER with flexion (SCFE)
• Stance
– Limb lengths
– Trendelenburg sign
• Gait
– Antalgic
– Trendelenburg
– Foot progression
• Hop test
• If “snapping” symptoms
– Iliopsoas provocation
• Supine
• Groin
• Flex-Abduction-ER to
Extension-IR
– IT band provocation
• Standing or side lying
• Greater trochanter
• Extension to flexion
Special Tests
Ober’s test
Impingement
(FADIR) test
Patrick (FABER) test
Key exam points
• Log rolling
• Heel tap
• Impingement test
– Flexion, adduction, internal rotation
• ROM
– Internal rotation and abduction
• Point tenderness over bony prominence
Radiographs
• AP Pelvis
• Frog lateral Pelvis
Always get both hips
Advanced imaging
• MRI
– Infection, Tumor
– Early Perthes or SCFE
– FAI, DDH, labral tears
• US
– Infection, TS, JIA
• Bone scan
– Osteomyelitis vs. SA
– Tumor
– Multiple sites
• CT
– Osteoid osteoma
– Tumor
– Stress fracture
Case examples
#1
11 y.o. male with left “knee” pain
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Left knee/thigh pain for 3 months
Insidious onset, no trauma
Walks with limp and left foot turned out
No fever
• Obese male
• Antalgic, Trendelenburg gait
• Knee exam
– No effusion, no laxity
• Hip exam
– No pain with log rolling
– Obligate external rotation with flexion (Drehmann’s sign)
– -10 internal rotation
• Positive “attempted” impingement test
• No tenderness to palpation
What’s the diagnosis?
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B.
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Growing pains
Groin pull
SCFE
Meniscus tear
Apophysitis
Slipped capital femoral epiphysis
SCFE
http://www.childrensortho.com/slippedcapital-femoral-epiphysis-childrensorthopaedics-atlanta.html
SCFE
Most common hip problem in adolescents
• African-American 2.25 times more likely than Caucasians
• Boy:girl 1.43:1
• 40% bilateral
• >60% of SCFE patients are >90th %ile for weight
– Atypical body habitus should raise suspicion for potential
endocrine abnormality
Etiology
• Unknown
• Associated with:
– Mechanical abnormalities
– Endocrine abnormalities
Clinical history
• Typical age group 10-16
• Pain
– Can be groin, thigh or knee
– Often mistaken for “Groin pull” or “growing pains”
– Sometimes absent
• Limp
– External rotation of foot
– Difficulty sitting
• Typically overweight and
early puberty
• Trendelenburg gait
• External rotation of limb
• Limited hip motion
– Obligate external rotation
with flexion (Drehmann’s sign)
– Limited and painful internal
rotation
– Limited abduction
Imaging
• AP and frog lateral
– Include both hips looking for asymptomatic slip
– More obvious on lateral
• MRI
– Normal x-rays
– Pre-slip
Klein’s
line
Double densityBlanch sign of
Steel
Slip
angle
Femoral head stability
• Stable
– Patient can ambulate (with or without crutches)
• Unstable
– Patient unable to ambulate
• Good correlation with AVN
– Stable ~0%
– Unstable 0-60%
• Zaltz (CORR 2013)
– Overall rate 24.9%
SCFE – Delay in diagnosis
• Kocher (Pediatrics 2004) • Green (HSSJ 2005)
– 196 patients
– Average delay 8 weeks
– Slip severity
– 102 patients
– Average time from 1st
primary care visit to
ortho clinic 76 days
– 52% of primary visits for
hip, groin, knee or thigh
pain in obese children
did not lead to SCFE
diagnosis or referral
• <30° - 10 weeks
• 30-50° - 14.4 weeks
• >50° - 20.6 weeks
– Distal thigh/knee pain
– Medicaid
– Stable
Staying Out of Trouble in Pediatric Orthopaedics – John Flynn Ed.
