10/12/2019 Approach to hip pain in childhood - UpToDate

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Approach to hip pain in childhood

Author: Peter A Nigrovic, MD
Section Editors: Jan E Drutz, MD, William A Phillips, MD, Robert Sundel, MD
Deputy Editor: Mary M Torchia, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Sep 2019. | This topic last updated: Dec 05, 2018.

INTRODUCTION

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) [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 "Evaluation of the child with a limp" and "Radiologic evaluation
of the hip in infants, children, and adolescents".)

EVALUATION

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
normal

● Neoplastic – Pain is characteristically worse at night and unrelated to activity; may be associated with systemic symptoms
and laboratory abnormalities (eg, anemia, leukopenia, thrombocytopenia, elevated lactate dehydrogenase or uric acid)

History — Pain from true hip pathology is typically experienced in the groin, though children and even adults may localize the
pain to the thigh or knee. Lateral discomfort, for example around the greater trochanter, typically is caused by pathology outside
the joint and is generally reassuring. Pain that alters function (limp, alteration in activities) should be explored fully, whereas
transient or fleeting hip pains are typically of limited significance.

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).

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● Acute onset of hip pain, particularly when it is severe, is associated with infectious processes (eg, septic arthritis, Lyme
disease, bacterial osteomyelitis), transient synovitis, and trauma. Hip pain of insidious onset is more likely to be caused by
slipped capital femoral epiphysis (SCFE), Legg-Calvé-Perthes disease (LCP), or juvenile idiopathic arthritis (JIA, formerly
juvenile rheumatoid arthritis).

● Severe pain (eg, refusal to bear weight) typically is caused by acute infections (eg, septic arthritis, osteomyelitis),
malignancy (eg, leukemia, osteosarcoma), and trauma (eg, fracture). Less severe pain (eg, limps, but willing to bear
weight) is more characteristic of transient synovitis, JIA, LCP, or SCFE.

● A history of previous episodes of similar symptoms in the same or contralateral hip increases the likelihood of JIA, in
particular psoriatic JIA, or transient synovitis, which has a recurrence rate of up to 15 percent [2].

● Conditions that affect the hip alone (eg, SCFE, LCP) are unlikely if the patient has joint pain at other sites. JIA rarely
presents with isolated hip involvement.

● Systemic symptoms increase the likelihood of infections, systemic arthritis, or neoplasms and decrease the likelihood of
orthopedic conditions (table 1). Fever >38.5°C (101.3°F) is associated with acute infections, but also with acute and chronic
inflammatory processes (eg, systemic JIA, inflammatory bowel disease) and malignancy. Similarly, gastrointestinal
symptoms, weight loss, fatigue, and weakness may indicate systemic disease that requires further investigation.

● Recent upper respiratory tract infection may suggest transient synovitis but is nonspecific; viral infections are common in
children and also may coincidentally precede septic arthritis or trauma [3,4].

● The recent use of antibiotics can alter the presentation of septic arthritis or osteomyelitis.

● A positive family history of inflammatory arthritis, psoriasis, inflammatory bowel disease, or uveitis may be associated with
JIA.

● Avid sports participation, a fall, or other injury suggests traumatic hip pain. However, minor trauma occurs commonly in
childhood, and initial symptoms of inflammatory or malignant disease often are attributed to an incidental injury.

● Sexual activity may suggest infectious (eg, gonococcal) or reactive (eg, Chlamydia trachomatis) arthritis; however
involvement of the hip is unusual.

Examination — 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. The differential diagnosis is
narrowed markedly by identification of arthritis affecting other joints and may also be informed by findings such as psoriasis or a
change in the growth parameters (table 2). Thus the evaluation of hip pain requires a general examination, with emphasis on
the musculoskeletal system [5].

Examination of the painful hip should be performed after the remainder of the examination to optimize patient cooperation.

● Observation – The hip examination begins with simultaneous observation of both hips; the hips should be uncovered. The
examiner should look for asymmetry of the pelvis, thighs, and knees. The position in which the femur and pelvis are held
should be noted; partial flexion and external rotation of the hip may indicate increased intra-articular pressure. Swelling,
heat, and overlying erythema rarely are identifiable on physical examination, regardless of the severity of hip disease.
However, atrophy of soft tissues may indicate that the problem is long standing.

● Palpation – The hip joint cannot be palpated directly, but tenderness at the anterior superior iliac spine, greater trochanter,
or elsewhere along the femur suggests a source of pain external to the hip joint.

