Transcript irritable hip.

Hip pain
Irritable hip
Pain and limping
DD
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Septic arthritis.
Perthes.
Irritable hip (transient synovitis).
Slipped capital femoral epiphysis.
Brucellosis.
Tuberculosis.
Rheumatoid arthritis (single joint in
children).
PYOGENIC ARTHRITIS
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seen in children under the age of 2
years.
The
organism
(usually
a
staphylococcus) reaches the joint
either directly from a distant focus
OR
by local spread from
osteomyelitis of the femur.
PATHOPHYSIOLOGY
The Limping Child: Age 3 – 6
Septic Arthritis
Bacteria
White cells
Enzymes
Enzymes
Destroy cartilage
Irreversible joint damage
Clinical features
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child is ill and in pain.
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The affected limb may be held
absolutely still and all attempts at
moving the hip are resisted. With
care and patience.
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it may be possible to localize a
point of maximum tenderness
over the hip;
Diagnosis
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Confirmed by aspirating pus from the
joint.
In
neonates
the
most
common
presenting feature is a total lack of
movement in the affected limb
(pseudo
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paralysis).
Local signs of inflammation are usually
absent .
X-rays
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During the acute stage of bone infection,
x-rays may show
slight
displacement
lateral
of the femoral
head, suggesting the presence of a joint
effusion.
The Limping Child:
Age 3 – 6
WIDENED JOINT SPACE
Septic arthritis
Child refuses to walk •
Movement of hip is painful •
May have fever •
Elevated WBC •
Progressively sicker •
Progressive joint destruction •
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In
children
the
epiphysis
may
become
necrotic
and later appear
unusually dense or
'fragmented' on
x-ray.
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Ultrasound scans also will help to
reveal a joint effusion.
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Antibiotics should be given as
soon
as
the
diagnosis
is
reasonably certain,
but not before obtaining a
sample of joint fluid (or pus)
for microbiological investigation
and
testing
for
antibiotic
sensitivity.
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The joint is aspirated
under
general
an
aesthesia and.
if pus is withdrawn,
arthrotomy is advisable.
antibiotics are instilled
locally and the wound is
closed
without
drainage.
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The hip is kept on traction or
splinted in abduction until all
evidence of disease activity has
disappeared.
Legg Calve’ Perthes'
disease (COXA PLANA )
Perthes' disease
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Disorder of childhood characterized
by necrosis of the femoral head.
Although the incidence is only 1 in
10 000.
Should always be considered in the
differential Diagnosis of hip pain in
young children.
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4-8 years old
Patients are usually
and show delayed skeletal maturity.
Boys
are affected
often as girls.
4
four
times as
Pathogenesis
femoral head may depend for its blood
supply almost entirely on the lateral
epiphyseal vessels.
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whose situation in the retinacula makes them
susceptible to stretching and pressure from an
effusion.
Causes of avascular necrosis
of the
femoral head
Steroids
Infection
Perthes’ disease
Sickle cell disease
Hypothyroidism
Skeletal dysplasia – classically
multiple epiphyseal dysplasia
Pathology
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The pathological process takes
years
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2-4
to complete, passing through
three stages.
Bone death.
revascularization and repair.
Distortion and remodelling.
‫الشفق القطبي‬
Clinical feature
The patient - usually a boy
 of 4-8 years .
 Complains of pain and
 Starts to limp.
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The hip looks normal.
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Although there may be a little
wasting of the thigh.
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Movements are diminished and
their extremes painful.
later
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,
abduction
is
nearly
always limited and usually internal
rotation.
X-rays
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Before x-ray changes appear, the
ischaemic area with decrease uptake ,can
sometimes be demonstrated as a 'void'
on
radioisotope
scanning.
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The earliest changes
on
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X RAY:
are increased density
of the bony epiphysis
.
apparent widening
of the joint space.
Flattening.
fragmentation .
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lateral displacement of the epiphysis
follow,
with rarefaction and broadening of
the metaphysis.
MRI
Differential diagnosis
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non-specific transient synovitis
called
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irritable hip
the so.
Symptoms last for a week or two and clear up
completely.
Ultrasound may show a joint effusion,
but the x-rays are always normal.
The child should be kept in bed until pain
disappears and the effusion resolves.
Treatment
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As long as the hip is painful, the child
should
be
in
bed
with
skin
traction applied to the affected leg.