PCP Treatment of SCFE
Make the correct diagnosis
• Urgent orthopaedic referral
– If known diagnosis then
typically sent to hospital for
admission
• Reduced weight bearing
– Wheelchair
– Crutches
• Stable slips can become
unstable slips with increased
risk of AVN and
impingement
• High index of suspicion in
obese patients with “normal”
radiographs
– Pre-slip
Orthopaedic
Treatment
• Screw fixation
– In-situ
– Manipulative reduction
• Head repositioning
• Osteotomy
• Prophylactic pinning
#2
7 y.o. male with limp
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Intermittent limp for several months
Worse during and after activities
Occasional right groin pain
No fever
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Limp
+ Trendelenburg sign
No pain with log rolling
Limited Abduction, IR and ER with pain at extremes
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B.
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Perthes
Transient synovitis
Apophysitis
Growing pains
Metastatic Wilms tumor
Legg-Calve-Perthes disease
www.perthesdisease.org
http://www.childrensortho.com/l
egg-calve-perthes-diseasechildrens-orthopaedicsatlanta.html
Perthes
• Self-limited avascular
necrosis affecting the
femoral head
• Unknown etiology
• Interruption of blood
supply to femoral head
→ Bone necrosis →
collapse → repair
– Perhaps due to repetitive
injuries over time
– Mechanical kinking of
vessels?
– Environmental factors?
– Role of coagulopathies?
• Higher incidence in
hypercoagulable patients
– e.g., Protein S
deficiency, factor V
Leiden
Perthes
• Common between ages 4 and 8 years
– Can occur between 2 and 12
• 4-5x more common in boys
• Bilateral in 10-15%
– Typically at different stages
Perthes
• Pain is usually not severe
– Groin, thigh or knee
• Limp is typical reason for medical attention
• Muscle atrophy noted if chronic
• Delayed bone age and short stature
– 90% of children with Perthes
Perthes
• Limited hip rotation (internal) & abduction
– Early on due to spasm, synovitis
– Later due to bony impingement
• Positive Trendelenburg sign and/or gait
– Weak hip Abductors
• Leg length discrepancy
– Apparent
• Adduction contracture
– True
• Femoral head flattening
Imaging
• X-ray
Increased joint space
Sclerotic epiphysis
Decreased height
Adduction
Subluxation
• MRI
– If radiographs are normal and clinical suspicion
Prognostic factors
• Age at onset of symptoms
– Under 6 generally do well
– Over 8 typically have long term problems without treatment
• Maybe even with treatment
Unfortunately we have no control
over these factors
• Head involvement
– <50% involved more favorable
– MRI helpful to determine involvement earlier than x-ray
• ROM
4 phases of Perthes disease
• Initial
– Synovitis, no bony changes, cartilage space widens, MRI useful
• Fragmentation
– Epiphysis shows “crescent sign” with subchondral fracture
• Re-ossification
– Resolution of synovitis
• 1st 3 phases can last 18-24 months
• Healing
– Can continue until skeletal maturity
PCP Treatment of Perthes Disease
• Activity restriction
– Sports
– PE
– Crutches
• Referral to
Orthopaedics
• NSAIDs
– Short duration
• www.perthesdisease.org
Orthopaedic Treatment
• Non-operative
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Activity restrictions
NWB
NSAIDs
Physical therapy
• Containment
– Casting
– Bracing
– Surgery
• Femoral osteotomy
• Pelvic osteotomy
• Core decompression
• Bisphosphonates
#3
14 y.o. male with right groin pain
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Acute onset during soccer match
Felt “pop” as he was kicking the ball
Still able to walk but could not continue playing
Has had aching in his groin during practice for several
weeks prior this injury
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Antalgic gait
Point tender over AIIS
No pain with passive ROM except extension
Weakness and pain with hip flexion
No swelling, redness, warmth
No pain with heel tap
A.
B.
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D.
E.