● Range of motion – Range of motion should be evaluated in both the supine and prone position. The pelvis should be
stabilized as much as possible during examination of range of motion, since pelvic motion can compensate for loss of

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mobility within the hip. Prone examination is particularly helpful in this regard. With the knees flexed to 90 degrees and both
feet caused to "fall outward," subtle asymmetry in internal rotation is readily appreciated (figure 1). Hip extension is also
best evaluated prone. Most patients with true hip pathology experience groin or thigh pain with internal rotation.

Children with septic arthritis of the hip usually do not permit any range of active or passive motion, whereas children with
septic sacroiliac arthritis or femoral/pelvic osteomyelitis may permit gentle manipulation of the hip. In children with transient
synovitis, the range of motion may improve markedly within a short interval of nonsteroidal anti-inflammatory drug
administration. Children with sacroiliac arthritis may have pain with maneuvers that torque the pelvis (eg, Flexion of the hip
and knee, with Abduction and External Rotation with Extension at the hip [the FABERE test] (figure 2)).

● Ability to bear weight – The inability to bear weight is a sign of serious pathology until proven otherwise. Children who are
unable to bear weight should not be sent home until a diagnosis is made and therapy instituted. Refusal to walk can arise
from pathology outside the lower extremities, including the pelvis and spine; in particular, discitis or other spinal pathology
may present in the young child as isolated refusal to bear weight. (See "Back pain in children and adolescents: Causes",
section on 'Discitis'.)

Laboratory evaluation — The laboratory evaluation of the child with hip pain is directed by the findings from the history and
physical examination.

● When an acute severe process, such as septic arthritis or osteomyelitis, is suspected, a complete blood count (CBC) with
differential, acute phase reactants (eg, CRP or ESR), and blood culture should be obtained. (See 'Septic arthritis' below
and 'Osteomyelitis' below.)

Children with suspected septic arthritis also require arthrocentesis to obtain synovial fluid for Gram stain, culture, and WBC
count with differential. (See "Bacterial arthritis: Clinical features and diagnosis in infants and children", section on
'Laboratory evaluation'.)

● Lyme serology may be warranted if the child has arthritis and lives in or has traveled to a Lyme-endemic area [6,7]. (See
"Epidemiology of Lyme disease", section on 'Epidemiology' and "Lyme disease: Clinical manifestations in children", section
on 'Arthritis'.)

● In children with chronic hip pain, or hip pain with insidious onset, acute phase reactants (CRP, ESR) and CBC can be
helpful. Normal acute phase reactants suggest mechanical conditions; elevated acute phase reactants suggest systemic
inflammatory disease or malignancy. Anemia, leukopenia, or thrombocytopenia may suggest an underlying chronic illness,
including malignancy.

● We do not routinely recommend HLA-B27 testing in the evaluation of hip pain in children. HLA-B27 is associated with a
specific subtype of JIA (enthesitis-related arthritis). However, HLA-B27 has limited utility in the diagnostic evaluation
because it is frequently observed in normal individuals and may be absent in some patients with enthesitis-related arthritis
and other types of JIA affecting the hip [8].

● We also do not routinely recommend testing for rheumatoid factor (RF) or anti-DNA antibodies. RF is typically associated
with a florid polyarthritis. Anti-DNA antibodies, which are used in the evaluation of systemic lupus erythematosus (SLE),
generally are not necessary because SLE does not cause isolated hip pain in children or adolescents. (See "Origin and
utility of measurement of rheumatoid factors", section on 'When is it useful to measure RF?' and "Antibodies to double-
stranded (ds)DNA, Sm, and U1 RNP", section on 'Anti-DNA antibodies'.)

Imaging — 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.

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The need for imaging in children who present with mild hip pain and have a normal physical examination, normal laboratory
values, and reliable follow-up is controversial. Some authors advocate following these children clinically without obtaining
radiographs [9], whereas others obtain radiographs in all children with hip pain. Our practice is to limit plain radiographs to
cases in which specific bony lesions are suspected (eg, trauma, tumors, advanced LCP, SCFE), in order to minimize associated
gonadal radiation.

