Approach to hip pain in childhood
- Peter A Nigrovic, MD
Peter A Nigrovic, MD
- Associate Professor of Medicine
- Harvard Medical School
- Section Editors
- Jan E Drutz, MD
Jan E Drutz, MD
- Section Editor — General Pediatrics
- Professor of Pediatrics
- Baylor College of Medicine
- William Phillips, MD
William Phillips, MD
- Section Editor — Pediatric Orthopedics
- Professor of Pediatrics and Orthopedics
- Baylor College of Medicine
- Robert Sundel, MD
Robert Sundel, MD
- Section Editor — Pediatric Rheumatology
- Associate Professor of Pediatrics
- Harvard Medical School
Hip pain is common in children and adolescents and has a broad range of causes, ranging from the benign to the potentially devastating (table 1) . The evaluation and common causes of hip pain in children are reviewed here. The causes of limp in children, approach to the child with a limp, and radiographic imaging of the hip in children and adolescents are discussed separately. (See "Overview of the causes of limp in children" and "Approach to the child with a limp" and "Radiologic evaluation of the hip in infants, children, and adolescents".)
Overview — The history and examination of the child with hip pain are focused on distinguishing between infectious, inflammatory, orthopedic, and neoplastic etiologies (table 2). This distinction helps to determine the appropriate laboratory and radiographic evaluation. (See 'Common causes of hip pain in children' below.)
●Infectious – Infectious pain is usually acute, localized, and severe (eg, refuses to bear weight); it is generally accompanied by fever, elevated white blood cell (WBC) count, and elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
●Inflammatory – Inflammatory pain typically is chronic or has insidious onset (with the exception of transient synovitis, which has acute onset); may be accompanied by other findings (eg, rash, nail pits, uveitis), involve joints other than the hip, and recur; refusal to bear weight is uncommon
●Orthopedic – Pain is usually localized to the hip but may be referred to the thigh or knee; may have acute or insidious onset; pain increases with activity and decreases with rest; systemic symptoms are absent; ESR and CRP are usually normalTo continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Spahn G, Schiele R, Langlotz A, Jung R. Hip pain in adolescents: results of a cross-sectional study in German pupils and a review of the literature. Acta Paediatr 2005; 94:568.
- Taylor GR, Clarke NM. Recurrent irritable hip in childhood. J Bone Joint Surg Br 1995; 77:748.
- Kunnamo I. Infections and related risk factors of arthritis in children. A case-control study. Scand J Rheumatol 1987; 16:93.
- Taylor GR, Clarke NM. Management of irritable hip: a review of hospital admission policy. Arch Dis Child 1994; 71:59.
- Goff I, Rowan A, Bateman BJ, Foster HE. Poor sensitivity of musculoskeletal history in children. Arch Dis Child 2012; 97:644.
- Glotzbecker MP, Kocher MS, Sundel RP, et al. Primary lyme arthritis of the pediatric hip. J Pediatr Orthop 2011; 31:787.
- Bachur RG, Adams CM, Monuteaux MC. Evaluating the child with acute hip pain ("irritable hip") in a Lyme endemic region. J Pediatr 2015; 166:407.
- Gran JT, Husby G. HLA-B27 and spondyloarthropathy: value for early diagnosis? J Med Genet 1995; 32:497.
- Beach R. Minimally invasive approach to management of irritable hip in children. Lancet 2000; 355:1202.
- Miralles M, Gonzalez G, Pulpeiro JR, et al. Sonography of the painful hip in children: 500 consecutive cases. AJR Am J Roentgenol 1989; 152:579.
- Gough-Palmer A, McHugh K. Investigating hip pain in a well child. BMJ 2007; 334:1216.
- Zawin JK, Hoffer FA, Rand FF, Teele RL. Joint effusion in children with an irritable hip: US diagnosis and aspiration. Radiology 1993; 187:459.
- Alexander JE, Seibert JJ, Aronson J, et al. A protocol of plain radiographs, hip ultrasound, and triple phase bone scans in the evaluation of the painful pediatric hip. Clin Pediatr (Phila) 1988; 27:175.
