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Pediatric Hip and Groin Kyle J. Cassas, MD Steadman Hawkins Clinic of the Carolinas Educational Objectives Identify common causes of pediatric hip and groin pain/injury. Formulate differential diagnoses. Describe various prevention and treatment strategies. Employ return to sport recommendations. Disclosures: none Sports and Recreational Activity 38 million children and adolescents 3.2 million ER visits – Children 5-14 Leading cause of ER visits (12-17) www.cdc.gov High School Sports Injuries High School Participation (2005-2006) – 7.5 million HS – 2 million injuries – 500,000 visits – 30,000 hospitalizations 2010-2011 1.7/1000 AEs 3.6/1000 Comp MMWR Sept 29, 2006 www.cdc.gov www.nfhs.org “Kids are not Little Adults” Think Fracture/Physeal Injury – Sprain or contusion Overuse Injuries – ½ all injuries (HS and middle school) “Adult” Injuries – ACL Tear – Little League Elbow/Shoulder – Stress Fractures Batson J. 2010 ACSM Annual Meeting Changing Landscape High Intensity Volume of Training Multiple Leagues “Year-Round” Early Specialization Parental Pressures Risk Factors Intrinsic Extrinsic Insufficient Rest Environmental Fatigue and Stress Training Surface Poor Training and Conditioning Training Load Nutrition and Hydration Lack of Protective Equipment Who is Responsible for Prevention? Coaches Parents Athlete Health Care Providers Sports Societies and Organizations Pediatric Limp Pediatric Limp Common All ages – Septic arthritis – Osteomyelitis – Malignancies Pediatric Limp Under 2 – Toddler’s fracture – DDH – CP Age 3-5 years – Transient Synovitis – Septic Hip – Leukemias Transient Synovitis vs Septic Hip? Differentiating Between Septic Arthritis and Transient Synovitis of the Hip in Children: An Evidence-Based Clinical Prediction Algorithm. Kocher M. The Journal of Bone and Joint Surgery 81:1662-70 (1999) Septic Hip Kocher Criteria Non-WB Fever ESR>40 WBC>12,000 mm3 4/4 = 99% 3/4 = 93% 2/4 = 40% 1/4 = 3% Validation of a Clinical Prediction Rule for the Differentiation Between Septic Arthritis and Transient Synovitis of the Hip in Children Kocher M. et al. J Bone Joint Surg Am. 2004;86:1629-1635. Prospective Study: 1997-2002 Septic Arthritis-51 Transient Synovitis-103 “CPR-Very Good Diagnostic Performance” Factors Distinguishing Septic Arthritis from Transient Synovitis of the Hip in Children Caird MS. et al. J Bone Joint Surg Am. 2006;88:1251-1257. Prospective Study: 4 years (2000-2004) 0 Oral Temp>38.5°C 1 CRP>2mg/dl 2 ESR>40mm/hr 3 Refusal to WB 4 WBC > 12,000/mm3 5 16.9% 36% 62% 82% 93% 97%C “Clinical Judgment” 12%-septic arthritis had 0/1 Pediatric Limp Age 5-9 years – Legg-Calve-Perthes Age 11-16 – SCFE – JRA – Tarsal Coalition – Osteochondritis Dessicans DeLee: DeLee and Drez's Orthopaedic Sports Medicine, 2nd ed Legg-Calve-Perthes Disease Etiology? 4-10 y/o M:F 4:1 Caucasians Bilateral 20% Legg-Calve-Perthes Disease Pain Limp Limited ROM Thigh atrophy Flexion contracture Treatment Rest Non-weight bearing Activity Restriction Abduction Bracing? Refer! Prognostic Factors Age Hip Motion Extent X-ray Good Poor <5 Maintained <50% No sublux >8-9 Stiff >50% Sublux Slipped Capital Femoral Epiphysis Adolescent 11-13 (pre-pubescent growth phase) 25-30% Bilateral Overweight Acute Chronic Clinical Findings Insidious Painful limp “Ache” Easily misdiagnosed Loss of abduction/IR ER w/ hip flexion Klein’s Line Slip Severity Complications AVN Chondrolysis Varus Deformity Osteoarthritis Risk of contra-lateral slip Surgery Apophyseal Injury Apophyseal Injury Sudden, violent muscle contraction POP ROM Pain and swelling Weakness Apophyseal Injury Relative Rest Activity Modification Ice NSAID’s Therapy Surgery ? Snapping Hip Syndrome External – ITB Internal – Iliopsoas Rehab Checklist for Return to Sports SAFE to return with little risk for re-injury Sports specific tests or drills Pain free Educate and Counsel Checklist for Return to Sports 10% Rule Equipment Training Programs Muscle Imbalance/Flexibility Early Detection Summary Injuries Common Age based diagnosis Perthes and SCFE Prevention RTP Resources National SAFE KIDS Campaign – www.safekids.org National Youth Sports Safety Foundation – www.nyssf.org AOSSM Stop Youth Sports Injuries – www.sportsmed.org/stop/ USA Baseball: www.asmi.org THANKS FOR YOUR ATTENTION Kyle J. Cassas MD: [email protected] (864) 454-7422