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Approach to hip pain in childhood

Approach to hip pain in childhood
Literature review current through: Jan 2024.
This topic last updated: Dec 05, 2023.

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".)

(See "Evaluation of limp in children".)

(See "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); stiffness and pain are worst in the morning and after periods of inactivity, improving with exercise; 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 2); the onset, duration, severity, and location of the pain; associated systemic symptoms; past medical history; family history; and social history (table 3).

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), trauma (eg, fracture), transient synovitis, discitis, or secondary avascular necrosis. Less severe pain (eg, the child limps but is willing to bear weight) is more characteristic of transient synovitis, JIA, LCP, SCFE, or secondary avascular necrosis.

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 [IBD]) and malignancy. Similarly, gastrointestinal symptoms (eg, change in bowel habits), 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.

Systemic glucocorticoid use may be associated with secondary avascular necrosis.

A positive family history of inflammatory arthritis, psoriasis, IBD, 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 from an effusion. 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. Overlying skin thickening or atrophy may indicate localized scleroderma.

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 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.

Acute severe hip pain – 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 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'.)

Chronic or insidious hip pain – 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.

Lyme serology – 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'.)

Laboratory tests not routinely recommended – 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 common in healthy 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 antinuclear antibodies (ANA). RF is typically associated with a florid polyarthritis. ANA, which is used in the diagnosis of systemic lupus erythematosus (SLE) and to help risk-stratify patients with juvenile idiopathic arthritis (JIA), generally is not necessary because neither SLE nor ANA-associated forms of JIA cause isolated hip arthritis. (See "Rheumatoid factor: Biology and utility of measurement", section on 'Clinical uses of rheumatoid factor testing' and "Measurement and clinical significance of antinuclear 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.

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) 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 avoided in patients with moderate or advanced renal failure. (See "Nephrogenic systemic fibrosis/nephrogenic fibrosing dermopathy in advanced kidney disease".)

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 anatomic resolution, ability to detect infection or venous thromboembolism, and lack of radiation exposure [19,20].

Bone scans should be interpreted by radiologists with experience 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 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 [21]. In transient synovitis, bone scan reveals diffuse increased uptake three to four hours after injection [22]. 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 'Imaging'.)

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 — Common causes of hip pain in children are listed in the table (table 1).

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 [4,23-25]. As with most infections, studies generally indicate that males are affected more commonly than females. (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 [23]. 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 [23]. The presentation of septic arthritis may be altered by recent use of antibiotics or when indolent organisms (eg, Kingella kingae, which typically occurs in children age 6 to 36 months) are involved [26]. (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 [23,27-29]. 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 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 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 [30]. MRI is more sensitive and specific than bone scan in the diagnosis of osteomyelitis [31]; 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

Lyme disease – 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'.)

Infections with pain referred to the hip – 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 [32]. The etiology is unclear; posttraumatic, allergic (eg, hypersensitivity reaction), and infectious causes have been proposed [3,4,33-35].

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 [32,33,36]. The male-to-female ratio is greater than 2:1. Symptoms affect both hips in as many as 5 percent of cases [33]. Even in symptomatically unilateral disease, ultrasound or MRI can detect bilateral effusions in 25 percent of children, representing an important clue that the diagnosis is transient synovitis rather than septic arthritis, which is rarely bilateral [14,37].

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 [33].

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; K. kingae typically occurs in children age 6 to 36 months [23,27,28,38,39]. 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 [40]. 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 [41].

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 [2,42,43]. 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 [32,33,44].

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) [4,33]. 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 [34,35]. 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 [22]. Note that a joint effusion under pressure (aseptic or septic) can reduce femoral blood flow as measured by bone scan [45], 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 "Chronic nonbacterial osteomyelitis (CNO)/chronic recurrent multifocal osteomyelitis (CRMO)")

Familial Mediterranean fever (see "Clinical manifestations and diagnosis of familial Mediterranean fever", section on 'Joint pain')

Avascular necrosis secondary to glucocorticoid treatment of rheumatologic disease such as systemic lupus erythematosus (see 'Legg-Calvé-Perthes and secondary avascular necrosis' below)

Arthritis associated with gastrointestinal conditions — Extraintestinal manifestations of inflammatory bowel disease or celiac disease in children and adolescents may include arthritis of the hip. (See "Clinical manifestations and complications of inflammatory bowel disease in children and adolescents", section on 'Joints' and "Epidemiology, pathogenesis, and clinical manifestations of celiac disease in children", section on 'Non-gastrointestinal manifestations'.)

Idiopathic chondrolysis of the hip — Idiopathic chondrolysis of the hip is a rare, 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 [46].

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 [46].

Clinical features include insidious onset of hip pain, stiffness, and limp in the absence of systemic symptoms [47]. 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 [48].

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 [16,46,49].

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 eight years of age [50,51]. LCP is bilateral in at least 10 to 20 percent of patients [52,53]. The male-to-female ratio is 3 to 4:1, and African-Americans are rarely affected [54,55].

