Download - Pediatric Hip Pain: Septic Arthritis, Transient Synovitis, and

Pediatric Hip Pain: Pediatric Hip Pain: Septic Arthritis, Transient Septic Arthritis, Transient

Synovitis, and OsteomyelitisSynovitis, and Osteomyelitis

Benjamin Easter, MS IIIBenjamin Easter, MS IIIGillian Lieberman, MDGillian Lieberman, MD

Core Radiology Clerkship, BIDMCCore Radiology Clerkship, BIDMCNovember 16, 2009November 16, 2009

AgendaAgenda

Patient PresentationPatient PresentationAnatomy ReviewAnatomy ReviewDifferential Diagnosis of Hip Pain/LimpDifferential Diagnosis of Hip Pain/LimpSeptic Arthritis vs. Transient SynovitisSeptic Arthritis vs. Transient SynovitisOsteomyelitisOsteomyelitisDiagnose our PatientDiagnose our Patient

Our Patient Our Patient ––

History and Physical ExamHistory and Physical Exam

HPI:HPI: MB is a 20 month old previously healthy female with 1 day MB is a 20 month old previously healthy female with 1 day history of sudden pain in her L hip. Refuses to walk. No recent history of sudden pain in her L hip. Refuses to walk. No recent falls or trauma. falls or trauma. Further history: Further history: NonNon--contributorycontributoryVitalsVitals: T 37.3, HR 120, BP 105/59, RR 24: T 37.3, HR 120, BP 105/59, RR 24Focused Exam:Focused Exam: L leg was extended and internally rotated. L L leg was extended and internally rotated. L hip tender to palpation. No warmth, tenderness, or erythema of hip tender to palpation. No warmth, tenderness, or erythema of lower extremity, lower back, or SI joint. Knee and ankle can be lower extremity, lower back, or SI joint. Knee and ankle can be manipulated through FROM. Resists manipulation of hip. Will manipulated through FROM. Resists manipulation of hip. Will not bear weight on L. An insect bite was apparent on left calf.not bear weight on L. An insect bite was apparent on left calf.Remainder of exam:Remainder of exam: Benign Benign

Hip AnatomyHip Anatomy

Children’s Hospital of Philadelphia. Available at: http://www.chop.edu/healthinfo/anatomy-of-a-joint.html. Accessed November 12, 2009.

Advanced Technology Hip Surgery. Available at: http://www.hipsurgery.co.il/english/introduction.htm. Accessed November 12, 2009.

Hip Blood SupplyHip Blood Supply

Wheeless’ Textbook of Orthopaedics. Available at: http://www.wheelessonline.com/ortho/blood_supply_to_femoral_head_neck. Accessed November 12, 2009.

Fx of femoral neck can disrupt perfusion through branches of circumflex femoral arteries, leading to avascular necrosis (AVN)

Exhaustive Differential Diagnosis of Exhaustive Differential Diagnosis of Hip Pain/Limp in ChildrenHip Pain/Limp in Children

InfectiousInfectiousSeptic ArthritisSeptic Arthritis-- Hip/SI JointHip/SI JointOsteomyelitsOsteomyelits-- femoral head, pelvisfemoral head, pelvisDiskitisDiskitisLyme ArthritisLyme ArthritisPsoas abscessPsoas abscessCellulitisSoft tissue abscessPyomyositisAppendicitisPelvic inflammatory diseasePelvic abscesssBursitis

Mechanical/OrthopedicMechanical/OrthopedicSlipped Capital Femoral Epiphysis (SCFE)Slipped Capital Femoral Epiphysis (SCFE)LeggLegg--CalveCalve--Perthes (LCPD)Perthes (LCPD)Developmental Dysplasia of HipDevelopmental Dysplasia of HipPatellofemoral pain syndromeMyositis ossificans

NeoplasticNeoplasticOsteoid OsteomaOsteoid OsteomaOsteogenic SarcomaOsteogenic SarcomaEwing SarcomaEwing SarcomaLeukemiaLeukemiaSpinal Cord TumorsSpinal Cord TumorsLeukemiaLeukemiaLymphomaLymphoma