Plain radiographs — Plain radiographs can identify bony abnormalities, including:

● Some forms of trauma (eg, fracture (image 1))

● Tumors and other malignancies (eg, osteoid osteoma (image 2))
● Advanced (but not early) LCP (image 3) or JIA (image 4)
● SCFE (image 5), though early SCFE may not be evident on plain films

Plain radiographs also can sometimes identify processes causing changes in the joint space, such as effusion (image 6),
though small effusions often are not evident with this modality and radiographs can usually be omitted in cases in which a
superior modality for evaluating the joint space, such as ultrasonography or magnetic resonance imaging (MRI), will also be
used to evaluate the soft tissues [10].

When plain radiographs are necessary, anteroposterior and frog-leg views are obtained (the frog-leg is the true lateral of the
femur) [11]. The radiographic appearance of a child's hip varies with skeletal maturity, and images of the pelvis (ie, bilateral
images) are sometimes recommended to permit comparison of the two sides.

Ultrasonography — Ultrasonography is an excellent technique for identifying small joint effusions (image 7) and is useful for
evaluating for inflammatory arthritis, including septic arthritis or transient synovitis [12,13]. We routinely evaluate both hips.
Bilateral effusions suggest a systemic arthritic disorder or transient synovitis because as many as one-quarter of patients with
symptomatically unilateral transient synovitis have bilateral effusions [14]. By contrast, septic arthritis is almost always unilateral.

Ultrasonography also may be used to guide aspiration of the hip when assaying joint fluid is deemed appropriate (eg, isolated
unilateral hip effusion in a febrile child).

MRI — MRI provides the highest resolution imaging of the painful hip. MRI can identify marrow changes suggestive of
osteomyelitis [15], early LCP (image 8) [16], and early SCFE [17,18]. MRI images are significantly degraded by motion.
Sedation is necessary for patients who cannot remain still (eg, young or anxious children).

When inflammatory arthritis is in the differential diagnosis, MRI should be ordered with gadolinium contrast to distinguish
synovitis (inflammation of the synovial membrane) from joint effusion; both appear "bright" on T2 weighted images, but synovial
tissue enhances while joint fluid does not. Imaging with gadolinium should be performed with caution in patients with moderate
or advanced renal failure. (See "Nephrogenic systemic fibrosis/nephrogenic fibrosing dermopathy in advanced renal failure".)

When an acetabular labral tear is suspected (eg, snapping or catching of the hip and pain with internal rotation and extension in
an athletic adolescent, particularly after activities that involve pivoting or twisting), an MRI arthrogram after intra-articular
administration of contrast may be necessary to establish the diagnosis. (See "Radiologic evaluation of the hip in infants,
children, and adolescents", section on 'Acetabular labral tear'.)

Bone scan — Bone scan is best reserved for situations in which MRI is not possible (eg, sedation is unavailable, medical
devices/implants that are not MRI safe) or if multifocal disease is suspected. Three-phase bone scintigraphy has historically
been of great value in diagnosing the child with hip pain [13]. However, MRI is preferable to bone scan in most conditions
because of its superior anatomical resolution. (See 'MRI' above.)

Bone scans should be performed only at centers experienced in distinguishing normal from abnormal studies in pediatric
patients. The epiphyses of growing children take up the tracer used in bone scans, complicating the interpretation of bone

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scans in children.

In the acute setting, a bone scan can be used to help differentiate septic arthritis or transient synovitis from osteomyelitis. In
septic arthritis, the characteristic finding is increased uptake on both sides of the joint during the early or "blood pool" phase
[19]. In transient synovitis, bone scan reveals diffuse increased uptake three to four hours after injection [20]. In contrast, in
osteomyelitis, the bone scan generally demonstrates increased uptake on only one side of a joint (image 9). (See "Bacterial
arthritis: Clinical features and diagnosis in infants and children", section on 'Other imaging tests'.)

In more chronic cases, a bone scan can identify avascular necrosis or LCP (decreased uptake in the femoral head) earlier in
the course than can a plain radiograph. (See "Radiologic evaluation of the hip in infants, children, and adolescents", section on
'Legg-Calvé-Perthes disease'.)

Bone scan also can help in the diagnosis of early tumors and myelodysplastic disease. (See 'Neoplastic' below.)

COMMON CAUSES OF HIP PAIN IN CHILDREN

Infectious

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 'Epidemiology'.)

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

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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 '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')

Inflammatory

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.)

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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 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 'Arthritis')

● 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].

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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].

Orthopedic/mechanical

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 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].

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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".)

