CHAPTER 5 Andrew Hamer Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK A child with hip disease often presents to healthcare professionals with an unexplained limp, often in the absence of a history of pain or trauma. Unexplained thigh or knee pain should, however, raise the suspicion of hip abnormalities. See Box 5.1 for a summary of important causes of childhood hip pain. This was previously called congenital dislocation of the hip (CDH) and is due to a failure of normal development of the acetabulum leading to failure of normal development of the hip. All babies are screened by physical examination in the neonatal period, although this is unreliable at detecting many cases. Ultrasound screening should detect at risk cases. DDH is associated with a breach presentation, a positive family history and other congenital deformities. Missed cases of DDH may present before 5 years of age as a delay in walking, a limp or discrepancy in leg length. Missed cases may lead to a non‐congruent joint and early osteoarthritic degeneration in adulthood (Figure 5.1). Figure 5.1 Anteroposterior radiograph of child with dislocated right hip. Note the lateral displacement of the femur and poorly developed ossific nucleus of the hip Perthes’ disease is relatively rare, and is a segmental avascular necrosis of the femoral head. This can lead to subsequent healing and deformity of the hip. This condition occurs in boys usually between the ages of 5 and 10 years. The precise cause is unclear, but the condition is associated with a positive family history, low birth weight and lower socioeconomic groups. A limp, hip pain or knee pain may result. Treatment aims are to contain the femoral head in the acetabulum to reduce the risks of future osteoarthritis. This condition is typically seen in overweight boys at the time of the adolescent growth spurt, at the ages of 11–15. Girls may also experience the condition but this is more uncommon. The diagnosis may be difficult, but a frog lateral X‐ray radiograph will show the deformity (Figure 5.2). Surgical stabilization to fix the slipped epiphysis in situ should be carried out urgently. The contralateral hip is at high risk of slippage, and patients and parents should be warned to return if any hip or knee pain occurs on the unoperated side. Figure 5.2 X‐ray radiograph of a child’s left hip. Displacement of the epiphysis relative to the femoral neck is easily seen This is relatively uncommon in children, but should be suspected if a child presents with systemic illness, toxic and inability to walk. Movement of the affected joint is not possible because of pain. Diagnosis is helped by a raised white cell count, erythrocyte sedimentation rate and C‐reactive protein. An effusion may be seen on ultrasound, and urgent aspiration will help with diagnosis. Urgent surgical drainage is vital to reduce the risk of late osteoarthritis. Staphylococcus aureus is usually the infecting organism, but diagnosis may be particularly difficult in neonates. A reactive effusion may occur in the hip joint in association with systemic viral illness. Affected children are not acutely ill and can move the hip, but with some degree of stiffness. An effusion may be seen on ultrasound; the condition is usually self‐limiting and responsive to non‐steroidal anti‐inflammatory drugs. Distinguishing this condition from septic arthritis can be difficult, and occasionally these children must undergo aspiration to exclude a septic hip. Perthes’ disease in the early stages may present with an effusion without changes visible on X‐ray examination. Juvenile chronic arthritis may present with hip pain. General management of the arthritic process is important, with physiotherapy to prevent joint contracture. Systemic therapy with disease‐modifying agents can be very effective. These therapies have important potential toxicities and must be prescribed knowledgeably. Pain from the hip is usually felt in the groin or lateral or anterior thigh. Hip pain may also be referred to the knee, and occasionally even down to the front of the ankle; this may confuse the unwary! Although buttock pain may originate from the hip, the lumbar spine is the usual source. Hip disorders often produce a limp, a reduction in walking distance and associated stiffness. These functional limitations may affect activities of daily living, such as getting in and out of the bath and putting on socks and shoes. Patients with advanced hip disease can become dependent on others, sometimes requiring expensive social services input. See Box 5.2 for a summary of the causes of hip pain in adults.
Pain in the Hip
Hip pain in children
Developmental dysplasia of the hip (DDH)
Perthes’ disease
Slipped upper femoral epiphysis (SUFE)
Septic arthritis
Transient synovitis/‘irritable hip’
Other arthritides
Hip pain in adults
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