InflammatoryInflammatoryToxic/Transient SynovitisToxic/Transient SynovitisJuvenile Rheumatoid ArthritisJuvenile Rheumatoid ArthritisSpondyloarthropathySpondyloarthropathyKawasaki DiseaseKawasaki DiseaseDermatomyositisPolyarteritis nodosaHenoch Schonlein PurpuraSystemic Lupus Erythematosus

TraumaTraumaSprains, Strains, ContusionsSprains, Strains, ContusionsFracture (fx)Fracture (fx)-- Toddler’s, stress, otherToddler’s, stress, other

More Practical, Narrowed More Practical, Narrowed Differential DiagnosisDifferential Diagnosis

Septic ArthritisSeptic Arthritis-- can’t miss due to rapid joint can’t miss due to rapid joint destruction and morbiditydestruction and morbidityToxic SynovitisToxic Synovitis-- most common diagnosis in most common diagnosis in children with limp*children with limp*OsteomyelitisOsteomyelitis-- high morbidity if missedhigh morbidity if missedTraumaTraumaAcquiredAcquired-- LeggLegg--CalveCalve--Perthes Disease (LCPD), Perthes Disease (LCPD), Slipped Capital Femoral Epiphysis (SCFE)Slipped Capital Femoral Epiphysis (SCFE)CancerCancer

*Fischer SU, Beattie TF. The limping child: epidemiology, assessment, and outcome. JBJS Br 1999; 81(6):1029-1034.

Septic Arthritis (SA) of the HipSeptic Arthritis (SA) of the Hip

Infancy, 3Infancy, 3--6 year olds6 year oldsStaph, Group B Strep, GonococcalStaph, Group B Strep, GonococcalSpreadSpread

Direct InoculationDirect InoculationLocal SpreadLocal SpreadHematogenous SpreadHematogenous Spread-- 72%*72%*

MechanismMechanism-- Bacteria in synovial Bacteria in synovial membranemembrane acute inflammatory acute inflammatory responseresponse cartilage destructioncartilage destructionsynovial effusionssynovial effusions necrosisnecrosisComplicationsComplications-- necrosis/joint necrosis/joint destruction, growth arrest, sepsisdestruction, growth arrest, sepsisTxTx-- antibiotics, arthrocentesisantibiotics, arthrocentesis

*Morgan DS, Fisher D, Marianos A, Currie BJ. An 18 year clinical

review of septic arthritis from tropical Australia. Epidemiol Infect 1996; 117:423.

Health Resources. Available at: http://www.health-

res.com/differential-diagnosis-of-septic-arthritis/. Accessed November 12, 2009.

Transient Synovitis (TS)Transient Synovitis (TS)

Inflammation of joint spaceInflammation of joint spacePain and limited ROM in hipPain and limited ROM in hipNo clear precipitantNo clear precipitant

allergic allergic posttraumaticposttraumaticPostPost--infectious (classically follows URI)*infectious (classically follows URI)*

Benign clinical course that resolves with Benign clinical course that resolves with conservative tx (NSAIDs)conservative tx (NSAIDs)

*Taylor GR, Clarke NM. Management of irritable hip: a review of hospital admission policy. Arch Dis Child 1994;71:59. *Haueisen DC, Weiner DS, Weiner Se. The characterization of “transient synovitis of the hip” in children. J Pediatr Orthop 1986;6:11.

Transient Synovitis and Septic Arthritis Transient Synovitis and Septic Arthritis –– Different Entities, Similar PresentationDifferent Entities, Similar Presentation

atraumatic, acutely irritable hip atraumatic, acutely irritable hip progressive signs of fever progressive signs of fever limp or refusal to bear weight limp or refusal to bear weight limited ROM limited ROM abnormal labsabnormal labs

Because of the morbidity of SA Because of the morbidity of SA and the relatively benign course and the relatively benign course of TS, it is very important to be of TS, it is very important to be

able to distinguish between these able to distinguish between these two entities. What is the role of two entities. What is the role of

imaging in this process?imaging in this process?

