pediatric hip pain: septic arthritis, transient synovitis, and
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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
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
Childrens 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)-- Toddlers, stress, otherToddlers, stress, other
More Practical, Narrowed More Practical, Narrowed Differential DiagnosisDifferential Diagnosis
Septic ArthritisSeptic Arthritis-- cant miss due to rapid joint cant 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.
Lets view some examples of Lets view some examples of diagnoses that can be made on diagnoses that can be made on
plain film alone. plain film alone.
Toddlers Fracture on Plain FilmToddlers 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.
Toddlers 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
Avulsion Fracture on Plain Film Avulsion Fracture on Plain Film
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
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 Ar