The etiology of LCP remains undefined. Associations with obesity, skeletal immaturity, and lower socioeconomic status have been reported [55-57]. Children with LCP are more likely to have been born small for gestational age and/or with breech presentation than matched controls [58]. Passive smoke exposure may be a risk factor [59]. Approximately 10 percent of cases are familial, and patients often lag behind their peers in bone age and height [52,60]. Twin studies show familial clustering but no particular enrichment in monozygotic twins, suggesting a modest role for genetic predisposition [61]. Avascular necrosis also may occur secondary to an underlying condition (eg, renal failure, glucocorticoid use, systemic lupus erythematosus, human immunodeficiency virus, Gaucher disease) [62].

Clinical features of LCP and secondary avascular necrosis of the hip include insidious onset of hip pain with limp and activity-related pain [63]. The pain is not always relieved by rest or medication.

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) [64,65]. Later in the course, radiographs show fragmentation and then healing of the femoral head, often with residual deformity (image 3). Gradual revascularization occurs subsequently [66].

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 [67,68].

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 [53,69-71]. 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 [52,72].

Rarely, hip changes radiologically suggestive of LCP may be the first presentation of Stickler syndrome, a genetic connective tissue disorder. Stickler syndrome is the most common cause of retinal detachment, which can lead to blindness. This complication may be prevented by early recognition and treatment. Therefore, we recommend referring children with LCP who accrue at least four points on the "Cambridge LCP-Plus" Score to a genetic specialist to evaluate for possible Stickler syndrome [73]. "Cambridge LCP-Plus" Score items include:

Ophthalmic retinal detachment – Four points

Myopia (short sighted) before the age of 10 years – Two points

Family history of retinal detachment (single relative) – Two points

Family history of retinal detachment (more than one relative) – Four points

Orofacial history of cleft palate repair – Three points

High arch palate or bifid uvula on examination – Two points

Family history of cleft palate repair – Two points

Auditory sensorineural loss – Two points

Family history of deafness – One point

Musculo-skeletal spinal abnormalities (flattened vertebrae, end plate changes, scoliosis, kyphosis) and/or short stature – Two points

Hypermobility (Beighton score>6) – One point

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 female and 13.5 years in males, 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 [74,75].

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 [76,77], a delay that may be associated with increased slip severity [78]. Simultaneous external rotation and abduction of the hip during hip flexion is a useful, though variably present, finding [79]. (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 [80,81]. 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 [82]. 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 to avoid pain is important to avoid progression to a displaced fracture; this may require use of crutches and should be guided by an orthopedic specialist. (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 [83]. 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 [84,85]. (See "Overview of common presenting signs and symptoms of childhood 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 [86,87]. 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 [84,88]:

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 Ewing sarcoma")

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')

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword[s] of interest.)

Basics topic (see "Patient education: Transient synovitis (The Basics)")

SUMMARY AND RECOMMENDATIONS

Causes – Hip pain in children has a broad range of causes, ranging from the benign to the potentially devastating (table 1). (See 'Common causes of hip pain in children' above.)

Evaluation – The history and examination of the child with hip pain is focused on distinguishing between infectious, inflammatory, orthopedic/mechanical, and neoplastic causes (table 2). This distinction helps to determine the appropriate laboratory and radiographic evaluation. (See 'Overview' above and 'Common causes of hip pain in children' above.)

History – Important aspects of the history in the child with hip pain include the age and sex of the child; the onset, duration, severity, and location of the pain; associated systemic symptoms; past medical history; family history; and social history (table 3 and table 2). (See 'History' above.)

The characterization of pain guides additional evaluation:

True hip pathology usually causes pain in the groin, though children and even adults may localize the pain to the thigh or knee.

Lateral discomfort (eg, around the greater trochanter) usually is caused by pathology outside the joint.

Pain that alters function (limp, alteration in activities) should be explored fully, whereas transient or fleeting hip pains are typically of limited significance.

Examination – The examination focuses on determining whether the pain originates from inside or outside the hip joint and whether it is an isolated problem or a manifestation of an inflammatory condition. 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 supine and most especially the prone positions (figure 1), and assessment of ability to bear weight. The inability to bear weight is a sign of serious pathology until proven otherwise. (See 'Examination' above.)

Laboratory evaluation – The clinical findings direct the laboratory evaluation, which often includes a complete blood count with differential, erythrocyte sedimentation rate or C-reactive protein, and blood cultures (if osteomyelitis or septic arthritis is suspected). (See 'Laboratory evaluation' above.)

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 (table 2). The imaging strategy depends upon the suspected etiology. (See 'Imaging' above.)

Plain radiographs can identify bony abnormalities (eg, fracture, bone tumors).

Ultrasonography can identify joint effusions (eg, septic arthritis, transient synovitis).

MRI can identify osteomyelitis, early Legg-Calvé-Perthes, and early slipped capital femoral epiphysis. MRI with contrast can identify inflammatory arthritis, and MRI arthrogram can identify acetabular labral tear.

Bone scan is an alternative when MRI is not possible and for suspected multifocal disease.

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References

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