Transcript Hip Pathology - Pediatrics House Staff

A 13 year old boy with
complaints of “butt
pain”
Morning Report
July 1, 2009
 Otherwise healthy
 Noted the pain after attending
a school dance……but “he did
not dance”
 Afebrile
 What do you want to
know????
His exam is “normal” except for
tenderness over the right
gluteus muscle
He is sent home with NSAID’s
and a diagnosis of
musculoskeletal strain
Don’t forget…….Give
“what if” instructions….
It is now 5 days later……
 Now complaining of right knee
pain and he is limping
 No fever noted at home, Temp
is 99 in the office
 Now what????????
Films are ordered….given
Tylenol #3
 Plain films of the hips and
knees are “normal”….
Everyone in thinking SCFE
Anatomy
SCFE
SCFE
 Usually in boys at puberty
 Usually unilateral
 Stable or unstable
 Diagnostic radiograph: frog
leg hip films
 Surgical intervention
SCFE Severity
But he does not have a
SCFE……..
What do you do now?
What else is in your
differential of a limping
child?
Differential
 Toddler
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Septic arthritis
Discitis
Sepsis
Osteomyelitis
Pyomyositis
Neoplasia
 Leukemia, bone
tumors…
 JIA?
 Transient synovitis
 Child (3-10 years)
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Septic Arthritis
Osteomyelitis
Pyomyositis
Neoplasia
 Leukemia, bone
tumors…
Discitis
JIA?
Perthes
Synovitis
 Adolescent…add
 SCFE
If you send him home…
again, the “what if”
instructions are KEY….
The plot thickens…….
 4 days later, the child returns for
more tylenol #3
 Still limping
 Increasing pain with extension of
the hip and internal rotation of the
leg but there is no redness,
warmth or swelling
 Now fever to 102, HR is 130, RR 24,
BP 90/50
Systemic symptoms
 His left elbow is red and swollen
 Disoriented
 Jaundiced (Bili 12/8, SGOT and
SGPT nl)
 Febrile
 Anemic (hgb 6, WBC 24)
The patient is hospitalized
………..and a diagnostic
procedure is performed
DIFFERENTIAL????
The CT
Normal
Not normal
The Psoas (part of the
posterior abdominal wall)
Psoas Abscess
 Hip symptoms
 Can be a “primary diagnosis”
 Can be associated with GI
pathology or sometimes with GU
pathology
 Not usually associated with hip
infection
In the hospital…….
 Psoas abscess and elbow drained
 Antibiotics begun
 All cultures positive for St A…blood and
abscess and elbow
 Remains febrile on POD 1
 Remains febrile on POD 2
 Remains febrile on POD 3 but continues to
“feel better”, jaundice resolves
Want to do anything else, antibiotics are
given and appropriate???????????
In the hospital…….
 Remains febrile on POD 4
 Remains febrile on POD 5
 Remains febrile on POD 6
“feels better” but febrile……. Now
what?????
Another diagnostic
procedure was
performed……..
Repeat CT reveals concern
for hip disease…the
acetabulum appears
“moth-eaten”
And the child returns to the OR for I and D of
the hip joint……. After which he is afebrile…
Septic Arthritis of the Hip
A True Emergency
Septic Arthritis of the Hip
 Usually in children under 3 years
 Usually unilateral
 Fever, high WBC, high sed rate
 Diagnostic radiographs:
ultrasound, CT/MRI
 Plain films are normal in 50% of
cases!!!!!
When the Xray is diagnostic:
there is a loss of the architecture of
the pelvis and widening of the joint
space
The MRI
Septic Arthritis Risk
Factors for Poor Outcome
 Over 5 days to surgical
drainage
 Associated osteomyelitis in
the proximal femur
Morals of the story:
Sometimes you just have
to keep looking…..
A limping child =
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Fever
Severe pain
Night pain
Functional
impairment
 Escalating symptoms
Peds in Review
 http://pedsinreview.aappublications.
org/cgi/reprint/27/5/170
Approach to Acute Limb Pain in
Childhood
Shirley M. L. Tse, MD
Ronald M. Laxer, MD
The Hospital for Sick Children;
University of Toronto, Toronto, Ontario,
Canada