Neoplastic

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 "Treatment for
tenosynovial giant cell tumor and other benign neoplasms affecting soft tissue and bone", section on 'Tenosynovial giant
cell tumor')

SUMMARY
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● 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, 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.)

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GRAPHICS

Causes of hip pain in children

Infectious Mechanical/orthopedic
Septic arthritis of the hip Slipped capital femoral epiphysis (SCFE)

Septic arthritis of the sacroiliac joint Avascular necrosis

Lyme disease - Legg-Calvé-Perthes disease

- Secondary avascular necrosis
Osteomyelitis of femoral head or pelvis
Femoral stress fracture
Psoas abscess
Muscular strain
Appendicitis or abdominal/pelvic abscess
Iliac apophysitis
Inflammatory
Snapping iliopsoas tendon
Transient synovitis
Trochanteric bursitis
Systemic arthritis
Acetabular labral tear
- Spondyloarthropathy
Femoroacetabular impingement
- Juvenile idiopathic arthritis (formerly juvenile rheumatoid arthritis; rare as
isolated hip pain)
Neoplastic
- Infectious/post-infectious
Osteoid osteoma
Idiopathic chondrolysis of the hip
Leukemia
Chronic recurrent multifocal osteomyelitis
Solid tumor, primary or metastatic

Pigmented villonodular synovitis (PVNS)