Role of Imaging Role of Imaging ––

Plain RadiographsPlain RadiographsBy ACR Appropriateness criteria, plain films of By ACR Appropriateness criteria, plain films of the area of interest are the #1 study in all the area of interest are the #1 study in all limping/hip pain children!*limping/hip pain children!*AdvantagesAdvantages

Rapid overviewRapid overviewRule out certain conditions e.g. fxRule out certain conditions e.g. fxRule in certain conditions e.g. SCFERule in certain conditions e.g. SCFEFast, cheap, readily availableFast, cheap, readily availableAutomatic control from contralateral hipAutomatic control from contralateral hip

*American College of Radiology. ACR Appropriateness Criteria-

Limping Child Ages 0-5 Years. 2007. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonPediatricImaging/Limping

ChildUpdateinProgressDoc6.aspx. Accessed November 10, 2009.

Let’s view some examples of Let’s view some examples of diagnoses that can be made on diagnoses that can be made on

plain film alone. plain film alone.

Toddler’s Fracture on Plain FilmToddler’s Fracture on Plain Film

Gable H. Image Interpretation. Available at: http://www.imageintGable H. Image Interpretation. Available at: http://www.imageinterpretation.co.uk/images/ankle/TODDLERS%20AP.jpg. erpretation.co.uk/images/ankle/TODDLERS%20AP.jpg. Accessed November 12, 2009. Accessed November 12, 2009.

Toddler’s Fracture on frontal radiograph of R lower extremity–

oblique, nondisplaced fx of tibial diaphysis

LeggLegg--CalveCalve--Perthes Disease on Plain FilmPerthes Disease on Plain Film

Legg-Calve-Perthes Disease on frontal radiograph of pelvis -AVN of L femoral head

PACS, CHB

Avulsion Fracture on Plain Film Avulsion Fracture on Plain Film

PACS, CHB

Frontal radiograph of pelvis showing avulsion fx of R ischial tuberosity in 14 yo F athlete

SCFE on Plain FilmSCFE on Plain Film

“Frog leg”/lateral radiograph of pelvis showing R SCFE with “ice cream falling off cone” appearance

PACS, CHB

In review, plain films are the In review, plain films are the initial study of choice in all initial study of choice in all

children with hip pain or limp. children with hip pain or limp. What are the imaging What are the imaging

recommendations for patients recommendations for patients with suspected SA?with suspected SA?

Imaging of Suspected Septic Arthritis Imaging of Suspected Septic Arthritis -- ACR Appropriateness Criteria and Score*ACR Appropriateness Criteria and Score*

Plain Films Plain Films –– 9 9 Early ChangesEarly Changes-- effusion, soft effusion, soft tissue swellingtissue swellingLate ChangesLate Changes-- cortical cortical destruction, periosteal reactiondestruction, periosteal reaction

Ultrasound of Hip Ultrasound of Hip –– 88Detect effusionDetect effusionGuide aspiration (provides Guide aspiration (provides definitive diagnosis)definitive diagnosis)

TcTc--99m bone scan of lower 99m bone scan of lower extremity extremity –– 77

Good for nonfocal physical examsGood for nonfocal physical exams54% of patients with no diagnosis 54% of patients with no diagnosis after clinical, laboratory, and after clinical, laboratory, and radiographic evaluation had radiographic evaluation had abnormal bone scans+abnormal bone scans+

MRI of area of interest MRI of area of interest –– 77Detect effusion, synovial Detect effusion, synovial inflammationinflammationNonspecific changesNonspecific changes

*American College of Radiology, 2007.+Aronson J, Garvin K, Seibert J, et al. Efficiency of the bone scan for occult limping toddlers. J Pediatr Orthop

1992;12(1):38-44.

