- The differentiation of septic hip from other inflammatory causes of hip pain in the child can
be difficult - Transient synovitis is a self-limited condition of unknown etiology.1 There is some
evidence linking it to a viral infection, but this has not been substantiated. There is
often an antecedent upper respiratory infection that may be a predisposing factor,
and it is one of the most common causes of painful (irritable) hip in childhood. Synovitis
can occur in toddlers and in adolescence, but most patients are between 3 and
8 years with a mean age of 6 years. - Septic arthritis is an orthopedic emergency. Purulent exudate is toxic to hyaline
cartilage, and can damage or destroy a joint relatively quickly. Beginning treatment
within 4 days from the initial onset of symptoms usually affords a good prognosis - PERTHE’S condition is initiated by the loss of blood flow to the femoral head. The subsequent healing brings
on the clinical syndrome of pain, femoral head collapse, and eventual osteoarthritis.The age range is again
similar to transient synovitis (3–10 years) but, unlike septic arthritis, it is more common
in older children (6–8 years). - CLINICAL PRESENTATIONS
- In septic arthritis the child is febrile, appears ill, and is not animated, tending to
lie still. There is no weight bearing. When there is a joint effusion, the joint will be
held in a position that maximally increases the volume of the affected joint. The
child will therefore posture the leg with the hip in slight flexion, abduction, and
external rotation. Any motion, even a toggle of rotation of the hip, will be very
painful. - A child with transient synovitis will look well, often playing with toys in the examination
room but not moving the hip. There is no or, at most, low-grade fever (<38C).
There can be posturing of the hip but the pain on range of motion is less severe.The child may refuse to walk but, unlike a patient with a septic hip, will commonly walk with a limp - A child with LCP disease looks well and has no fever. The child is ambulatory and
can have a limp, which may be subtle. There is little pain on motion of the hip but there
is guarding of the hip while moving it. Pain is worse with flexion and internal rotation.
This motion is the opposite of the direction the hip would take with an effusion. Pain on
flexion and internal rotation is often the first evidence of irritability, and commonly is
the last to resolve for all diagnoses. - CLINICAL ALGORITHM
- First, it is clear that a child not bearing weight would require a referral, but the ability
to walk at presentation does not rule out the possibility of a septic hip - Second, determine if the child looks ill and/or has a fever. There is a definitive difference
in the appearance of a child with sepsis and one with transient synovitis or LCP
disease - Third, determine the range of motion and its quality. Pain with flexion and internal
rotation is a sensitive indicator of hip irritability/inflammation. It is often the first physical
finding present and the last to resolve.Assessment of the range of motion is of
particular benefit in differentiating a septic hip from an inflammatory cause. Usually
an inflamed hip has pain at the ends of motion. If the hip is moved in the central range
of its motion, there is no pain. Pain is elicited when the motion is extended beyond this
central arch. A septic hip has pain with all motion. - Fourth, apply the clinical algorithms of Kocher and colleagues11 and the CRP level12
in the context of the findings already identified in the aforementioned points - CRITERIA OR ???
- The tendency with such criteria is to depend on them at the exclusion of other very important
information, in this case physical examination and, in particular, range of motion. Thus
the physician should not depend solely on such algorithms to make the diagnosis.Rather, algorithms should be used as tools in addition to all the information gathered
by history, physical examination, and imaging
Non–weight bearing
Erythrocyte sedimentation rate (ESR)- 40 mm/h
White blood cell count (WBC)- >12 109/L
Temperature – >38.5C
Probability of Septic Arthritis
Presence of 0 predictors -<0.2%
Presence of 1 predictor – 3.0%
Presence of 2 predictors – 40%
Presence of 3 predictors -93.1%
All 4 predictors present -99.6%
- +BELIEVE YOUR EYE,HAND,USG,XRAY,CRP-
Superintendent, ICH.