Femoral neck fracture
Herniated disc
SCFE
Labral tear
Apophyseal avulsion
Apophysitis
Apophyseal avulsion fractures
http://www.childrensortho.com/newsl
etter/kids-corner/ksc-pelvicinjuries/ksc_08.htm
Apophysitis
• Skeletally immature
– 10-18 years of age
• Gradual onset
• Point tender over bone
• Pain when inserting
muscles are stressed
• May have swelling
Apophyseal avulsion
fractures
• Skeletally immature
– 12-18 years of age
• Sudden onset
– Kicking, Jumping, Hurdles
• Point tender over bone
• Swelling, ecchymosis
• May have antecedent
symptoms from
apophysitis
Apophysitis
• Iliac Crest
– Abdominal (internal/external oblique and
transversus)
• ASIS
– Sartorius
• AIIS
– Rectus femoris
• Ischial Tuberosity
– Hamstrings
• Greater Trochanter
– Gluteus medius/minimus
• Lesser Trochanter
– Iliopsoas
• Inferior Pubic ramus
– Adductors
Ischial apophysitis
Iliac apophysitis
Avulsion fractures
ASIS
AIIS
PCP Treatment of Apophysitis
• Guidance
– Symptoms may wax and
wane for several years
– May progress to fracture
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Rest
Ice
NSAIDs
Stretching (therapy)
Activity modification
• Can they play sports?
– How much does it hurt
and how much are they
adding to the team?
– May fracture
– Not the hip “joint”
• Refer to Orthopaedics
if:
– Symptoms don’t respond
to treatment
PCP Treatment of Pelvic Avulsion Fractures
• Conservative unless severely
displaced (>2 cm)
• No sports, PE
• Crutches
– 2-3 weeks
– Until walking without pain
• Rest
• NSAIDs (± narcotics)
• PT
– Restore flexibility, strength and
function
if:
– Displaced >2 cm
– Pain not improved with
medication, rest and
crutches
– Pain continues >6-8
weeks
• Can take 6-12 weeks to return to
pain free sports
• Risk of re-injury without complete
healing and/or rehab
#4
17 y.o. female with right groin pain
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Pain is increasing, worse with activities
Physically active, cheerleader
No specific trauma
1st born, FT, Breech
• “feels like hip needs to pop”
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Thin, healthy appearing
No LLD
No Galeazzi sign
Decreased ER/IR on contralateral side
Positive impingement test
No snapping with IS or IT band testing
Mild tenderness over hip capsule
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B.
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Growing pains
Snapping hip
DDH
Impingement
Labral tear
Developmental dysplasia of the hip
DDH
http://www.childrensortho.com/developme
ntal-dysplasia-hip-childrens-orthopaedicsatlanta.html
http://www.hipdysplasia.org
DDH
• Although not typically painful in early years, DDH is
one of the most common etiologies of hip OA
• Only as the hip wears does pain begin
– Lateral, groin or buttock pain
– Mechanical symptoms
• Snapping or popping
– Sense of “instability” or “giving way”
• Older adolescents and young adults
• Females
• Infant DDH risk factors
DDH – delay in diagnosis
• Nunley JBJS 2011
– 57 mature patients with DDH
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97% insidious onset of pain
77% with mild to moderate pain on daily basis
72% had groin pain, 66% had lateral hip pain
97% with positive impingement test
Mean time from onset of symptoms to diagnosis was 61.5 months
Mean number of health care providers seen prior to diagnosis was 3.3
DDH
• ROM
– Increased rotation
– Maybe decreased abduction
• LLD
• Trendelenburg sign
DDH
Anatomic Abnormality
• Oblique, shallow acetabulum
Mechanical Abnormality
• Overload of rim/labrum
• Instability and shearing
Imaging
• Upsloping roof
– Acetabular index
• Decreased lateral
coverage
• Shenton’s line disrupted
– Subluxation
• May be retroverted with
“cross-over”
Mild to moderate cases frequently read as
“normal, no fracture or dislocation” or
“positive cross-over c/w FAI”
PCP Treatment of DDH
• Activity modification
• NSAIDs
• Physical therapy
• Referral to
Orthopaedics
• www.hipdysplasia.org
• Non-operative
• Core strengthening,
proper alignment/posture
– NSAIDs
– Activity modification
– Limited roles
• Injection
• Osteotomy
– Acetabulum
– Femur
• Salvage
– Hip fusion
– Total hip arthroplasty
– Resurfacing
– Only for advanced DJD
– To isolate hip as pain
generator
Ganz – Periacetabular osteotomy (PAO)
• Series of cuts around the acetabulum which allows
correction of mature dysplasia
Case # 5
17 y.o. male with right groin pain
• Pain with activities
• Groin ache when sitting for long periods of time
• Played football and had constant trauma
– Nothing specific to the hip
• “Stiff”
– Can’t sit cross-legged
• 1st born, FT, not breech
• Just moved from AZ and has seen several providers
including Psychiatry because of his pain
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Athletic male
Normal gait
IR limited to neutral on both sides
+ impingement test
A.
