Transcript Hip Pain in a Child

Hip Pain in a Child: Myositis or
Appendicitis
Andaleeb Raja MD
Muhammad Waseem MD
Husayn Al-Husayni MD
Lincoln Medical & Mental Health Center
Bronx, New York
Case Presentation
• 11 year old boy presenting with fever & hip pain
for 2 days
• Denied abdominal pain, vomiting or change in
bowel habits
• Denied knee pain or history of trauma/falls
• Denied recent travel or sick contacts
• Denied family history of joint disease
• Discharged home after Hip X rays were negative
and initial labs were reviewed
Pelvis X-Ray
Labs
• WBC 11,200/mm with 74% Neutrophils
• ESR 5 mm/hr
• CRP 15.51 mg/L (0.25-3.0)
• Blood Culture: Gram (+) cocci in clusters
Case Presentation
• Recalled to the ER the next day
– Blood cultures - Gram (+) cocci in clusters
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Still c/o fever, but now walking with a limp
Described right hip and groin pain
Pain was constant in nature, “sharp & achy”
Pain was exacerbated when he walked
He was unable to walk without being supported
Physical Exam
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Vitals: T100.5 HR 120 RR 20 BP 125/85
General: ill appearing, but alert, awake
HEENT: dry mucous membranes
Chest: clear to auscultation, B/L breath sounds
CVS: tachycardic
Abd: mild RLQ tenderness initially, but not reproducible. No masses,
no guarding
• GU: (+) cremasteric reflex, no hernia, no scrotal swelling
• Ext:
– (+) tenderness over pelvic area and anterior thigh
– No deformity, bruising or swelling noted over hip.
– Equal thigh measurements. Unable to elicit hop test (patient
refused to walk)
– ROM hip intact
– Palpable small inguinal lymph nodes bilaterally
Labs
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WBC 13,900/mm with 85% neutrophils
Hemoglobin 14.1 g/dl
Platelets 204/mm
CRP 116.56 mg/L
CK 91 U/L (40-210)
UA specific gravity >1.045, 0-2/hpf WBC & RBC
Electrolytes: WNL
Radiology
• Plain film Pelvis with Right hip – normal on previous visit
• Non-contrast CT scan hip/Lower abdomen
– Inflamed tip of the appendix with mild periappendiceal fluid
CT Scan Hip
CT Scan Hip
Learning Objectives
• Understanding the atypical presentation of acute
appendicitis in children
• Recognize pyomyositis as a rare but important
etiology to be considered in patient with hip pain
and fever
• Review of the differential diagnoses of hip pain in
children
Case Discussion
• Appendicitis is a difficult diagnosis in children as it may
have an atypical presentation
• Classic symptoms are often not seen
• Can lead to misdiagnosis
• High morbidity/mortality
• Pathophysiology in children may be different due to the
change in anatomic location
• Inability to walk/walking with limp reported to be a
significant finding
• 1/4 of patients may present with a limp or right hip
stiffness
Case Discussion
• Pyomyositis - Rare
– Hip pain, limp, fever
– Uncommon infectious process involving skeletal muscle
– Caused by pus producing bacteria (staph aureus most frequently
involved)
• This patient had (+) staph aureas in Blood cultures
– CK may remain normal, while ESR and CRP are usually elevated
• Child had normal CK but elevated CRP, leukocytosis
– CT can be used to identify and localize the abscess
• No abscess was seen on CT
– Large muscle groups (thigh) are likely targets
– Correct diagnosis is based on high index of suspicion
– Important to recognize to reduce morbidity/mortality associated
with the condition
Differential Diagnosis
• Transient Synovitis
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Most common cause of hip pain in children
Consider in absence of trauma history
Self limiting
Usually more frequent in boys
Important to distinguish between this and septic
arthritis, which requires drainage and antibiotics
Differential Diagnosis
• Slipped Capital Femoral Epiphysis
– Present with limp or vague thigh/hip pain
– Typically involves obese children
• Legg-Calve-Perthes Disease
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Avascular necrosis of femoral head
Pain localized to hip, limping
Plain films may show epiphyseal fragmentation
MRI more sensitive
Differential Diagnosis
• Psoas Muscle Abscess
– Relatively rare in children
– Vague symptoms because of the posterior
location of the psoas mucle
– Classic symptoms: limp with fever and abdominal
pain
– Blood cultures often positive
– Physical Exam: psoas cannot be examined easily
(deep structure)
– Psoas sign: pain when the hip is passively
extended or actively flexed against resistance
• Attributed to inflammation causing spasm of psoas
muscle
Differential Diagnosis
• Pelvic Osteomyelitis
– Rare but should be considered in a child who
presents with hip pain
– MRI should be obtained in presence of
suspicion
References
• Frick SL. Evaluation of the child who has hip pain. Orthop Clin North
Am. 2006 Apr;37(2):133-40
• Yang WJ, Im SA, Lim GY, Chun HJ, Jung NY, Sung MS, Choi BG. MR
imaging of transient synovitis: differentiation from septic arthritis.
