PAINFUL HIP
Christopher G. Anton, MD
DIFFERENTIAL DIAGNOSIS
Common
-
Transient Synovitis
-
Septic Arthritis
-
Osteomyelitis
-
Slipped Capital Femoral Epiphysis (SCFE)
-
Legg-Calvé-Perthes (LCP)
-
Juvenile Idiopathic Arthritis (JIA)
-
Trauma
Less Common
-
Idiopathic Chondrolysis
-
Osteoid Osteoma
-
Osteonecrosis
-
Malignancy
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
-
Age and history are helpful in narrowing differential diagnosis
Helpful Clues for Common Diagnoses
-
Transient Synovitis
-
a.k.a. irritable hip, toxic synovitis
-
Age: 18 months to 10 years; most common from age 4-7
-
Typically follows recent upper respiratory infection
-
Radiographs
-
Normal
-
Widening of medial joint space, lateral displacement of femoral head
-
-
70% hip effusion on ultrasound
-
Hip held in flexion, external rotation, and abduction, restricted abduction and internal rotation
-
± fever (often < 38° C)
-
May have mildly elevated erythrocyte sedimentation rate and white blood cell
-
Symptoms improve (usually within 48 hours) in 1-5 weeks
-
If symptoms persists beyond 1 week, consider another diagnosis
-
Recur in up to 17%
-
Legg-Calvé-Perthes develops in 1-3%
-
-
-
Septic Arthritis
-
Important to diagnose early to avoid destruction of joint
-
Delay in treatment ≥ 4 days results in suboptimal recovery
-
-
Age: < 4 years old
-
Staphylococcus aureus most common cause
-
Umbilical catheter, sepsis, and prior venous puncture have been implicated
-
-
Hip held in flexion
-
Infants can present with low-grade fever and feeding intolerance
-
Radiographs
-
Normal
-
Periostitis of proximal femur in neonates within days after start of symptoms
-
-
Treatment: Surgical drainage, IV antibiotics, traction
-
-
Osteomyelitis
-
Staphylococcus aureus most common
-
Streptococcus pneumonia (hypogammaglobinemia, sickle cell disease, asplenia)
-
Referred pain from spine or sacroiliac joints
-
Importance of scrutinizing spine and sacroiliac joints when imaging hips
-
-
May take up to 10-14 days before radiographs depict changes or osteomyelitis
-
Treatment: Abscess drainage, debridement, IV antibiotics
-
-
Slipped Capital Femoral Epiphysis (SCFE)
-
Salter-Harris type 1 femoral epiphyseal fracture
-
Age: 10-15 years old
-
M:F = 2:1; occurs earlier in girls
-
Predisposed: Obesity and endocrine disorders
-
Bilateral (18-36%)
-
Opposite side occurs within 18-24 months of 1st occurrence
-
-
Presentations: Acute, chronic, and acute on chronic
-
Radiographs
-
Widened femoral physis, medial and posterior displacement of femoral head (best seen frog leg lateral view)
-
Capital femoral epiphysis displacement without intersection of Klein line
-
Klein line: Line along lateral femoral neck and continuing toward acetabulum; ordinarily crosses small portion of femoral ossification center
-
-
-
Legg-Calvé-Perthes (LCP)
-
Juvenile Idiopathic Arthritis (JIA)
-
a.k.a. juvenile rheumatoid arthritis (JRA)
-
Age: < 16 years old
-
Symptoms with > 6 week duration
-
Other causes of arthritis are excluded
-
Stiff, swollen, painful, warm, and decreased motion in joint involved
-
MR: Synovitis, ± erosions, ± rice bodies
-
Joint space narrowing and ankylosis are late findings
-
-
Trauma
-
Acute (fracture) or repetitive (stress fracture) trauma
-
Helpful Clues for Less Common Diagnoses
-
Idiopathic Chondrolysis
-
Destruction of articular cartilage of femoral head and acetabulum
-
Stiffness, limpness, and pain around hip
-
Radiographs
-
Concentrically joint space narrowing, < 3 mm with osteopenia and pelvic tilt
-
-
MR: Rectangular hypointense T1 and hyperintense T2WI signal abnormality of center 1/3 of femoral head, ± ill defined within acetabulum
-
-
Osteoid Osteoma
-
Benign composed of osteoid and woven bone
-
3 types: Cortical (most common), cancellous, or subperiosteal
-
< 2 cm nidus surrounded by dense sclerotic bone
-
Most common location is femur
-
Age: 10-30 years old, uncommon before age 5
-
Classic history: Pain at night relieved by nonsteroidal anti-inflammatory agents
-
NECT: Depicts nidus better than MR
-
Bone scan: Increased flow, “double density” pattern
-
Intense uptake by nidus surrounded by less intense activity of reactive bone
-
-
-
Osteonecrosis
-
Most commonly located in anterolateral weightbearing portion of femoral head
-
T2WI: “Double line” sign
-
Many causes, including sickle cell disease, trauma, steroid therapy, vasculitis, Gaucher disease, hemophilia
-
-
Malignancy
-
Primary such as chondroblastoma
-
Metastatic disease: Most commonly neuroblastoma
-
± pathologic fracture
-
Image Gallery
![]() Longitudinal ultrasound shows a normal hip for comparison with no significant joint fluid, evidenced by a normal joint space with a concave anterior margin
![]() ![]() Stay updated, free articles. Join our Telegram channel![]() Full access? Get Clinical Tree![]() ![]() ![]() |