Acute Painful Hip of Childhood

Differential diagnosis by age

  • 1-4yrs
    • DDH
    • Transient synovitis
    • Child abuse
  • 4-10yrs
    • Transient synovitis
    • Perthe’s
  • >10 yrs
    • SUFE
    • Overuse syndrome
  • All
    • Septic arthritis
    • Juvenile idiopathic arthritis
    • Trauma
    • Malignancy
    • Reactive arthritis
    • NAI

Investigations

  1. Not usually indicated unless targetted to specific diagnosis
  2. Bloods
    1. FBP
    2. CRP + ESR
    3. Blood cultures + joint aspirates
  3. Imaging
    1. Plain films – AP + frog leg lateral pelvis
    2. Consider joint above and below

Juvenile Idiopathic Arthritis

  1. Assesement
    1. Fever
    2. Rash
    3. Lymphadenopathy
    4. Hepatosplenomegaly
    5. Serositis
    6. Psoriatic plaques
    7. Nail involvement
    8. Dactylitis
    9. Uveitis
    10.  SIJ involvement
  2. Subtype into
    1. Systemic arthritis
    2. Polyarthritis RF+
    3. Polyarthritis RF-
    4. Oligoarthritis (persistent vs. extended)
    5. Psoriatic
    6. Enthesitis
    7. Unclassifiable
  3. Investigations
    1. Only if clinical indications; judicious use
    2. FBP
    3. ESR + CRP
    4. RF + anti-CCP
    5. HLA B27
  4. General principles of management
    1. Physio + OT
    2. Splinting
    3. NSAIDs
    4. DMARDS including biologics
    5. Adjuvant steroids

Septic arthritis

  1. Workup
    1. FBP
    2. CRP
    3. Joint aspiration and blood cultures
    4. XR to exclude trauma
    5. Consider bone scan
  2. ID considerations
    1. Commonly S. aureus, but may also be S. pyogenes and H. influenzae
    2. Consider urgent arthrotomy and washout
    3. Flucloxacillin 50mg/kg QID IV
    4. Elevate and immobilise limb

Slipped Upper Femoral Epicondyle

  1. Presentation
    1. Antalgic gait
    2. Obligatory external rotation of leg during hip flexion
    3. Appropriate age (>10)
  2. Workup
    1. B/L XR AP and frog leg pelvis
    2. if unstable and acute, substitute cross-table lateral XR for frog leg
  3. Management
    1. Urgent ortho referral
    2. Immobilise and make non-weight bearing
      1. Reduce risk of further slippage -> avascular necrosis
    3. Fixation with screw

Transient synovitis

  1. Presentation
    1. Occasionaly, post-viral
    2. Unilateral pain
    3. Mild limitation of function
    4. Positive log roll – involuntary muscle gaurding in affected limb when doing the same movement as when you test for tone in a neuro exam
    5. Rest with abducted hip in external rotation
  2. Management
    1. Complete bed rest
    2. Improvement after 3/7; resolution within 2/52
    3. NSAIDs

Perthe’s Disease

  1. Benign disease of femoral head with cycles of necrosis, collapse, repair and remodelling
  2. Phenotype of short stature, delayed bone age and hyperactivity is characteristic
  3. Other presentation feautres include
    1. Gluteal wasting +/- postive Trendelenburg’s
    2. Groin and knee pain
    3. Typically unilateral
  4. Workup
    1. B/L XR hip
    2. Consider MRI
  5. Management
    1. Mobilisation with monitoring
    2. PCM + NSAIDs
    3. Surgical containment – proximal femoral osteotomy to bring more femoral head under weight-bearing portion of acetabulum
    4. Salvage procedure – recreate acetabular socket
  6. Prognosis
    1. Worse with age and degree of epiphyseal involvement
    2. In general <5 yrs do very well

Developmental Dysplasia of the Hips

  1. Presentation
    1. Ortolani – flex hips to right angles + abduct with fingers over greater trochanter. Apply anterior pressure.
    2. Barlow – attempt to relocate after Ortolani’s, feeling for instability
    3. Decreased hip adduction if infant is too big for Ortolani + barlow
  2. Workup
    1. US hips
    2. XR hips
  3. Management
    1. Splinting
    2. Closed reduction
    3. Open reduction if teratological cause
    4. Spica casting with reduction
    5. Salvage osteotomy

Juvenile Idiopathic Arthitis

Diagnostic criteria

  1. Onset <16 years
  2. Arthritis involving >1 joint with 2 of
    1. Limitation in ROM
    2. Pain with movement
    3. Fever
  3. Disease >6/52
  4. Exclusion of other juvenile arthritis
  5. Subtype into
    1. Polyarthritis (>4 joints)
    2. Oligo(pauci)arthritis (<5 joints)
    3. Systemic (+fever)

Workup

  1. FBC – reduced Hb, elevated platelets
  2. ESR, CRP
  3. ANA – can be up or normal
  4. RF, anti-CCP – can be up or normal

Treatment

  1. Lifestyle modification
  2. MDT
  3. NSAIDs
  4. DMARDs
    1. MTX or sulfasalazine + folic acid
    2. TNF-alpha inhibitor, or IL-receptor antagonist
    3. Corticosteroids are DMARD-sparing

Shoulder X-Ray Crib Sheet

  1. Usual details
  2. Bones – clavicle, scapula, humerus – #, deformities, sclerosis, degeneration, acromion morphology (hooked implies impingement of supraspinatus)
  3. Joint spaces –  ACJ (in line with small gap), GHJ
    1. In the axillary Y-view (lateral) look for coracoid and humerus. Humerus anterior to coracoid = anterior dislocation. Humerus posterior to glenoid = posterior dislocation. Humerus posterior to coracoid overlying glenoid = normal
  4. Spaces and Lines
    1. Space between humerus and acromion should be >6mm, less implies supraspinatus impingement
    2. Gothic arch line between scapula and humerus – disruption implies #
Gothic Arch