B.
C.
D.
E.
Impingement
SCFE
DDH
Snapping hip
Hernia
Femoro-acetabular impingement
FAI
http://www.childrensortho.com/femoroacet
abular-impingement-childrensorthopaedics-atlanta.html
FAI
• Cam type
– Femoral origin
• SCFE, Perthes
– Lack of head/neck offset
– Males, younger
• Pincer type
– Acetabular origin
• Protrusio
– Females, older
• Mixed type
CAM
• Jamming of an abnormal
femoral head with increasing
radius into the acetabulum
• Labral damage
– Relatively little as labrum
moves out of the way
• Cartilage damage
– Deep cartilage delamination,
large defects
– Antero, anterolateral lesions
PINCER
• Linear contact between
acetabular rim and neck
• Labral damage
– Degeneration with
intrasubstance ganglion
– Ossification of the rim
• Cartilage damage
– Adjacent to labral injury; small
areas
– “Contre-coup” lesion; posteroinferior acetabulum
FAI
• Adolescents and young adults
• Groin pain
– Worse with flexion activities
• Stairs, shoes, cars, squatting
– Lateral, cutting movements
• Lateral, buttock pain
• Decreased internal rotation
– Especially with flexion
• Trendelenburg sign
Imaging
• Radiographs
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• MRI
Cross-over sign
Ischial spine sign
Posterior wall sign
Lack of anterior offset
– Arthrogram
• Increases
sensitivity/specificity for
labral and cartilage injury
FAI – Delay in Diagnosis
• Clohisy CORR 2009
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51 patients with FAI
65% insidious onset of pain
Groin pain in 83%
88% had positive impingement test
Average time from initial symptoms to diagnosis was 3.1 years
Patients saw an average of 4.2 (1-16) healthcare providers
• 16% PCP, 46% orthopods, 15% PT, 5% chiropractors
• 13% had surgery that did not improve their pain
FAI
PCP Treatment of FAI
• NSAIDs
• Referral to
Orthopaedics
Refer patients with symptoms of
DDH/FAI despite “normal” x-rays
• Non-operative
• Core strengthening,
proper alignment/posture
– NSAIDs
– Activity modification
– Limited roles
• Injection
– Only for advanced DJD
– Isolate the hip as pain
generator
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Arthroscopy
Arthrotomy
Surgical dislocation
Osteotomy
• Salvage
– Hip fusion
– THA
– Resurfacing
Labral tear
Labral tears
• Majority are secondary to FAI or DDH
• Rarely isolated injury
• Supra-physiologic motion
– Dancer, gymnast
• Pain
– Insidious from repetitive trauma
– Acute from traumatic event
Treatment
• NSAIDs
• Treat underlying cause
– DDH
– FAI
Case #6
16 y.o. female with a “dislocating hip”
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Lateral hip pain, worsening
No specific trauma
First started snapping several years ago
1st born, FT, Breech
• “see, my hip is dislocating”
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Thin, healthy appearing
No LLD
No Galeazzi sign
Symmetric IR/ER
Positive Ober test
A.