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For about
3 weeks.
Then to follow up
it is essential that they attend periodically
for radiological review .
Containment
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This means keeping the
femoral head well seated
within the acetabulum.
Surrounded by its socket.
Containment
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can be achieved by holding the hips
widely abducted in plaster.
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A removable splint until the bone
changes have run their course (at
least a year).
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OR
by
performing
a
varus
osteotomy of the femur.
An
innominate osteotomy of the
pelvis.
SLIPPED UPPER
FEMORAL EPIPHYSIS
Incidence and aetiology
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Boys ate affected more often than girls.
Slip of the upper (capital) femoral
epiphysis (SUFE or SCFE)
an incidence of 5:100 000 population.
the peak incidence is related to the start
of puberty, hence it is earlier in girls.
Cause and pathology
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A slipped epiphysis
is an insufficiency
fracture through the
hypertrophic zone of
the
cartilaginous
growth plate.
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Normal forces, exacerbated by
obesity with delayed gonadal
development.
and repetitive minor trauma,
precipitate a slip.
Puberty.
Tall children .
Clinical features
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The patient - usually a boy of 14 or 15
years .
presents with pain in the groin, the
anterior part of the thigh or the knee
(referred pain).
he may also limp.
The onset may be sudden and in 30 per
cent there is a history of trauma (acute
slip').
However, in the majority
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symptoms are chronic I.e.
chronic slip,
or else a long period of pain may
culminate in a sudden climax
following minor trauma
acute-on chronic slip.
On examination
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the leg is externally rotated and is 1
or 2 cm short.
Characteristically there is limitation of
abduction and medial (internal) rotation.
Following an acute slip, the hip is
irritable and all movements are
accompanied by pain.
Hip Flexion Causes Abduction &
External Rotation
OR
SCFE
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Associations with ,
Obesity
Endocrine issues
Hypothyroidism
Grading of the severity of slip of the
upper (capital) femoral
epiphysis.
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Slip severity
Mild
Moderate
Severe
Metaphysis uncovered (%)
<33%
33–66%
>66%
X-rays
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In
the
anteroposterior
view
the
epiphyseal plate seems to be too wide
and too 'woolly'.
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Trethowan's sign
A line drawn
along the superior surface of the neck
remains superior to the head instead of
passing through it .
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lateral view
In the
the femoral
epiphysis is tilted backwards; small degrees
of tilt can be detected by measuring the angle
between the epiphyseal base and the femoral
neck .
Slip angle
Treatment
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Manipulation is dangerous and
should be avoided.
Minor displacement
Displacement of less than onethird the width of the epiphysis is
treated by accepting the position
and
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fixing the epiphysis with
two thin threaded pins or
screws. This is always
done
under
x-ray
control.
fixation
position
in
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Severe displacement
If the displacement is more than half
the epiphyseal width, corrective
surgery will be needed.
TUBERCULOSIS
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The disease may start as a synovitis,
or as an osteomyelitis in one of the
adjacent bones.
Once arthritis develops, destruction
is
rapid
and
may
result
in
pathological dislocation.
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Healing usually leaves a
ankylosis
fibrous
with considerable
limb shortening and deformity.
Clinical features
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Pain in the hip is the usual
presenting symptom,
The patient walks with a limp;
though in late, neglected cases a
cold abscess may point in the thigh
or buttock.
muscle wasting may be obvious and
joint movements are limited and
painful.
Investigations
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Blood examination
E S R.
Mantoux test
ELAIZA TEST .
X-rays
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The first x-ray change
is general rarefaction
of bone around the
hip,
In a child, the femoral
epiphysis
may
be
enlarged,
again
suggestive of chronic
synovitis.
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Later changes are erosion and eventually
destruction of the articular surfaces on
both sides of the joint.
Complications
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However, if the joint is destroyed, the
usual result is an unsound
ankylosis.
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The
fibrous
leg is scarred and thin.
and shortening
severe.
is
likely
to
be
Treatment
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If the disease is caught early, antituberculosis chemotherapy should
result in healing.
During the acute phase, the joint may
need to be splinted in abduction
or held in traction until the
symptoms subside.
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An abscess in the femoral neck is
best evacuated.
If the joint has been destroyed,
arthrodesis may become necessary,
but usually nor before the age of 14.
In adults joint replacement is
feasible