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From: Rakesh Goyal rakesh_dr1710@yahoo.

Date: 30 June 2019 at 7:32 am
To: rakesh goyal



Septic arthritis

●Septic arthritis of the hip – Septic arthritis is a "diagnosis not to miss" in the evaluation of a child with hip
pain, given the potential for rapid joint destruction and long-term morbidity that can accompany delay in
diagnosis and treatment. The epidemiology of septic arthritis of the hip is not well defined. An early peak
appears to occur in the first months of infancy, with an overall average age of three to six years [4,21-23].
As with most infections, studies generally indicate that boys are affected more commonly than girls. (See
"Bacterial arthritis: Epidemiology, pathogenesis, and microbiology in infants and children", section on
Children with septic arthritis of the hip typically are febrile and ill-appearing, although occasionally the
presentation is more subtle [21]. Neonates and infants may present with irritability and pseudoparalysis of
the affected limb, even without fever. Weight-bearing and motion of the affected hip are quite painful and
strongly resisted in all patients [21]. The presentation of septic arthritis may be altered by recent use of
antibiotics or when indolent organisms (eg, Kingella kingae) are involved [24]. (See "Bacterial arthritis:
Clinical features and diagnosis in infants and children", section on 'Clinical features'.)
Clinical and laboratory features predictive of septic arthritis of the hip include fever >38.5°C (101.3°F)
within the week before presentation; refusal to bear weight; elevated erythrocyte sedimentation rate (ESR)
>40 mm/h; C-reactive protein (CRP) >2 mg/dL (20 mg/L); and peripheral white blood cell (WBC) count
>12,000 cells/microL [21,25-27]. Diagnosis is confirmed by ultrasound-guided aspiration of inflammatory
hip fluid with identification of a causative organism by blood or synovial fluid culture. (See "Bacterial
arthritis: Clinical features and diagnosis in infants and children", section on 'Diagnosis'.)
Therapy consists of urgent and, in some cases, repeated drainage to avoid buildup of intra-articular
pressure that may impede local blood flow, and administration of parenteral antibiotics. (See "Bacterial
arthritis: Treatment and outcome in infants and children".)
●Septic arthritis of the sacroiliac joint – Septic arthritis of the sacroiliac joint also can present with pain in
the region of the hip. Examination reveals that gentle hip motion is not painful, whereas maneuvers that
torque the pelvis (eg, Flexion of the hip and knee, with Abduction and External Rotation with Extension of
the sacroiliac joint [the FABERE test] (figure 2)) reproduce the patient's symptoms.
Osteomyelitis — Osteomyelitis of the femur or pelvis can present with hip pain. The diagnosis of
osteomyelitis should be made as soon as possible, because delay in treatment increases the likelihood of
a poor outcome. Osteomyelitis of the proximal femur, which is intra-articular (ie, within the joint capsule),
frequently is associated with septic arthritis of the hip.

Clinical features of osteomyelitis include fever, localized pain, and decreased mobility. The proximal femur
is the most common site of osteomyelitis in children. Pelvic osteomyelitis, a rare condition, also typically
presents with hip pain and limp. However, children with pelvic osteomyelitis often permit careful
manipulation of the painful hip, a feature that distinguishes it from and septic arthritis of the hip. The
presentation of osteomyelitis may be altered by the recent use of antibiotics. (See "Hematogenous
osteomyelitis in children: Clinical features and complications", section on 'Clinical features'.)

The diagnosis of osteomyelitis may be strongly suggested by plain film, bone scan, or magnetic resonance
imaging (MRI) (image 10). Although soft tissue edema can be seen early in the course of osteomyelitis,
bone changes may not be seen for five to seven days. Bone scan has the advantage of detecting
multifocal disease, which occurs in 7 percent of cases of pediatric osteomyelitis, especially in neonates
[28]. MRI is more sensitive and specific than bone scan in the diagnosis of osteomyelitis [29]; however,
these benefits must be weighed against cost, need for sedation, and the ability of bone scan to detect
multifocal disease [15]. (See "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section
on 'Advanced imaging'.)

Other infections — Arthritis is the most common manifestation of late Lyme disease. The knee is involved
in more than 90 percent of cases, but the hip may be involved. (See "Lyme disease: Clinical manifestations
in children", section on 'Arthritis'.)

In addition, hip pain may be referred from infections at other sites, including:

●Psoas abscess (see "Psoas abscess", section on 'Clinical manifestations')

●Appendicitis (see "Acute appendicitis in children: Clinical manifestations and diagnosis", section on
●Appendicitis (see "Acute appendicitis in children: Clinical manifestations and diagnosis", section on
'Clinical manifestations')
●Abdominal or pelvic abscess (see "Fever of unknown origin in children: Etiology", section on 'Intra-
abdominal abscess' and "Causes of acute abdominal pain in children and adolescents")
●Discitis (see "Back pain in children and adolescents: Causes", section on 'Discitis')

Transient synovitis — Transient synovitis is characterized by pain and limitation of motion in the hip, arising
without clear precipitant and resolving gradually with conservative therapy. It is relatively common, with a
cumulative lifetime risk of 3 percent in one prospective study [30]. The etiology is unclear; posttraumatic,
allergic, and infectious causes have been proposed [3,4,31-33].