Gothic Arch

Axillary Y-view

Axillary Y-view

Wrist X-Ray Crib Sheet

  1. Usual details of film
  2. Bones – #, sclerosis, cystic degeneration, deformities
  3. Joints – loss of joint space implies OA, increase in joint space implies ligamentous injury
  4. Lines and angles
    1. Radial inclination – normal is 15-25 degrees; loss of radial inclination implies a bad reduction
    2. Volar tilt – normal is 10-25 degrees, a negative volar tilt indicates dorsal angulation of the distal, radial articular surface
    3. Ulnar variance
      1. Ulnar variance refers to the difference between the levels of radial and ulnar articular surfaces
      2. Ulnar variance is said to be neutral if articular surfaces of radius and ulna are at the same level, positive if ulnar articular surface is distal to radial and negative if ulnar articular surface is proximal to radial
      3. Negative ulnar variance is associated osteonecrosis of lunate bone
      4. Positive ulnar variance is associated with, scapholunate instability, ulnar impaction syndrome, triangular fibrocartilage tears lunotriquetral ligament tears and previous excision of radial head

Radial inclination

Volar tilt

Hip X-Ray Crib Sheet

  1. Hedge and play for time
    1. Name, age, film details etc.
    2. Comment on position (testicles should be symmetrical, cocyx and pubic symphysis should have a 2cm gap [impiclication of less gap is pelvic tilt])
  2. Identify the bones – femur, pubis, ischium, illium, acetabulum, sacrum, coccyx, comment on #, sclerosis, osteopenia, deformity
  3. Identify the joints – sacroilliac, pubic symphysis and commment on joint space increase or loss
  4. Lines
    1. Shenton’s line – loss of arch implies NOF
    2. Illioischial line – represents the posterior column, disruption impllies PC#
    3. Illiopectineal line – represents the anterior column, disruption implies AC#

 

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Own The … Ankle Exam

Examination Summary

  • Look
    • Shoes, aids
    • Gait
    • Scars, swelling, atrophy, colour
    • Hindfoot and forefoot alignment
    • Too many toes sign
    • Medial arch
    • Hallux valgus, hammer, mallet or claw toe
  • Feel
    • Temperature
    • Tenderness
    • Swelling
  • Move
    • Ankle joint – extension and flexion
    • Subtalar joint – inversion and eversion
    • Midtarsal – supination and pronation
    • Small joints
  • Special tests
    • Single and double heel raise – posteriro tibial test
    • Jack test for pes planus
    • Anterior draw
    • TFL test
    • Neurovascular assesement

Additional Details for Clinical Examination

  • Look
    • Ask if anything hurts when they walk – just makes doing the gait bit so much easier
    • For gait, separate it into heel strike, foot flat, toe off
    • ‘The patient displays reciprocal gait’ is a flash way of saying all good
    • The hindfoot is normally in <6 degrees of valgus
    • When looking from the back, only the 5th and abit of the 4th should be visibile. Anything more indicates pes planus secondary to posterior tibial pathology
    • Claw toe is hyperextension of MTP and flexion of the IP joints and is idiopathic, due to neurological disease or RA
    • Hammer toe is flexion of the PIP and extension of the DIP and MTP
    • Mallet toe is flexion of the DIPMove
  • Move
    • Ankle joint – grasp the heel in the left hand and the mid-foot with the right
    • Subtalar joint – grasp the heel alone
    • Mid-tarsal joint – Heel is held still with one hand while the other moves the tarsus up and down and from side-to-sode
  • Special tests
    • When doing the single heel raise, make sure the patient isn’t cheating by pushing off the wall
    • Jack test – patient weight-bears while the clinician dorsiflexes the hallux and watches for the formation of an arch. A positive result (arch formation) results from the flatfoot being flexible. A negative result (lack of arch formation) results from the flatfoot being rigid

Videos

Start with Talley

Some random English man

Special tests – anterior draw, talar tilt, Er, squeeze, Achilles rupture

Own The … Hip Exam

Adapted from Bailey’s and McRae

Summary

  • Inspection
    • Gait
    • Front     pelvic tilt, rotational deformity
    • Side        lumbar lordosis
    • Back       pelvic tilt, scoliosis, gluteal wasting
    • Skin, scars, soft tissues, deformity
  • Palpation
    • Anterior joint line
    • Adductor origin
    • Greater trochanter
    • Ischial tuberosity
  • Movement
    • Flexion and extension
    • Abduction and adduction
    • Internal and external rotation
  • Special tests
    • Thomas’ test
    • Leg length assessment – real/apparent
    • Trendelenburg test
    • Snapping hip
    • Impingement tests

In general

Talley and O’Connor

MacLeod’s

Gait

Trendelenburg lurch / Duchenne sign

The patient tries to reduce pain by shifting body weight over the hip. Often associated but not invariably with a positive Trendelenburg sign.

Antalgic

High-stepping

The main differentials are a common peroneal nerve palsy, an L5 root lesion and a motor neuropathy. Myopathies are also possible.

In-toeing

Can be caused by persistent femoral anteversion. The foot may catch on the back of the calf of the weight-bearing leg, tripping the patient.

Special Tests

A rather good summary

Thomas and Modified Thomas tests

Patrick’s / FABER test

Pain during this test is often the very first sign of osteoarthritis