Episode Details

Episode 180: Pediatric Hip Pain

Future Dr. Pena-Brockett explains the differential diagnosis in a 14-year-old patient who has a new onset of left hip pain. Dr. Arreaza adds comments and explains toxic synovitis.  

Written by Natalie Pena-Brockett, MSIV, California Health Sciences University. Comments by Hector Arreaza, MD.

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Having a limping kid can be terrifying. Many questions may cross your mind: Is this a permanent damage? What is going on here? Where is the pain located? Do I need to send this child to the hospital? Today, hopefully, we can help you ease some of your fears. 

Case: This is a 14-year-old boy with no past medical history, no trauma, presents to the family medicine clinic with a complaint of left-sided hip pain. Mom notes that her son has been limping for the last week and complaining of pain in his left hip and knee when he walks. He has never experienced this pain before this week. He does not take any medications. Physical exam: He is afebrile and all of his vitals are within normal limits. On exam, you note that his BMI is at the 90th percentile (overweight), and has an antalgic gait where he is favoring the right side and has tenderness on his left groin. His left foot is turned outward while standing up straight. His left knee has negative findings on specialized tests, but he has restricted movement of the left hip. 

Discussion: This is a common topic that you will see on board exams or limping into your office. Although pediatric hip pain may seem like a benign musculoskeletal concern, taking the time to take a complete history and perform a thorough physical exam is critical to assess the severity of the patient’s concern.

Physical Exam for Pediatric Hip Pain.

1. Observation: Every physical exam begins the moment you first see the patient. This allows you to gauge the patient’s comfort level, the natural stature, length, and positioning of the patient’s extremities, skin changes, gait, and ability to bear weight. 
2. Palpation: In medicine, our hands are one of our greatest tools for evaluating patients, especially those with musculoskeletal concerns. This is the time to palpate the area for any tenderness or gross deformities of the pelvis, hip, knee, or leg. 
3. Special Tests: In the world of MSK, we have all sorts of tests to evaluate the range of movement of our joints and tendons. When specifically evaluating the hip, the most common are the FABER(flexion, abduction, external rotation),test to assess the sacroiliac joint, Ober’s Test to assess the iliotibial band, and Straight Leg Raise to assess for lumbar radiculopathy.

Legg-Calve Perthes Disease

-Legg-Calve Perthes disease is an idiopathic avascular necrosis of the femoral head. 

-It is most commonly observed in patients between the ages of 2-12 years and in a higher ratio of males to females 1. 

-It often manifests as an atraumatic limp with limited movement in abduction and internal rotation. 

-X-ray imaging may demonstrate a widening of the joint space and sclerosis of the femur, and MRI will confirm osteonecrosis of the femoral head. 

-Early diagnosis is key to minimizing the risk of developing osteoarthritis of the hip. 

-The goal of treatment is to maintain the shape of the femoral head and the range of