- Ehrendorfer S, LeQuesne G, Penta M, et al. Bilateral synovitis in symptomatic unilateral transient synovitis of the hip: an ultrasonographic study in 56 children. Acta Orthop Scand 1996; 67:149.
- Jaramillo D, Treves ST, Kasser JR, et al. Osteomyelitis and septic arthritis in children: appropriate use of imaging to guide treatment. AJR Am J Roentgenol 1995; 165:399.
- Bleck EE. Idiopathic chondrolysis of the hip. J Bone Joint Surg Am 1983; 65:1266.
- Lalaji A, Umans H, Schneider R, et al. MRI features of confirmed "pre-slip" capital femoral epiphysis: a report of two cases. Skeletal Radiol 2002; 31:362.
- Umans H, Liebling MS, Moy L, et al. Slipped capital femoral epiphysis: a physeal lesion diagnosed by MRI, with radiographic and CT correlation. Skeletal Radiol 1998; 27:139.
- Connolly LP, Connolly SA. Skeletal scintigraphy in the multimodality assessment of young children with acute skeletal symptoms. Clin Nucl Med 2003; 28:746.
- Royle SG, Galasko CS. The irritable hip. Scintigraphy in 192 children. Acta Orthop Scand 1992; 63:25.
- Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am 1999; 81:1662.
- Bennett OM, Namnyak SS. Acute septic arthritis of the hip joint in infancy and childhood. Clin Orthop Relat Res 1992; :123.
- Betz RR, Cooperman DR, Wopperer JM, et al. Late sequelae of septic arthritis of the hip in infancy and childhood. J Pediatr Orthop 1990; 10:365.
- Yagupsky P, Dagan R. Kingella kingae: an emerging cause of invasive infections in young children. Clin Infect Dis 1997; 24:860.
- Kocher MS, Mandiga R, Zurakowski D, et al. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am 2004; 86-A:1629.
- Caird MS, Flynn JM, Leung YL, et al. Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am 2006; 88:1251.
- Cruz AI Jr, Aversano FJ, Seeley MA, et al. Pediatric Lyme Arthritis of the Hip: The Great Imitator? J Pediatr Orthop 2017; 37:355.
- Nelson JD. Acute osteomyelitis in children. Infect Dis Clin North Am 1990; 4:513.
- Morrison WB, Schweitzer ME, Bock GW, et al. Diagnosis of osteomyelitis: utility of fat-suppressed contrast-enhanced MR imaging. Radiology 1993; 189:251.
- Landin LA, Danielsson LG, Wattsgård C. Transient synovitis of the hip. Its incidence, epidemiology and relation to Perthes' disease. J Bone Joint Surg Br 1987; 69:238.
- Haueisen DC, Weiner DS, Weiner SD. The characterization of "transient synovitis of the hip" in children. J Pediatr Orthop 1986; 6:11.
- Tolat V, Carty H, Klenerman L, Hart CA. Evidence for a viral aetiology of transient synovitis of the hip. J Bone Joint Surg Br 1993; 75:973.
- Miron D, Luder A, Horovitz Y, et al. Acute human parvovirus B-19 infection in hospitalized children: A serologic and molecular survey. Pediatr Infect Dis J 2006; 25:898.
- Harrison WD, Vooght AK, Singhal R, et al. The epidemiology of transient synovitis in Liverpool, UK. J Child Orthop 2014; 8:23.
- Singhal R, Perry DC, Khan FN, et al. The use of CRP within a clinical prediction algorithm for the differentiation of septic arthritis and transient synovitis in children. J Bone Joint Surg Br 2011; 93:1556.
- Yagupsky P, Dubnov-Raz G, Gené A, et al. Differentiating Kingella kingae septic arthritis of the hip from transient synovitis in young children. J Pediatr 2014; 165:985.
- Kermond S, Fink M, Graham K, et al. A randomized clinical trial: should the child with transient synovitis of the hip be treated with nonsteroidal anti-inflammatory drugs? Ann Emerg Med 2002; 40:294.