Pediatr Radiol. 2006 Nov;36(11):1154-1158
• Katz DA. Slipped capital femoral epiphysis: the importance of early
diagnosis. Pediatr Ann. 2006 Feb;35(2):102-111
• Weber-Chrysochoou C, Corti N, Goetschel P, Altermatt S, Huisman TA,
Berger C. Pelvic osteomyelitis: a diagnostic challenge in children. J
Pediatr Surg. 2007 Mar;42(3):553-557
References
• Becker T, Kharbanda A, Bachur R. Atypical clinical features of pediatric
appendicitis. Acad Emerg Med. 2007 Feb;14(2):124-129
• Reynolds SL. Missed appendicitis in a pediatric emergency
department. Pediatr Emerg Care. 1993 Feb;9(1):1-3
• Bundy DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE. Does
this child have appendicitis? JAMA. 2007 Jul 25;298(4):438-451
• Colvin JM, Bachur R, Kharbanda A. The presentation of appendicitis in
preadolescent children. Pediatr Emerg Care. 2007 Dec;23(12):849-855
• Sakellaris G, Tilemis S, Charissis G. Acute appendicitis in preschoolage children. Eur J Pediatr. 2005 Feb;164(2):80-83
References
• Kumar A, Anderson D. Primary obturator externus
pyomyositis in a child presenting as hip pain: a
case report. Pediatr Emerg Care. 2008;24:97-98
• Iyer S, Lobo M, Capell W. Obturator internus
pyomyositis: a differential diagnosis for septic
arthritis of the hip. J Paediatr Child Health.
2005;41:534-535
• Fowler T, Strote J. Isolated obturator externus
muscle abscess presenting as hip pain. J Emerg
Med. 2006 ;30:137-139
Question
• A 12 year old male presented to the ED with a 2 day history of fever
and right hip pain. He was noted to be limping on arrival. He denied
any history of trauma. Abdominal physical examination findings
revealed no guarding, but there was minimal tenderness in the right
lower quadrant. Laboratory evaluation revealed a WBC 15.2. Hip
radiographs were normal. What is the next best step in his
management?
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b)
c)
d)
e)
Admit for observation
Joint aspiration
CT scan abdomen and pelvis
Pelvic ultrasound
Administer a dose of IV antibiotics, then discharge home with
24-hour follow up
Answer - C
• Because of the varied location of the appendix, the
presentation of pain in a patient with acute appendicitis
can be diverse. A patient with a low lying appendix can
present with hip pain without significant abdominal
findings.
• It is important to include appendicitis in the differential
diagnosis of hip pain. If the diagnosis is delayed,
appendicitis is associated with significant morbidity and
mortality. A computed tomography of the abdomen and
pelvis is the imaging modality of choice.