Transient synovitis typically occurs in children between the ages of three and eight years, with a mean age
at presentation of five to six years [30,31,34]. The male-to-female ratio is greater than 2:1. Symptoms
affect both hips in as many as 5 percent of cases [31]. Even in symptomatically unilateral disease,
ultrasound can detect bilateral effusions in 25 percent of children [14].

Most children have had symptoms for less than a week at the time of presentation. However, in a
retrospective review, 12 percent of patients had discomfort dating back at least one month [31].

Children with transient synovitis generally are well appearing. Systemic symptoms, including high fever,
may occur, but fever typically is absent or low grade.

Hip infection must be excluded. Patients who are nontoxic with minimal fever (temperature <38.5°C
[101.3°F]), WBC count <12,000 cells/microL, and ESR <20 mm/hour or CRP <2 mg/dL (20 mg/L) often can
be followed clinically, though some patients with K. kingae infection may also present more indolently
[21,25,26,35,36]. Patients with clinical or laboratory findings of concern should undergo hip imaging
(typically ultrasonography of both hips). Diagnostic arthrocentesis may be necessary to definitively exclude
septic arthritis. (See 'Imaging' above.)

The management of transient synovitis is conservative, with the use of nonsteroidal anti-inflammatory
drugs and return to full activity as tolerated [37]. One report suggested that patients treated with
ultrasound-directed hip aspiration may recover faster, potentially from reduction in capsular stretch, but
since most children recover quickly we do not recommend this procedure except where necessary to
exclude septic arthritis [38].

The prognosis usually is excellent, with full recovery to be expected. Recurrence rates from 4 to 15 percent
have been reported, but most children with recurrent transient synovitis have a benign course [2,39,40]. A
small percentage (1 to 2 percent in most series) may go on to develop Legg-Calvé-Perthes disease (LCP)
with avascular necrosis of the ipsilateral femoral head [30,31,41].

Despite the frequency of transient synovitis, its etiology remains obscure. Although posttraumatic or
allergic mechanisms have been proposed, an infectious cause commonly is assumed, because between
32 and 50 percent of children presenting with transient synovitis have had a recent upper respiratory tract
infection (URI) [4,31]. In one small series of patients with transient synovitis, approximately one-half had
elevated blood and/or synovial fluid interferon levels and approximately one-half had elevated antibody
titers to Mycoplasma pneumoniae or a range of viruses (sometimes more than one), including parvovirus
B19 [32,33]. Synovial fluid viral cultures, performed in a subset of patients, remained negative. The
significance of these findings is uncertain because no control patients were tested. Traumatic arthropathy
and septic arthritis also may be preceded by viral infections [3,4]. In fact, in the only published comparison
with septic arthritis, the prevalence of preceding URI was no different between groups (32 percent in
transient synovitis versus 29 percent in septic arthritis) [4].

A subset of transient synovitis may be early LCP (idiopathic avascular necrosis) or a forme fruste of this
disorder. One large series documented reduced femoral blood flow in 15 of 192 patients with transient
synovitis, of whom four went on to develop overt LCP [20]. Note that a joint effusion under pressure
(aseptic or septic) can reduce femoral blood flow as measured by bone scan [42], so this finding is open to
multiple interpretations.

Systemic rheumatologic disease — Systemic rheumatologic diseases can present with isolated hip pain.
Of these, the most common are specific subtypes of juvenile idiopathic arthritis (JIA), particularly
enthesitis-related arthritis and psoriatic arthritis, which can start as isolated or recurrent hip arthritis. The
skin manifestations of psoriatic arthritis may be subtle, such as dryness behind the ears or nail pits (picture
1), and may emerge years after the onset of arthritis. (See "Spondyloarthritis in children" and "Clinical
manifestations and diagnosis of psoriatic arthritis".)

Other types of JIA rarely present with isolated hip disease, though polyarticular JIA (seronegative and
Other types of JIA rarely present with isolated hip disease, though polyarticular JIA (seronegative and
seropositive) and systemic JIA commonly involve the hip as one of multiple affected joints and/or in the
setting of an obvious systemic inflammatory state. (See "Oligoarticular juvenile idiopathic arthritis" and
"Polyarticular juvenile idiopathic arthritis: Clinical manifestations, diagnosis, and complications" and
"Systemic juvenile idiopathic arthritis: Clinical manifestations and diagnosis".)

