DISCUSSION RESPONSE
konxidum
responseweek10.docx
HPI: Clay is a 7-year-old male who presents in your office with complaints of right thigh pain and a limp. The pain began approximately 1 week ago and has progressively worsened. There is no history of trauma.PE: Pleasant Caucasian boy, in mild distress. VS and growth pattern stable.MS: flexion and internal rotation of the right hip and limited abduction of the right hip. Limb lengths are equal.
Location: right thigh
Onset: 1 week ago
Characteristics: unknown
Aggravating/Alleviating factors: unknown
Timing of symptoms: progressively worsened, no specifics
Environment: no specifics, however, no hx of trauma
Severity: unknown
Additional questions: Does it hurt worse during activity, when sitting, or when lying? What helps the pain (i.e. hot, cold, medication, rest, elevation, compression)? What is the severity of the pain on a scale of 1-10? What does the pain feel like (i.e. aching, sharp, consistent, throbbing, dull)? Have you ever experienced this pain before? Do you experience pain in any other joints? Any recent illnesses, recent abx use, or recent steroid use?
Additional information: Medical hx, surgical hx, family hx, immunization hx, allergies, current medications
Diagnostic tests and labs: Since etiology of the hip pain is unknown, we have to differentiate between orthopedic, infectious, or inflammatory causation. CBC, ESR, CRP. Plain radiographs to confirm or rule out differentials: When plain radiographs are necessary, anteroposterior and frog-leg views are obtained (the frog-leg is the true lateral of the femur) (Gough-Palmer & McHugh, 2007).
Primary diagnosis: Transient synovitis- this inflammatory condition causes pain in the hip and limited ROM. It commonly occurs in males between the ages of 3 and 8 and has an acute onset. Causation is unclear and can occur without a precipitant. Most children that present to the provider’s office have only had symptoms for less than a week and are generally well appearing. Can sometimes be preceded by a viral infection, such as a URI.
• Positives: pain in hip, limited ROM in hip, male, between ages of 3-8, no known precipitant, symptoms began 1 week ago and are progressively getting worse, acute onset
• Negatives: none identified.
Differential diagnosis:
Legg-Calve-Perthes disease (LCP)- this is avascular necrosis of the hip. Symptoms include hip pain with limp and activity-related pain that is not always relieved by rest or medication. Occurs bilaterally in 10-20 percent of children. This usually occurs between the ages of 3 and 12 and more common in males (Wenger et al., 1991). Etiology is unclear, although there may be a familial factor and patients commonly are smaller than children their age.
• Positives: hip pain, limp, pt between ages 3-12, male
• Negative: no familial hx that is known, symptoms are not bilateral in nature.
Slipped Capital Femoral Epiphysis- this condition is commonly seen in obese children and, if male, has not reached the fourth Tanner stage yet (Kocher et al., 2004). Two most common symptoms are pain and altered gait. Occurs bilaterally in 20-40 percent of cases. Other symptoms are pain that is described as nonradiating, dull, or aching that occurs in the hip, groin, thigh, or knee with no preceding trauma. Acute SCFE includes external rotational deformity, limited ROM of the hip, shortening, and inability to bear weight (Uvodich et al., 2019).
• Positives: limited ROM of the hip, young male, pain in hip with no preceding trauma, altered gait
• Negatives: patient is not obese (growth pattern stable), patient has ability to bear weight
Treatment and Management: Use of nonsteroidal anti-inflammatory drugs and return to full activity as tolerated is the recommended conservative treatment for transient synovitis (Kermond et al., 2002). Ultrasound directed hip aspiration is not recommended since most children recover quickly without it (Liberman et al., 2013), unless infection is indicated.
References:
Gough-Palmer, A., McHugh, K. (2007). Investigating hip pain in a well child. BMJ; 334:1216.
Kermond, S., Fink, M., Graham, K, et al. (2002). A randomized clinical trial: should the child with transient synovitis of the hip be treated with nonsteroidal anti-inflammatory drugs? Ann Emerg Med; 40:294.
Kocher, M.S., Bishop, J.A., Weed, B., et al. (2004). Delay in diagnosis of slipped capital femoral epiphysis. Pediatrics; 113:e322.
Liberman, B. Herman, A., Schindler, A., et al. (2013). The value of hip aspiration in pediatric transient synovitis. J Pediatr Orthop; 33:124.
Uvodich, M., Schwend, R., Stevanovic, O., et al. (2019). Patterns of Pain in Adolescents with Slipped Capital Femoral Epiphysis. J Pediatr; 206:184.
Wenger, D.R., Ward, W.T., Herring, J.A. (1991). Legg-Calvé-Perthes disease. J Bone Joint Surg Am; 73:778.