Let’s look at our patient’s Let’s look at our patient’s initial imaging…initial imaging…

Our Patient’s Plain FilmsOur Patient’s Plain Films

All Images-

PACS, CHB

FrontalRadiographs of Pelvis and Left Lower Extremity

LateralRadiographs of Pelvis and Left Lower Extremity

Frog leg position (femur abducted, externally rotated) provides lateral view of femoral heads

All films read as normal

Our Patient’s UltrasoundOur Patient’s UltrasoundTwo Primary RolesTwo Primary Roles

Detect joint effusionDetect joint effusionGuide aspiration of effusion which provides only definitive diagGuide aspiration of effusion which provides only definitive diagnosis of SAnosis of SA

Because TS is most common cause of limp, some algorithms use U/SBecause TS is most common cause of limp, some algorithms use U/Sbefore plain films in evaluation of these children*before plain films in evaluation of these children*

PACS, CHB

Normal joint space-anechoic, concave

Iliopsoas Tendon

Femoral Head

Femoral Metaphysis

Sagittal Ultrasound of MB’s hips

*

Joint Effusion-increased size, convex shape

* Fischer, 1999

What’s the problem with Ultrasound?What’s the problem with Ultrasound?

Both SA and TS present with joint effusion, so Both SA and TS present with joint effusion, so ultrasound can’t make this allultrasound can’t make this all--important important distinctiondistinctionOptions for distinguishing SA from TSOptions for distinguishing SA from TS

1. Clinical Criteria1. Clinical Criteria2. Arthrocentesis2. Arthrocentesis

Option 1Option 1--

Kocher Criteria* for Kocher Criteria* for Differentiating SA and TSDifferentiating SA and TS

1.1.

FeverFever

2.2.

NonNon--weight bearingweight bearing

3.3.

ESR>40 mm/hrESR>40 mm/hr

4.4.

WBC>12,000/mmWBC>12,000/mm33

Prospective Prospective ConfirmationConfirmation

Only 59% chance of Only 59% chance of SA if all 4 criteria metSA if all 4 criteria met++

*Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic Arthritis and transient synovitis of the hip in children. JBJS (Am)

1999;81(12):1662-70. +Luhmann SJ, Jones A, Schutmann M, et al. Differentiation Between Septic Arthritis and Transient Synovitis of the Hip in Children with Clinical Prediction Algorithms. JBJS

2004;86:956-962.

CriteriaCriteria Chance of SAChance of SA

00 0.2%0.2%11 3.0%3.0%22 40%40%33 93%93%44 99.6%99.6%

Our Patient and the Kocher CriteriaOur Patient and the Kocher Criteria

How would our patient score on the Kocher How would our patient score on the Kocher Criteria?Criteria?

AfebrileAfebrileNon weight bearingNon weight bearingESR 86 mm/hrESR 86 mm/hrWBC 12,500/mmWBC 12,500/mm3

She meets 3 of the Kocher criteria, so her chance of SA is 93%If her chance were lower, we could stop here93% chance of SA requires us to proceed with arthrocentesis

Option 2 Option 2 ––

ArthrocentesisArthrocentesisAspiration provides Aspiration provides definitive diagnosis and definitive diagnosis and fluid can be sent for fluid can be sent for culture and sensitivityculture and sensitivityBut aspiration is invasive, But aspiration is invasive, so we don’t want to do it so we don’t want to do it in setting of low clinical in setting of low clinical suspicion for SAsuspicion for SAMB’s Kocher criteria MB’s Kocher criteria gave us a high suspicion gave us a high suspicion for SA, so we decided for SA, so we decided that aspiration was that aspiration was appropriateappropriate

Companion PatientSagittal Ultrasound-Guided Aspiration of Hip

* Effusion

Femur

Needle

PACS, CHB

MB’s parents did not MB’s parents did not consent to arthrocentesis consent to arthrocentesis

(they felt her clinical status (they felt her clinical status had improved). So we can’t had improved). So we can’t

definitively say what she definitively say what she had, but let’s look at some had, but let’s look at some

other patients with SA.other patients with SA.

