Hip pain in children

When a child complains of pain in the knee joint, examine the hip joint.

Does the child have a fever? If so, perform urgent blood culture + diagnostic arthrotomy to rule out septic arthritis (do not rely on hip aspiration alone).

Consider a slipped capital femoral epiphysis in an adolescent. If a child presents with unexplained, painful claudication, the hip joints should be examined clinically and radiographically. Usually, the child should be hospitalized for observation and appropriate regimen (+ traction). An examination is also performed to exclude tuberculous lesions of the hip joint or Perthes disease. If the patient has had limited motion in one hip joint, which spontaneously resolves after several days of rest (on bed rest), and the radiographic picture of this joint is normal, a retrospective diagnosis of transient synovitis of the hip joint (also known as irritable hip) may be made. If other joints are affected, a diagnosis of juvenile rheumatoid arthritis should be considered.

Perthes disease. This is osteochondritis of the femoral head, affecting children aged 3 to 11 years (more often 4-7 years). In 10% of cases, it is bilateral, and occurs in boys 4 times more often than in girls. Perthes disease manifests itself as pain in the hip joint or knee and causes lameness. When examining the patient, all movements in the hip joint are painful. On the radiograph of the hip joint in the early stage of the disease, a widening of the interarticular space is noted. In later stages of the disease, a decrease in the size of the nucleus of the femoral head is observed, its density becomes inhomogeneous. In even later stages, collapse and deformation of the femoral head, as well as new bone formation, may occur. A sharp deformation of the femoral head is a risk factor for the early development of arthritis. The younger the patient, the more favorable the prognosis. For mild forms of the disease (less than 1/2 of the femoral head is affected according to the lateral radiograph, and the total capacity of the joint cavity is preserved), treatment consists of bed rest until the pain subsides. Subsequent radiographic observation is necessary. For individuals with a less favorable prognosis (1/2 of the femoral head is affected, the interarticular space is narrowed), varus osteotomy may be recommended to retract the femoral head into the acetabulum.

Slipped upper femoral epiphysis. This condition occurs three times more often in men than in women, and affects adolescents aged 10 to 16 years. In 20% of cases, the lesion is bilateral; 50% of patients are overweight. This displacement occurs along the growth plate, with the epiphysis sliding down and back. The disease manifests itself as lameness, spontaneous pain in the groin and along the anterior surface of the thigh or knee. When examining the patient, flexion, abduction and medial rotation are impaired; when the patient is lying down, the foot is rotated outward. The diagnosis is established by a lateral radiograph (an X-ray in the anteroposterior projection may be normal). In untreated cases, avascular necrosis of the femoral head may develop, and abnormal tissue fusion is also possible, which predisposes to the development of arthritis. In case of lesser degrees of slippage, a bone nail can be used to prevent further slippage, but in case of severe degrees, complex reconstructive surgeries are necessary.

Tuberculous arthritis of the hip joint. It is rare nowadays. Children aged 2-5 years and elderly people are most often affected. The main symptoms are pain and lameness. Any movement in the hip joint causes pain and muscle spasm. An early radiographic sign of the disease is bone rarefaction. Subsequently, slight unevenness of the joint margin and narrowing of the interarticular space develop. Even later, bone erosions may be detected on radiographs. It is important to ask such a patient about contacts with tuberculosis patients. It is necessary to determine the ESR, perform a chest X-ray and the Mantoux reaction. The diagnosis can be confirmed by synovial membrane biopsy. Treatment: rest and specific chemotherapy; chemotherapy should be performed by experienced medical personnel. If significant destruction of the hip joint has already occurred, arthrodesis may be necessary.

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