- Liberman B, Herman A, Schindler A, et al. The value of hip aspiration in pediatric transient synovitis. J Pediatr Orthop 2013; 33:124.
- Kallio P, Ryöppy S, Kunnamo I. Transient synovitis and Perthes' disease. Is there an aetiological connection? J Bone Joint Surg Br 1986; 68:808.
- Uziel Y, Butbul-Aviel Y, Barash J, et al. Recurrent transient synovitis of the hip in childhood. Longterm outcome among 39 patients. J Rheumatol 2006; 33:810.
- Kallio PE, Paterson DC, Foster BK, Lequesne GW. Classification in slipped capital femoral epiphysis. Sonographic assessment of stability and remodeling. Clin Orthop Relat Res 1993; :196.
- Uren RF, Howman-Giles R. The 'cold hip' sign on bone scan. A retrospective review. Clin Nucl Med 1991; 16:553.
- Adib N, Owers KL, Witt JD, et al. Isolated inflammatory coxitis associated with protrusio acetabuli: a new form of juvenile idiopathic arthritis? Rheumatology (Oxford) 2005; 44:219.
- Dobbs MB, Morcuende JA. Other conditions of the hip. In: Lovell and Winter's Pediatric Orthopaedics, 6th ed, Morrissy RT, Weinstein SL (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.1125.
- del Couz García A, Fernández PL, González MP, et al. Idiopathic chondrolysis of the hip: long-term evolution. J Pediatr Orthop 1999; 19:449.
- Appleyard DV, Schiller JR, Eberson CP, Ehrlich MG. Idiopathic chondrolysis treated with etanercept. Orthopedics 2009; 32:214.
- Perry DC, Skellorn PJ, Bruce CE. The lognormal age of onset distribution in Perthes' disease: an analysis from a large well-defined cohort. Bone Joint J 2016; 98-B:710.
- Wenger DR, Ward WT, Herring JA. Legg-Calvé-Perthes disease. J Bone Joint Surg Am 1991; 73:778.
- Wiig O, Huhnstock S, Terjesen T, et al. The outcome and prognostic factors in children with bilateral Perthes' disease: a prospective study of 40 children with follow-up over five years. Bone Joint J 2016; 98-B:569.
- Sherry DD, Malleson PN. Nonrheumatic musculoskeletal pain. In: Textbook of Pediatric Rheumatology, 4th ed, Cassidy JT, Petty RE (Eds), WB Saunders, Philadelphia 2001. p.362.
- Johansson T, Lindblad M, Bladh M, et al. Incidence of Perthes' disease in children born between 1973 and 1993. Acta Orthop 2017; 88:96.
- Neal DC, Alford TH, Moualeu A, et al. Prevalence of Obesity in Patients With Legg-Calvé-Perthes Disease. J Am Acad Orthop Surg 2016; 24:660.
- Berthaume MA, Perry DC, Dobson CA, et al. Skeletal immaturity, rostral sparing, and disparate hip morphologies as biomechanical causes for Legg-Calvé-Perthes' disease. Clin Anat 2016; 29:759.
- Metcalfe D, Van Dijck S, Parsons N, et al. A Twin Study of Perthes Disease. Pediatrics 2016; 137:e20153542.
- Gaughan DM, Mofenson LM, Hughes MD, et al. Osteonecrosis of the hip (Legg-Calvé-Perthes disease) in human immunodeficiency virus-infected children. Pediatrics 2002; 109:E74.
- Wang NH, Lee FT, Chin LS, Lo WH. Legg-Calve-Perthes disease: clinical analysis of 57 cases. J Formos Med Assoc 1990; 89:764.
- Weinstein SL. Legg-Calvé-Perthes syndrome. In: Lovell and Winter's Pediatric Orthopaedics, 6th ed, Morrisy RT, Weinstein SL (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.1039.
- Dillman JR, Hernandez RJ. MRI of Legg-Calve-Perthes disease. AJR Am J Roentgenol 2009; 193:1394.
- Uno A, Hattori T, Noritake K, Suda H. Legg-Calvé-Perthes disease in the evolutionary period: comparison of magnetic resonance imaging with bone scintigraphy. J Pediatr Orthop 1995; 15:362.