Septic Arthritis Septic Arthritis ––

Companion Patient #1 Companion Patient #1 7 yo M presenting with R hip pain7 yo M presenting with R hip painSagittal Ultrasound of Hip

T2 Fat Sat Axial MRI

PACS, CHB

Femoral heads with normal bone marrow signal

Hyperintense fluid within joint space consistent with effusion

Joint space wideningPACS, CHB

XR AP Pelvis, Companion PatientEffusion Effusion bulging fat padsbulging fat pads

GlutealGluteal and and IliopsoasIliopsoas

*

*

Manaster BJ. Chronic Hip Pain: Radiographic Evaluation Radiographics 2000;20:S3-S25


Companion Patient #1 Companion Patient #1 7 yo M presenting with R hip pain7 yo M presenting with R hip pain

In this patient, septic arthritis was confirmed

by aspiration, but transient synovitis

could have had identical imaging.


Companion Patient #2Companion Patient #2 11 yo M p/w 3 day history of 11 yo M p/w 3 day history of

refusal to bear weight, fevers, chillsrefusal to bear weight, fevers, chillsPlain films at outside hospital read as normalPlain films at outside hospital read as normalThe now familiar ultrasound…The now familiar ultrasound…

PACS, CHB

*

Joint space shows effusion

Sagittal Ultrasound of Hips

Layering and echogenicity consistent with debris


Companion Patient #2Companion Patient #2 11 yo M Continued11 yo M Continued

Tc-99m Bone Scan of Anterior Pelvis

PACS, CHB

Diminished tracer uptake/photopenia in R capital femoral epiphysis indicating lack of perfusion

What’s the story?


Companion Patient #2Companion Patient #2 11 yo M Continued11 yo M Continued

MR Axial T2 Fluid Sensitive MR Coronal T1 Post-Contrast

Hyperintense collections showing joint effusion and surrounding edema

PACS, CHB

Lack of enhancement of R capital femoral epiphysis compared to L suggests avascular necrosis

PACS, CHB


Companion Patient #2 Companion Patient #2 What Happened?What Happened?

Septic Arthritis Septic Arthritis Joint Effusion Joint Effusion Tamponade of Tamponade of

Vascular Supply to Vascular Supply to Femoral Head Femoral Head

Avascular Necrosis of Avascular Necrosis of Femoral Head Femoral Head

Imaging of Septic Arthritis Imaging of Septic Arthritis -- ConclusionConclusion

Imaging can distinguish between Imaging can distinguish between SA and TS, but generally only late SA and TS, but generally only late in the disease process when there is in the disease process when there is already bone involvement/AVN.already bone involvement/AVN.

Back to Our Patient Back to Our Patient ––

Hospital CourseHospital Course

Day 2Day 2Spiked fever Spiked fever Now partially weight bearingNow partially weight bearingRepeat U/S showed Repeat U/S showed resolution of effusionresolution of effusionResolving U/S and partial Resolving U/S and partial weight bearing reduce weight bearing reduce suspicion for SAsuspicion for SASpiking fevers and hip pain Spiking fevers and hip pain increase suspicion for increase suspicion for osteomyelitisosteomyelitis PACS, CHB

Increased echogenicity along femur is thickened synovium, but effusion has largely resolved compared to above image

*

*

Sagittal Ultrasounds of our Patient’s L Hip-Admission (Above) and Hospital Day 2 (Below)

PACS, CHB

OsteomyelitisOsteomyelitis

Proximal femur is most common site in childrenProximal femur is most common site in childrenPelvic osteomyelitis may also occur (notably Pelvic osteomyelitis may also occur (notably children will allow careful examination of hip)children will allow careful examination of hip)Menu of ImagingMenu of Imaging

Plain FilmPlain Film-- more sensitive in later stages, shows more sensitive in later stages, shows bone destruction (if >30%) and effusion*bone destruction (if >30%) and effusion*Bone ScanBone Scan-- can detect multifocal disease in children can detect multifocal disease in children with suspected osteomyelitiswith suspected osteomyelitisMRIMRI-- useful if plain films negative, detect bone useful if plain films negative, detect bone marrow edema and effusionmarrow edema and effusion

*Myers MT, Thompson GH. Imaging the Child with a Limp. Pediatric Clinics of North America

1997;44(3): 637-658.

