Transcript POC Ultrasound for Pediatric Hip Pain

Reid Phillips – Thomas Jefferson Univ
HPI: Mom noticed limp 2 days ago. Boy indicated groin pain at that
time. Boy is 14 days s/p admission for asthma exacerbation secondary to
URI. Mom is primary caretaker, denies trauma.
PMH: asthma with prior intubation
Meds: albuterol and corticosteroid inhalers
FH: hemophilia A, RA
PE: T 100.5 P 100 BP 100/60 RR 18
No pelvic assymmetry. No skin findings. Right leg is flexed and externally
rotated while patient is supine. Right hip with markedly reduced ROM
due to pain. Left hip normal ROM. Right hip nontender to palpation.
Normal strength and sensation distally. Patient refuses to walk.
Vascular
Avascular Necrosis
Infectious
Septic Arthritis
Lyme Arthritis
Transient Synovitis
Osteomyelitis
Inflammatory
Reactive Arthritis
Juvenile Rheumatic Disease
Neoplastic
Bone tumor
Leukemia
Deficiency
Vitamin D
Collagen
Iatrogenic
Steroids
Intoxication
Heavy Metals
Congenital/Developmental
Legg-Calve-Perthes
Developmental Dysplasia
Slipped Capital Femoral Epiphysis
Sickle Cell Disease
Hemophilia
Automimmune/Allergic
Psoriasis
Trauma
Fracture
Soft Tissue Injury
Hemearthrosis
Labs
CBC
ESR/CRP
Blood Culture
Coags
Fracture
Avascular Necrosis
SCFE
LCPD
Other
H+P
Radiographs
AP
Frog leg
Negative or +Effusion
(20% sensitive for
effusion)
Ultrasound
Effusion
Transient Synovitis
Septic Arthritis
Osteomyelitis
Relative to radiology
85% sensitive
93% Specific
92% PPV
88% NPV
Cannot differentiate between causes of effusion
Vieira RL, Levy JA. Bedside ultrasonography to identify hip effusions in
pediatric patients. Ann Emerg Med. 2010;55:284–289.
Patient supine, legs extended,
Hip in question externally rotated
Linear transducer 5-10MHz
Transducer long axis aligned
parallel to femoral neck
Capsular-Synovial Thickness measured
from the concave aspect of femoral
neck to the posterior iliopsoas
Measure both hips
Effusion = Capsular-Synovial
Thickness > 5 mm or > 2mm larger
than asymptomatic hip
Infectious Arthritis
Transient Synovitis
Ages 2-12
2:1 male
Recent viral syndrome
Lack of fever
Can be polyarticular
Full ROM
Can last 2 weeks
No serious LT sequlae
VS
50% <2 years old
Fever
90% monoarticular
Joint tender
Erythema and swelling
ROM severely limited
Serious LT sequelae
(sepsis, arthritis, growth
disturbance, synovitis,
joint stiffness)
Kocher criteria
1. failure to bear weight
2. fever
3. ESR > 40
4. WBC > 12,000
Risk of Septic Arthritis
(Kocher 1999, 2004)
0 criteria
0.2%
1 criteria
3%
2 criteria
40%
3 criteria
93%
4 criteria
99.6%
Luhmann 2004
4 criteria 59%
Contraindications
Overlying skin infection
Coagulation disorder
Technique
Consider procedural anesthesia,
restraints
Clean locally for sterility
In-plane technique
22-gauge needle is inserted from
distal to joint
Target junction of the femoral head
and neck
Identify and avoid the circumflex
femoral vessels using color Doppler
Risks
Infection, bleeding, local
damage, pain
“As in adult patients, emergencyultrasound in children can be lifesaving,
timesaving, increase procedural efficiency and maximize patient
safety.” (American College of Emergency Physicians)
ED physician US has NPV of 88% for hip effusion but should probably
not be relied upon to rule out effusion given risks associated with
missing the diagnosis of septic joint. Order confirmatory study.
High percentages of children with transient synovitis have joint effusions
(86% in one study). Effusion does not indicate septic joint and
depending on clinical suspicion does not demand arthrocentesis.
1. Martin J et al (2014). Focus On: Pediatric Hip Ultrasound. ACME Online CME.
Accessed January 14, 2016 at http://www.acep.org/Education/ContinuingMedical-Education-(CME)/Focus-On/Focus-On--Pediatric-Hip-Ultrasound/
2. Plumb J et al (2015). The role of ultrasound in the emergency department
evaluation of the acutely painful pediatric hip. Pediatric Emergency Care CME
Review Article, 31:54-61.
3. Tsung JW et al (2008). Emergency department diagnosis of pediatric hip effusion
and guided arthrocentesis using point-of-care ultrasound. Clinical Communications:
Pediatrics 35, 4: 393-99.
4. Minardi JJ et al (2012). Septic hip arthritis: Diagnosis and arthrocentesis using
bedside ultrasound. Ultrasound in Emergency Medicine 43, 2: 316-18.
5. Itai S et al (2006). Sonography of the hip joint by the emergency physician It’s
role in the evaluation of children presenting with acute limp. Pediatric Emergency
Care 22, 8: 570-73.
6. Freeman K et al (2007). Ultrasound-guided hip arthrocentesis in the ED. American
Journal of Emergency Medicine 25, 80-86.
7. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic
arthritis and transient synovitis of the hip in children: an evidence-based
clinical prediction algorithm. J Bone Joint Surg Am. 1999;81:1662–1670.
8.
Kocher MS, Mandiga R, Zurakowski D, et al. Validation of a clinical
prediction rule for the differentiation between septic arthritis and transient
synovitis of the hip in children. J Bone Joint Surg Am. 2004;86-A:
1629–1635.
9. Luhmann SJ, Jones A, Schootman M, et al. Differentiation between septic
arthritis and transient synovitis of the hip in children with clinical prediction
algorithms. J Bone Joint Surg Am. 2004;86-A:956–962.
10. Goldberg DL et al (2015). Septic arthritis in adults. Up To Date. Accessed
January 17, 2016 at http://www.uptodate.com/contents/septic-arthritis-inadults?source=machineLearning&search=septic+joint+arthrocentesis&
selectedTitle=8~150&sectionRank=3&anchor=H10#H10