Other
Sickle cell pain crisis

Gaucher disease

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Clinical, laboratory, and radiographic features of selected causes of hip pain in children unrelated to acute
trauma or fracture
Cause
Infectious
Septic arthritis of the hip
Septic arthritis of the
sacroiliac joint
Lyme disease
Osteomyelitis of femoral
head or pelvis
Psoas abscess (referred
pain)
Appendicitis or
abdominal/pelvic abscess
(referred pain)
Discitis (referred pain)
Inflammatory
Transient synovitis
Systemic arthritis
Juvenile idiopathic
arthritis (formerly
juvenile rheumatoid
arthritis)
Infectious arthritis (eg,
Lyme arthritis, acute
rheumatic fever,
disseminated gonorrhea)
Postinfectious or reactive
Idiopathic chondrolysis of
the hip
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Typical age/risk
Clinical features
factors
0 to 6 years Fever and ill-appearance
M>F Pain with any active or
passive motion and refusal
to bear weight
Preferred position: Flexion,
abduction, and external
rotation of the hip
Late childhood Pain over sacrum
Fever
Pain with maneuvers that
twist the pelvis (eg, positive
FABERE test)
Any age Fever uncommon
Residence in or travel to Willing to bear weight
Lyme endemic region
Fever and ill appearance
Localized pain
Decreased mobility (but
may permit passive motion
of the hip)
Pain is increased with hip
extension but diminished
with hip flexion
Any age Associated gastrointestinal
complaints (pain, vomiting,
anorexia)
0 to 5 years Loss of lumbar lordosis
Refusal to bend forward
Minimal systemic toxicity
3 to 8 years Afebrile
M>F Well-appearing
Fall/winter season
Rarely causes isolated hip pain
Variable ages Associated clinical features of
underlying infection
Variable ages History of antecedent
respiratory, gastrointestinal, or
genitourinary infection
10 to 20 years Insidious onset
Decreased range of motion
in all planes
Absence of systemic
symptoms
Laboratory features
Elevated WBC count
(>12,000 cells/microL), ESR
(>40 mm/hour), and CRP
(>2 mg/dL [20 mg/L])
Positive synovial fluid or
blood culture
Elevated WBC count, ESR,
CRP
Positive synovial fluid or
blood culture
IgG antibodies to Borrelia
burgdorferi
Elevated WBC count, ESR,
and CRP
Elevated WBC count, ESR,
and CRP
Elevated WBC count, ESR,
CRP
WBC count usually normal
Elevated ESR
WBC count <12,000
cells/microL
ESR <20 mm/hour
CRP <2 mg/dL (20 mg/L)
Elevated ESR and/or CRP
Positive ANA, RF, or CCP in
some cases
Depend upon underlying
infection
Elevated ESR or CRP
Evidence of antecedent or
concomitant infection
None
Radiographic
features
Unilateral joint effusion
Widening of the joint space
Blurring of the subchondral
plate
Early (3 to 7 days): deep
soft-tissue swelling;
obliteration of fat pads
Late (10 to 21 days): lytic
sclerosis; periosteal new
bone formation
Loss of psoas muscle
definition
Abnormal soft tissue
shadows
(CT is preferred study)
Calcified appendicolith
(US is usually the preferred
initial imaging study)
Narrowing of intervertebral
joint space after two to
three weeks of symptoms,
followed by destruction of
vertebral end-plated and
disc herniation
Diagnosis is best made by
MRI
Unilateral or bilateral joint
effusion
Joint space narrowing
Erosive changes of the femoral
head and acetabula
Evidence of enthesitis or
arthritis
Narrowing of the joint
space, osteopenia,
protrusion acetabuli, and
premature physial fusion
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Chronic recurrent Any age
multifocal osteomyelitis F>M
Mechanical/orthopedic
Slipped capital femoral Early adolescence
epiphysis Mean age:
Girls: 12 years
Boys: 13.5 years
M>F (slightly)
Obesity
Endocrine disorders
Avascular necrosis
Legg-Calvé-Perthes 3 to 12 years
disease
M>>F
Secondary avascular Variable ages
necrosis
Femoral stress fracture Adolescents and young
adults
Endurance sports
Muscular strain Any age
Iliac apophysitis Adolescents
Sports that involve twisting
(eg, golf), sprinting, and
kicking
Snapping iliopsoas tendon Young athletes (ballet,
karate)
Trochanteric bursitis
Acetabular labral tear Adolescent athletes,
particularly sports that
involve pivoting or twisting
History of Legg-Calvé-
Perthes disease or SCFE
Femoroacetabular Dancers
impingement
Neoplastic
Osteoid osteoma 10 to 20 years
Malignant neoplasms, Variable ages
primary or metastatic
(eg, leukemia,
lymphoma, Ewing
sarcoma, etc)
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Fever (rarely)
Bone pain
May be associated with
pustular eruption on palms
and soles
Bilateral in 20 to 40 percent
of cases
Pain may be localized to the
knee or thigh
Insidious onset
Pain increases with activity
Signs and symptoms of
underlying condition (eg, renal
failure, glucocorticoid use,
systemic lupus erythematosus)
Pain may localize to the
anterior thigh
Pain reproduced with
hopping on affected leg
Pain with movement
Weakness
Pain and swelling at iliac
crest
Slowly progressive pain with
activity
Snapping sensation in
anterior groin
Sensation may be
reproduced by bringing the
hip from a flexed abducted
position to an extended
adducted position
Lateral hip pain over the
outer thigh
Pain aggravated by direct
pressure
Snapping, catching
Pain with internal rotation
and extension
Groin pain with turning,
twisting, and squatting
Pain is reproduced with
flexion and internal rotation
of the hip
Nocturnal pain
Prompt relief with NSAIDs
Nighttime pain
Constant pain (unchanged
by activity)
Pain <3 months duration
Elevated ESR or CRP
(sometimes)
Normal WBC count, ESR, Nondisplaced: Normal or
CRP widening and irregularity of
the capital femoral physis,
osteopenia, and increased
density of the metaphysis
Displaced: Posterior
displacement of femoral
epiphysis
Normal WBC count, ESR, CRP Early: Joint space widening and
subchondral fracture
Late: Sclerosis, fragmentation,
subchondral collapse of the
ossification center
Depend upon underlying Early: Joint space widening and
condition subchondral fracture
Late: Sclerosis, fragmentation,
subchondral collapse of the
ossification center
Normal WBC count, ESR, Periosteal elevation, cortical
CRP thickening, sclerosis,
fracture line
Normal WBC count, ESR,
CRP
Normal WBC count, ESR,
CRP
Normal WBC count, ESR, Catching of the posterior
CRP iliotibial band or anterior
portion of the gluteus
maximus muscle over the
greater trochanter can be
seen on dynamic
ultrasonography
Normal WBC count, ESR, Calcification occasionally
CRP present in the region of the
bursa or adjacent soft
tissues
Normal WBC count, ESR,
CRP
Normal WBC count, ESR, Nonspherical femoral head;
CRP lack of femoral head-neck
offset; acetabular
overcoverage
Osteoid nidus with or
without calcification (osteoid
nidus may be obscured by
dense sclerosis)
Abnormal CBC (anemia, Bony destruction
leukopenia, Subtle signs of space-
thrombocytopenia) occupying lesion (separation
Elevated LDH, uric acid or thinning of the pedicles)
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Systemic symptoms (eg,
fever, weight loss)