- Kim HK, Burgess J, Thoveson A, et al. Assessment of Femoral Head Revascularization in Legg-Calvé-Perthes Disease Using Serial Perfusion MRI. J Bone Joint Surg Am 2016; 98:1897.
- Ibrahim T, Little DG. The Pathogenesis and Treatment of Legg-Calvé-Perthes Disease. JBJS Rev 2016; 4.
- Yrjönen T. Long-term prognosis of Legg-Calvé-Perthes disease: a meta-analysis. J Pediatr Orthop B 1999; 8:169.
- Herring JA, Kim HT, Browne R. Legg-Calve-Perthes disease. Part II: Prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg Am 2004; 86-A:2121.
- Wiig O, Terjesen T, Svenningsen S. Prognostic factors and outcome of treatment in Perthes' disease: a prospective study of 368 patients with five-year follow-up. J Bone Joint Surg Br 2008; 90:1364.
- Canavese F, Dimeglio A. Perthes' disease: prognosis in children under six years of age. J Bone Joint Surg Br 2008; 90:940.
- Herngren B, Stenmarker M, Vavruch L, Hagglund G. Slipped capital femoral epiphysis: a population-based study. BMC Musculoskelet Disord 2017; 18:304.
- Perry DC, Metcalfe D, Costa ML, Van Staa T. A nationwide cohort study of slipped capital femoral epiphysis. Arch Dis Child 2017; 102:1132.
- Matava MJ, Patton CM, Luhmann S, et al. Knee pain as the initial symptom of slipped capital femoral epiphysis: an analysis of initial presentation and treatment. J Pediatr Orthop 1999; 19:455.
- Ledwith CA, Fleisher GR. Slipped capital femoral epiphysis without hip pain leads to missed diagnosis. Pediatrics 1992; 89:660.
- Kocher MS, Bishop JA, Weed B, et al. Delay in diagnosis of slipped capital femoral epiphysis. Pediatrics 2004; 113:e322.
- Renshaw TS. Pediatric Orthopedics, Saunders, Philadelphia 1986.
- Orava S, Jormakka E, Hulkko A. Stress fractures in young athletes. Arch Orthop Trauma Surg 1981; 98:271.
- Walker RN, Green NE, Spindler KP. Stress fractures in skeletally immature patients. J Pediatr Orthop 1996; 16:578.
- Clement DB, Ammann W, Taunton JE, et al. Exercise-induced stress injuries to the femur. Int J Sports Med 1993; 14:347.
- Cohen MD, Harrington TM, Ginsburg WW. Osteoid osteoma: 95 cases and a review of the literature. Semin Arthritis Rheum 1983; 12:265.
- Cabral DA, Tucker LB. Malignancies in children who initially present with rheumatic complaints. J Pediatr 1999; 134:53.
- Jones OY, Spencer CH, Bowyer SL, et al. A multicenter case-control study on predictive factors distinguishing childhood leukemia from juvenile rheumatoid arthritis. Pediatrics 2006; 117:e840.
- Spilberg I, Meyer GJ. The arthritis of leukemia. Arthritis Rheum 1972; 15:630.
- Rogalsky RJ, Black GB, Reed MH. Orthopaedic manifestations of leukemia in children. J Bone Joint Surg Am 1986; 68:494.
- Jordanov MI, Block JJ, Gonzalez AL, Green NE. Transarticular spread of Ewing sarcoma mimicking septic arthritis. Pediatr Radiol 2009; 39:381.
- Laboratory evaluation
- - Plain radiographs
- - Ultrasonography
- - MRI
- - Bone scan
- COMMON CAUSES OF HIP PAIN IN CHILDREN
- - Septic arthritis
- - Osteomyelitis
- - Other infections
- - Transient synovitis
- - Systemic rheumatologic disease
- - Idiopathic chondrolysis of the hip
- - Legg-Calvé-Perthes and secondary avascular necrosis
- - Slipped capital femoral epiphysis
- - Stress fracture
- - Osteoid osteoma
- - Other neoplasms