Other rheumatologic conditions that may involve the hip include:

●Acute rheumatic fever (see "Acute rheumatic fever: Clinical manifestations and diagnosis", section on
●Poststreptococcal arthritis (see "Acute rheumatic fever: Clinical manifestations and diagnosis", section on
'Poststreptococcal reactive arthritis')
●Chronic recurrent multifocal osteomyelitis (see "Hematogenous osteomyelitis in children: Evaluation and
diagnosis", section on 'Chronic nonbacterial osteomyelitis')
Idiopathic chondrolysis of the hip — Idiopathic chondrolysis of the hip is a poorly defined condition in
which the articular cartilage of the hip is injured by an undefined but presumably inflammatory process. An
association with spondyloarthropathy has been postulated but not confirmed. Some authors consider
idiopathic chondrolysis of the hip to be an independent subform of JIA [43].

Idiopathic chondrolysis of the hip usually occurs in the second decade of life. It affects females more often
than males. African-Americans are affected more severely. Symptoms usually are unilateral. However,
disease in the contralateral hip is sometimes noted on physical examination or imaging studies [43].

Clinical features include insidious onset of hip pain, stiffness, and limp in the absence of systemic
symptoms [44]. The range of motion is decreased in all planes.

MRI demonstrates cartilage loss and synovial hypertrophy. Biopsy reveals mild chronic inflammation and is
helpful to exclude infection [45].

Most patients go on to develop painful and disabling osteoarthritis of the hip, although some recover. In
case reports, administration of anti-inflammatory therapy has been useful in some patients [16,43,46].


Legg-Calvé-Perthes and secondary avascular necrosis — LCP is a syndrome of idiopathic osteonecrosis

(avascular necrosis) of the hip. It typically presents as hip pain and/or limp of acute or insidious onset in
children between the ages of 3 and 12 years, with peak incidence at five to seven years of age [47]. LCP is
bilateral in at least 10 to 20 percent of patients [48,49]. The male-to-female ratio is 3 to 4:1, and African-
Americans are rarely affected [50,51]. Associations with obesity, skeletal immaturity, and lower
socioeconomic status have been reported [51-53]. Twin studies show familial clustering but no particular
enrichment in monozygotic twins, suggesting a modest role for genetic predisposition [54]. Avascular
necrosis also may occur secondary to an underlying condition (eg, renal failure, glucocorticoid use,
systemic lupus erythematosus, HIV, Gaucher disease) [55].

The etiology of LCP remains undefined. Approximately 10 percent of cases are familial, and patients often
lag behind their peers in bone age and height [48,56].

Clinical features of LCP and secondary avascular necrosis of the hip include insidious onset of hip pain
with limp and activity-related pain [57].

Diagnosis of LCP demands a high index of suspicion. Initial radiographs are often normal. Early in the
course, bone scan shows decreased perfusion to the femoral head, and MRI reveals marrow changes
highly suggestive of the diagnosis (image 8) [58,59]. Later in the course, radiographs show fragmentation
and then healing of the femoral head, often with residual deformity (image 3). Gradual revascularization
occurs subsequently [60].

Children diagnosed with LCP should be made nonweight bearing and referred to an experienced pediatric
orthopedist for management. Therapy for LCP is poorly defined because no large controlled trials are
available, and long-term consequences become evident only after decades of follow-up. Treatment
focuses on containing the femoral head within the acetabulum through the use of splints or occasionally
surgery [61].

Almost all children do well in the short term. However, long-term outcome depends upon age at time of
disease onset and degree of involvement of the femoral head [49,62-64]. Children who are younger than
six to eight years have a better prognosis, perhaps because more time is permitted for femoral remodeling
and because before eight years of age the acetabulum is plastic and can mold to the deformed femoral
and because before eight years of age the acetabulum is plastic and can mold to the deformed femoral
head, maintaining congruity [48,65].

Slipped capital femoral epiphysis — In slipped capital femoral epiphysis (SCFE), the femoral epiphysis
slips posteriorly (image 5), resulting in a limp and impaired internal rotation.

The typical patient is an obese child in early adolescence (ie, a female who has not yet reached menarche
or a male who has not yet reached the fourth Tanner stage). The mean age of presentation is 12 years in
girls and 13.5 years in boys, near the time of peak linear growth. The male-to-female ratio is approximately
1.5:1. SCFE is bilateral in 20 to 40 percent of cases [66,67].

Patients may present with acute hip pain and inability to walk, often after minor trauma. However, they
usually come to attention after months of ill-defined hip or knee symptoms and limp, with or without an
acute exacerbation. The absence of pain, or pain localized to the knee or thigh instead of the hip, can lead
clinicians to overlook the diagnosis [68,69], a delay that may be associated with increased slip severity
[70]. Simultaneous external rotation and abduction of the hip during hip flexion is a useful, though variably
present, finding [71]. (See "Evaluation and management of slipped capital femoral epiphysis (SCFE)",
section on 'Clinical manifestations'.)