Pigmented villonodular Adults Recurrent joint effusions Well circumscribed areas of

synovitis Minimal pain bone erosion

M: male; F: female; WBC: white blood cell; ESR: erythrocyte sedimentation rate; CRP: C-reactive protein; FABERE: Flexion of the hip and knee, ABduction and
External Rotation of the hip, Extension of the opposite hip (also called the figure-of-four test); IgG: immunoglobin G; CT: computed tomography; US:
ultrasonography; MRI: magnetic resonance imaging; ANA: antinuclear antibodies; RF: rheumatoid factor; CCP: cyclic citrullinated peptides; SCFE: slipped
capital femoral epiphysis; NSAIDs: nonsteroidal anti-inflammatory drugs; CBC: complete blood count; LDH: lactate dehydrogenase.

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Epidemiology of common causes of hip pain in children

Disease Typical age M:F ratio Other

Septic arthritis Any, peak 0 to 6 years 1.2 to 2:1

Transient synovitis 3 to 8 years, mean 6 years 2:1 Fall/winter

Legg-Calvé-Perthes disease 3 to 12 years, peak 5 to 7 years 4:1 Rare in blacks

Slipped capital femoral epiphysis Early adolescence 1.5:1 Obese children

Mean 12 years, girls Endocrinopathy in 8%

Mean 13.5 years, boys Blacks > whites, Hispanics

M; male; F: female.

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Important aspects of the history in the evaluation of a child with hip pain unrelated to acute trauma or
fracture

Historical feature Potential clinical significance

Age Typical age for:

Bacterial arthritis: 0 to 6 years
Transient synovitis: 3 to 8 years
SCFE: Early adolescence
Idiopathic chondrolysis: 10 to 20 years

Sex More common in males: Legg-Calvé-Perthes disease, septic arthritis, transient synovitis, SCFE
More common in females: Idiopathic chondrolysis, chronic recurrent multifocal osteomyelitis

Pain

Onset Acute: Infectious, transient synovitis, acute trauma

Insidious: SCFE, Legg-Calvé-Perthes disease, spondyloarthritis

Severity Refusal to bear weight: Septic arthritis, osteomyelitis (femur or pelvis), malignancy, trauma, transient synovitis; also may
be due to discitis
Willing to bear weight with limp or antalgic gait: Transient synovitis, systemic JIA, SCFE, Legg-Calvé-Perthes disease

Location Isolated hip pain (which may be localized to the thigh or knee): Septic arthritis, osteomyelitis, Legg-Calvé-Perthes disease,
SCFE
Pain in other joints (uncommon): Viral/postviral, JIA

Associated systemic symptoms

Fever Infection, systemic JIA, IBD-associated arthritis, neoplasm

Other constitutional (eg, Systemic JIA, IBD-associated arthritis, neoplasm

fatigue, weight loss) or
gastrointestinal
symptoms

Rash Systemic JIA, viral/postviral

Past medical history

Previous episodes of hip Systemic JIA, transient synovitis, mechanical

pain

Renal failure SCFE

Endocrine disorder SCFE

(hypothyroidism, growth
hormone deficiency)

Recent infection Postinfectious or reactive arthritis, septic arthritis (if bacterial), osteomyelitis (if bacterial)

Recent antibiotics May alter the presentation of septic arthritis or osteomyelitis

Tick exposure Lyme arthritis

Family history Family history of inflammatory arthritis, psoriasis, IBD, or uveitis may be associated with JIA

Social history

Sports participation, Stress fracture, iliac apophysitis, snapping iliopsoas tendon, trochanteric bursitis; acetabular labral tear, femoroacetabular
particularly endurance impingement
sports or dance

Sexually active Infectious (eg, disseminated gonococcal) or reactive (Chlamydia trachomatis) arthritis

SCFE: slipped capital femoral epiphysis; JIA: juvenile idiopathic arthritis; IBD: inflammatory bowel disease.

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Prone examination of the hip

With the knees flexed to 90 degrees and both feet caused to "fall outward," subtle
asymmetry in internal rotation is readily appreciated.

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FABERE test (Patrick test, "figure of four" test)

The FABERE test (Patrick test or "figure of four" test) consists of Flexion of the
hip and knee, with ABduction and External Rotation at the hip, so that the ankle
of one leg is on top of the opposite knee (a figure four configuration). Force is
applied downwards on the bent knee and the opposite hip, causing Extension at
the sacroiliac joint ipsilateral to the bent leg. Pain in the sacral region from
pelvic torque during the FABERE test, in the absence of pain with passive motion
of the hip joint, suggests discomfort arising from the sacroiliac joint.

