Septic Arthritis

Transient synovitis of hip Self-limiting Inflammatory disorder of the hip **Imp to exclude septic arthritis MCC of acute hip pain and limp in children 2-12 yo

Sickle cell Disease

Juvenile Idiopathic arthritis Autoimmune Nonmigratory, nonsuppurative mono- and polyarthritis w/ bony destruction - >6 weeks

Legg-Calve-Perthes disease Avascular necrosis of femoral head Self-limited w/ sx lasting <18 months

Developmental dysplasia of hip Intrauterine loss of contact btw fetal femoral head and acetabulum

Slipped Capital femoral epiphysis (SCFE) Displacement of femoral head from femur neck d/t stress fracture through femoral capital epiphyseal plate; Endocrine basis

<16 yo 3-8 yo (~6) Acute onset following skin or URI Systemic sx Fever >101.3, chills, malaise Unilateral Acute hip pain severe pain w/ weight-bearing activities Refusal to bear weight Hot, Tender, Swollen, Restricted joint Acute onset Prior hx of viral illness (Fall/Winter) Mild systemic features Unilateral Acute abdominal pain Systemic sx Unilateral Associated w/ long bone osteomyelitis Morning stiffness + gradual loss of motion >6 weeks Accompanied by fever, nodules, erythematous rashes, pericarditis, and fatigue Pauciarticular (MC): Assymmetric, weightbearing joints (<4), risk of iridocyclitis blindness if untreated, Polyarticular: Symmetric, multiple (>5) small joints Acute febrile: Daily high, spiking fevers and maculopapular, evanescent, salmon colored rash, boys=girls, Remission in 1 year PE: Pain w/ passive ROM Restricted motion w/ minimal pain can bear weight Spontaneous improvement over 24-48 hrs CBC: Normal WBC ESR: Normal (<40) - Blood cultures XRAY: Normal (r/o legg-calve) XRAY: joint space. Soft tissue swelling + osteoporosis may be seen XRAY: Wide articular space, then necrosis XRAY (>6 mo): Abnormal relationship btw femoral head and acetabulum Ultrasound (6 weeks-6 mo): Abnormal relationship btw femoral head and acetabulum XRAY (BOTH hips in AP + frogleg lateral views): Posterior and medial displacement of femoral head, bare upper portion of femoral neck, wide growth plate + Sickling test WBC, ESR, platelets + Rheumatoid factor Limited abduction + internal rotation PE: <6mo: Barlow (abducted, ant. Pressure), Ortalani (adducted, post. Pressure) >6 mo: hip abduction PE: External rotation on hip flexion Gait w/ affected leg externally rotated TSH: to r/o hypothyroid *Limping child 3-10 yo (~5-7) Pt: Short stature, delayed bone age, hyperactivity Unilateral Limping gait at first painless, can proceed to pain w/ activity and w/ rest occurs over weeks - months Hip pain radiating into thighs, knees, groin, buttock, or abdomen Pain worse with activities Newborn 3 yo Risk: + Family Hx, First born female, Excessive uterine packing (Breech) Shortening of involved leg ROM Adolescents (10-16 yo) Risk: Obese, Male, African American, GH deficiency, hypothyroid Groin pain referred to anteromedial knee and thigh, Painful limp, and accentuated external rotation Unable to bear weight

CBC: WBC >12,000 ESR: >40 + Blood cultures XRAY: widened joint space (d/t purulent effusion) Ultrasound: Joint effusion **Aspiration: confirms infxn cell count >25,000 Gram stain + synovial cultures IV vancomycin IV nafcillin or IV cefazolin should be started w/ pending synovial cultures Immediate surgical drainage

Normal WBC

Ultrasound: joint effusion Aspiration: sterile (r/o septic)

Aspiration: WBCs, No crystals or organisms

Bed rest for 7 days w/ knee joint in position of comfort + NSAIDs

NSAIDs or corticosteroids 2 line = methotrexate

nd

Observation (if full ROM) Goal = maintain joint mobility

<6 mo: Pavlik harness (hip flexed + abducted) 6-15 mo: Spica cast

No weight bearing until surgically stabilized! Gentle closed reduction only in acute slips

Containment: Close observation Bracing w/ orthoses Surgically w/ osteotomies Good prognosis: <5 years Full ROM Femoral head involvement Stable joint

15-24 mo: Open reduction followed by spica cast Complications: Joint contractures AVN of femoral head Complications: Chondrolysis, AVN of femoral head Premature hip osteoarthritis hip arthroplasty