Osteomyelitis Osteomyelitis ––

Companion Patient #3Companion Patient #3 11 yo F fever, L hip pain, MSSA bacteremia11 yo F fever, L hip pain, MSSA bacteremia

PACS, CHB

Note LACK of effusion

*

Tc-99m Bone Scan

Increased tracer uptake in L ischium and acetabulum

PACS, CHB

Sagittal Ultrasound of L Hip


Companion Patient #3 Companion Patient #3 11 yo F fever, L hip pain, MSSA bacteremia11 yo F fever, L hip pain, MSSA bacteremia

MR Axial T2/Fluid Sensitive Sequences-

Inferior on Left and Superior on Right

Hyperintensity on Fluid Sensitive Sequence showing Marrow Edema

and Abscess

**

PACS, CHB

*


Companion Patient #3 Companion Patient #3 11 yo F fever, L hip pain, MSSA bacteremia11 yo F fever, L hip pain, MSSA bacteremia

MR Coronal T1 Pre-Contrast (Left) and Post-Contrast (Right)

PACS, CHB

Enhancement of L ischium with contrast suggests increased perfusion to infected bone


MR ImagesMR ImagesT1 Coronal MRI of Pelvis T2 Coronal MRI of Pelvis

Normal bone marrow intensity bilaterally without surrounding fluid

No difference in signal intensity or appearance between R and L femurs

No Evidence of Osteomyelitis

PACS, CHB


A ReviewA Review

20 month old female with pain in L hip and 20 month old female with pain in L hip and refusal to walkrefusal to walkPlain FilmsPlain Films-- NormalNormalU/SU/S-- Significant effusion in L hipSignificant effusion in L hipNo aspiration per parent’s requestNo aspiration per parent’s request2 days later2 days later-- resolving effusion and spiking resolving effusion and spiking feversfeversMRMR-- No evidence of osteomyelitisNo evidence of osteomyelitis

Our Patient’s DiagnosisOur Patient’s Diagnosis--

Transient SynovitisTransient Synovitis

Pain and limited ROM in hipPain and limited ROM in hipNo clear precipitantNo clear precipitantRole of Imaging in TSRole of Imaging in TS

Plain FilmsPlain Films-- exclude bony abnormalities, may be normal exclude bony abnormalities, may be normal or show effusionor show effusionU/SU/S-- shows effusion and may guide arthrocentesisshows effusion and may guide arthrocentesisMRIMRI-- may show joint effusion and synovial may show joint effusion and synovial inflammation, exclude osteomyelitisinflammation, exclude osteomyelitis

Imaging results not specific for TSImaging results not specific for TSTS is a clinical diagnosis that requires ruling out SA TS is a clinical diagnosis that requires ruling out SA by aspiration if suspicion highby aspiration if suspicion high

Review/ConclusionsReview/ConclusionsDDx of hip pain/limp in children is very broadDDx of hip pain/limp in children is very broadACR Appropriateness CriteriaACR Appropriateness Criteria

Everyone should get plain filmsEveryone should get plain filmsU/S, MRI, TcU/S, MRI, Tc--99m Bone Scan all have a role99m Bone Scan all have a roleLittle role for CTLittle role for CT-- limited to trauma, prelimited to trauma, pre--op planningop planning

Viewed radiographic appearance of Toddler’s fx, LCPD, Viewed radiographic appearance of Toddler’s fx, LCPD, avulsion fx, SCFEavulsion fx, SCFEViewed characteristics of SA, TS, and osteomyelitis on Viewed characteristics of SA, TS, and osteomyelitis on various imaging modalitiesvarious imaging modalitiesTS vs. SA is a hard and allTS vs. SA is a hard and all--important decisionimportant decision

Imaging not very helpful until late in disease processImaging not very helpful until late in disease processKocher Criteria can helpKocher Criteria can helpArthrocentesis provides definitive diagnosisArthrocentesis provides definitive diagnosis