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Delbet type III hip fracture

Ten-year-old girl who fell from a tree.

Courtesy of Klane White, MD.

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Osteoid osteoma radiograph

A) Full and B) coned views of the midshaft of the femur demonstrate a dense
sclerotic zone of cortical thickening laterally, which contains a small oval lucent
nidus (arrow).

Reproduced with permission from: Eisenberg RL. An Atlas of Differential Diagnosis,

Fourth Edition. Philadelphia: Lippincott Williams & Wilkins, 2003. Copyright © 2003
Lippincott Williams & Wilkins.

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Plain radiograph: Avascular necrosis of the hip (Legg-

Calvé-Perthes disease)

Projection radiograph of the pelvis demonstrates characteristic changes of

ischemic necrosis of the left femoral head (arrow). Mixed lucency and sclerosis
along with coxa plana is typical of an active process.

Courtesy of the Department of Diagnostic Imaging, Texas Children's Hospital.

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Juvenile idiopathic arthritis radiograph: Joint destruction

Radiograph of a 15-year-old boy with a four-year course of incompletely controlled systemic

symptoms and hip arthritis. It demonstrates a pattern of bilaterally symmetric hip joint-space
narrowing and erosive changes of the femoral heads and acetabulae.

Copyright © 2017 American College of Rheumatology. Used with permission.

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Slipped capital femoral epiphysis (SCFE)

Note the posterior displacement of the femoral epiphysis on the left, which appears like
ice-cream slipping off a cone (arrow).

Courtesy of Andrew Kienstra, MD and Charles G Macias, MD.

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Plain film left hip effusion

The iliopsoas fat pad on the left is bowed and inferiorly displaced (arrows),
suggesting effusion. The obturator (medial) and gluteal (superior) fat pads can
also be displaced by effusion.

Courtesy of Michael Rosenthal, MD, PhD.

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Ultrasonography left hip effusion

The anechoic fluid collection at the lateral aspect of the left hip adjacent to the femoral neck is a joint
effusion (Panel A). The effusion causes lateral bowing of the gluteus minimus muscle, which can sometimes
be seen on plain film as displacement of the gluteal fat pad. Ultrasound of the right hip shows no such
collection (Panel B).

Courtesy of Michael Rosenthal, MD, PhD.

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Magnetic resonance image: Avascular necrosis of the hip

(Legg-Calvé-Perthes disease)

T1-weighted coronal MR of the pelvis demonstrates lack of signal in the left

capital femoral epiphysis compared with the right (arrow). Fragmentation is
present. Note that the overlying synovial cartilage is maintained, as is the joint
space.

MR: magnetic resonance.

Courtesy of the Department of Diagnostic Imaging, Texas Children's Hospital.

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Osteomyelitis three-phase bone scan

Three-phase bone scan demonstrating asymmetric increased uptake in the left

proximal femur (arrows) of this four-month-old with osteomyelitis.

Courtesy of Rajvee Shah, MD.

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Osteomyelitis of the femur

(A) Plain radiograph of the pelvis demonstrates destructive lesion of the metaphysis of the
proximal left femur.
(B,C) Magnetic resonance imaging demonstrates high signal in this area, indicative of
osteomyelitis.

Courtesy of the Department of Diagnostic Imaging, Texas Children's Hospital.

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Sequential nail changes in psoriasis

Panel A: Mild nail involvement characterized by discrete pits in the nail plate and
early onycholytic separation of the lateral edges of the nail plate from the nail bed.
These nail changes are the earliest and the most common in psoriasis. Panel B:
Moderate nail involvement manifested by the combination of nail plate pitting and
more advanced distal onycholysis; the distal third of the nail plate is now
separated from the nail bed. Panel C: The most severe and the least common type
of psoriatic nail involvement, in which the normal nail plates have been replaced
by thickened hyperkeratotic masses.

Reproduced with permission from Richard D Sontheimer, DM. In: Resource Materials in
Rheumatology, number 19: Nail changes in rheumatic diseases.

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Osteoid osteoma computed tomography

Computed tomography demonstrates the lucent nidus characteristic of osteoid

osteoma with surrounding cortical thickening and periosteal reaction.

Courtesy of the Department of Diagnostic Imaging, Texas Children's Hospital.

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