B.
C.
D.
E.
DDH
Impingement
Labral tear
Hernia
Snapping hip
Snapping hip
http://www.childrensortho.com/snappinghip-syndrome-childrens-orthopaedicsatlanta.html
Snapping hip - “Coxa Saltans”
• Teenagers, young adults
• Active
– Ballet, dance
– Slender
• Extra-articular
– External snapping
– IT band
– Internal snapping
• Not active
– Iliopsoas
– “Video-gamer”
– Obese
• May be secondary to other
hip pathology
• Overall alignment
• Intra-articular
– Loose body
– Labral tears
– Flat feet
– Valgus leg
– Femoral anteversion
External snapping
• Painful and sometimes
audible popping over
lateral hip
• “My hip is dislocating”
• Iliotibial band moving
over greater trochanter
– Trochanteric bursitis
• Flexion-extension
• Ober test
“Can be seen from across the
room”
Internal snapping
• Painful and frequently
audible popping in the
groin
• Iliopsoas tendon moving
over
“Can be heard across the room”
– Pelvic brim (iliopectineal
eminence)
– Femoral head
– Lesser trochanter
• Flexion-abduction-ER to
extension-IR
Treatment of Snapping Hip
• Determine if there is
underlying pathology
– FAI
– DDH
• Extra-articular
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if:
– Intra-articular source
– Refractory cases
Rest, ice, NSAIDs
Foot orthotics
Physical therapy
Corticosteroid injection
Rarely surgical lengthening or
release
• Intra-articular
– Operative
#5
13 y.o. female with left groin pain
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Progressive pain in left groin for 3 months
Runs cross country and has for years
Pain starts during a run
No pain when walking
Relieved with Ibuprofen
No trauma
No fever
3rd child, not breech
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No tenderness
No erythema, warmth, lymphadenopathy
Normal ROM
Normal gait
A.
B.
C.
D.
E.
Stress fracture
Infection
Restless leg syndrome
Growing pains
Juvenile idiopathic arthritis
Femoral neck stress fracture
http://www.childrensortho.com/femoralneck-stress-fracture-sports-medicinechildrens-orthopaedics-atlanta.html
Stress fracture
• Active Adolescent
– Runners, endurance athletes
– Recent change in training
– Female athlete triad
• Amenorrhea, eating disorder and osteoporosis
• Groin pain
– Initially during activities only but then can progress to pain
at rest
• May have slightly decreased ROM
• “Hop test”
Imaging
• X-rays
– Frequently normal
initially
– Increased sclerosis
– Fracture line
– Callus
• MRI
– Normal x-rays
– High suspicion
Superior neck – tension side
Inferior neck – compression side
Treatment of femoral neck stress fractures
• Can progress to AVN,
non-union, displaced
fracture
• Surgery
• Compression side
if:
– Tension sided
– Continued pain despite
rest and crutches
– X-ray progression
– Crutches
• WBAT as long as pain
free
– Restricted activity 6-12 weeks
– Serial x-rays (MRI)
– Physical therapy
Summary
Hip Pain
• Hip pathology is common
– FAI and DDH may have very subtle findings
• Most adult hip arthritis is secondary to anatomic
abnormalities present in childhood and adolescence
• Making the correct diagnosis in a timely fashion can
influence outcome
– SCFE
– Perthes
– DDH, FAI
Key exam points
• Log rolling
• Heel tap
– Flexion, adduction, internal rotation
• ROM
– Internal rotation and abduction
• Point tenderness over bony prominence
Imaging
• AP/Frog lateral pelvis x-rays
• Radiographs with subtle abnormalities can be read as
normal
• Lifelines
– MRI
– Orthopaedic consult
THANK YOU
[email protected]
404-556-7500
Mary Beth Brock
[email protected]
678-686-6858
References
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