AcknowledgementsAcknowledgements

Thank you!Thank you!Adam Jeffers, MDAdam Jeffers, MDSarah Bixby, MDSarah Bixby, MDDiana Rodriguez, MDDiana Rodriguez, MDIva Petkovska, MDIva Petkovska, MDGillian Lieberman, MDGillian Lieberman, MDMaria LevantakisMaria Levantakis

ReferencesReferencesAdvanced Technology Hip Surgery. Available at: http://www.hipsuAdvanced Technology Hip Surgery. Available at: http://www.hipsurgery.co.il/english/introduction.htm. rgery.co.il/english/introduction.htm. Accessed November 12, 2009.Accessed November 12, 2009.American College of Radiology. ACR Appropriateness CriteriaAmerican College of Radiology. ACR Appropriateness Criteria-- Limping Child Ages 0Limping Child Ages 0--5 Years. 2007. Available 5 Years. 2007. Available at: at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/aphttp://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonPediatricp_criteria/pdf/ExpertPanelonPediatricImaging/LimpingChildUpdateinProgressDoc6.aspx. Accessed NovemberImaging/LimpingChildUpdateinProgressDoc6.aspx. Accessed November 10, 2009. 10, 2009. Children’s Hospital of Philadelphia. Available at: http://www.chChildren’s Hospital of Philadelphia. Available at: http://www.chop.edu/healthinfo/anatomyop.edu/healthinfo/anatomy--ofof--aa--joint.html. joint.html. Accessed November 12, 2009. Accessed November 12, 2009. Fischer SU, Beattie TF. The limping child: epidemiology, assessmFischer SU, Beattie TF. The limping child: epidemiology, assessment, and outcome. ent, and outcome. JBJS Br JBJS Br 1999; 81(6):10291999; 81(6):1029--1034. 1034. Haueisen DC, Weiner DS, Weiner Se. The characterization of “tranHaueisen DC, Weiner DS, Weiner Se. The characterization of “transient synovitis of the hip” in children. J sient synovitis of the hip” in children. J Pediatr Orthop 1986;6:11. Pediatr Orthop 1986;6:11. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septKocher MS, Zurakowski D, Kasser JR. Differentiating between septic Arthritis and transient synovitis of the ic Arthritis and transient synovitis of the hip in children. hip in children. JBJS (Am)JBJS (Am) 1999;81(12):16621999;81(12):1662--70. 70. Luhmann SJ, Jones A, Schutmann M, et al. Differentiation BetweenLuhmann SJ, Jones A, Schutmann M, et al. Differentiation Between Septic Arthritis and Transient Synovitis of Septic Arthritis and Transient Synovitis of the Hip in Children with Clinical Prediction Algorithms. the Hip in Children with Clinical Prediction Algorithms. JBJSJBJS 2004;86:9562004;86:956--962.962.Myers MT, Thompson GH. Imaging the Child with a Limp. Myers MT, Thompson GH. Imaging the Child with a Limp. Pediatric Clinics of North AmericaPediatric Clinics of North America 1997;44(3): 6371997;44(3): 637--658.658.Morgan, DS, Fisher, D, Marianos, A, Currie BJ. An 18 year clinicMorgan, DS, Fisher, D, Marianos, A, Currie BJ. An 18 year clinical review of septic arthritis from tropical al review of septic arthritis from tropical Australia. Epidemiol Infect 1996; 117:423. Australia. Epidemiol Infect 1996; 117:423. Taylor GR, Clarke NM. Management of irritable hip: a review of hTaylor GR, Clarke NM. Management of irritable hip: a review of hospital admission policy. Arch Dis Child ospital admission policy. Arch Dis Child 1994;71:59. 1994;71:59. Wheeless’ Textbook of Orthopaedics. Available at: Wheeless’ Textbook of Orthopaedics. Available at: http://www.wheelessonline.com/ortho/blood_supply_to_femoral_headhttp://www.wheelessonline.com/ortho/blood_supply_to_femoral_head_neck. Accessed November 12, 2009. _neck. Accessed November 12, 2009.

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