The diagnosis of SCFE usually can be made on plain radiographs, which reveal apparent posterior
displacement of the femoral epiphysis, like ice cream slipping off a cone (image 5). (See "Evaluation and
management of slipped capital femoral epiphysis (SCFE)", section on 'Diagnosis'.)

Stress fracture — Stress fractures are rare in children, but they can occur in athletes engaged in endurance
sports. The femur is the third most common site of stress fracture in children [72,73]. In young adults, pain
commonly is experienced in the anterior thigh and typically can be reproduced by asking the patient to
hop on the affected leg [74]. Plain radiographs usually are negative early in the course of the fracture. Bone
scan or MRI is the test of choice for diagnosis. A temporary change in activity pattern is important to avoid
progression to a displaced fracture. (See "Overview of stress fractures".)


Osteoid osteoma — Osteoid osteoma is a relatively common benign bone tumor. The proximal femur is the
most common site of occurrence [75]. Osteoid osteoma may occur in all age groups. However, most
patients present in the teenage years. The pain is typically nocturnal and aching, and it responds briskly to
nonsteroidal anti-inflammatory drug therapy. Osteoid osteoma may be visible as a lucency with
surrounding cortical thickening on plain radiograph (image 2) or computed tomography (image 11), or it
may be apparent only on bone scan or MRI. (See "Nonmalignant bone lesions in children and
adolescents", section on 'Osteoid osteoma'.)

Other neoplasms — Malignancy presenting as arthritis occurs rarely but is well reported. Hallmarks of
tumors presenting as arthritis include pain at night, bone pain distant from the joint, and abnormal
laboratory evaluation, particularly the complete blood count, which may show anemia, leukopenia, or a
platelet count lower than would be expected based upon the elevation of ESR. Elevated blood levels of
lactate dehydrogenase or uric acid can suggest leukemia [76,77]. (See "Clinical assessment of the child
with suspected cancer", section on 'Bone and joint pain'.)

Leukemia, principally acute lymphoblastic leukemia (ALL), is the most common cancer to present with joint
pain in children [78,79]. Children with ALL typically have severe, migratory musculoskeletal pain secondary
to leukemic infiltration of bone. (See "Overview of the clinical presentation and diagnosis of acute
lymphoblastic leukemia/lymphoma in children".)

Other cancers that can mimic arthritis include [76,80]:

●Neuroblastoma (especially in the very young child) (see "Clinical presentation, diagnosis, and staging
evaluation of neuroblastoma")
●Lymphoma (see "Overview of non-Hodgkin lymphoma in children and adolescents")
●Ewing sarcoma and other soft-tissue sarcomas (see "Clinical presentation, staging, and prognostic
factors of the Ewing sarcoma family of tumors")
●Pigmented villonodular synovitis, a benign but potentially destructive neoplasm of synovium (see
"Antineoplastic therapy for miscellaneous benign diseases affecting soft tissue and bone, including
tenosynovial giant cell tumor", section on 'Tenosynovial giant cell tumor')

●Hip pain in children has a broad range of causes, ranging from the benign to the potentially devastating
(table 1). (See 'Introduction' above.)
●The history and examination of the child with hip pain is focused on distinguishing between infectious,
●The history and examination of the child with hip pain is focused on distinguishing between infectious,
inflammatory, orthopedic/mechanical, and neoplastic causes. This distinction helps to determine the
appropriate laboratory and radiographic evaluation. (See 'Overview' above and 'Common causes of hip
pain in children' above.)
●Important aspects of the history in the child with hip pain include the age and sex of the child (table 3);
the onset, duration, severity, and location of the pain; associated systemic symptoms; past medical
history; family history; and social history (table 4). (See 'History' above.)
●The examination of the child with hip pain is targeted to determine whether the pain is coming from inside
or outside the hip joint and whether it is an isolated problem or a manifestation of a systemic condition,
such as inflammatory arthritis. Abnormal findings in other joints, in the skin, or in growth parameters may
suggest systemic disease (table 2). (See 'Examination' above.)
●The hip examination includes observation (for asymmetry and position of comfort), palpation (to localize
the source of pain), range of motion in both the prone (figure 1) and supine positions, and assessment of
ability to bear weight. (See 'Examination' above.)
●The laboratory evaluation of the child with hip pain is directed by the findings from the history and
physical examination. (See 'Laboratory evaluation' above.)
●Imaging is necessary in all patients in whom septic arthritis, skeletal injury, or tumor remains in the
differential diagnosis after history, examination, and initial laboratory evaluation. The imaging strategy
depends upon the suspected etiology. (See 'Imaging' above.)