Tuesday, June 17, 2008

Differential diagnosis of painful hip in children & clinical decision making

A case I saw toay (18.6.2008): Today a 14 year old girl came to me with complain of stiff hip. All the movements ware severely limited. Her parents told that in 2006 dec she suddenly suddenly complained of hip pain. They could not tell any thing on fever. Radiographs showed reduced joint space, irregular joint margin, decreased neck length, osteoporosis in the head and neck of femur. She has been diagnosed with 4 different diseases by 4 different doctors:
1. LP disease
2. tubercular arthritis
3. septic arthritis
4. transient synovitis
Following is a topic for 1st hand physiotherapists for quick referrals. Children with a painful hip present a diagnostic challenge since clinical differentiation between septic arthritis, transient synovitis and Perthes disease may be difficult. Septic arthritis, a potentially life-threatening and debilitating medical emergency, requires early recognition for successful treatment, while transient synovitis and Perthes disease may be managed conservatively. An "ideal" single test for discrimination between these conditions is currently not available.
Because of the very severe nature of the of septic arthritis we are focusing on diagnosis of septic arthritis only.
Kocher et al. septic arthritis diagnosis is based on four clinical variables:
1. History of fever,
2. Non-weight-bearing,
3. An erythrocyte sedimentation rate of >or=40 mm/hr,
4. And a serum white blood-cell count of >12000/mm(3) (>12.0 x 10(9)/L).
Many other researchers found these criteria may not good enough for diagnosis. Few other researchers found following criteria helpful for diagnosis of septic arthritis.
All children with septic arthritis had hip effusion shown by ultrasound and at least two of the following criteria: fever, elevation of erythrocyte sedimentation rate (ESR) and of C-reactive protein (CRP). None of the children without effusion on ultrasound or who lacked two or all criteria had septic arthritis. Radiographs had no significant impact on the decision-making in primary evaluation of acute hip pain.
Once the acuteness subsides physios should mobilize the joint. The presentation as late as the above mentioned case require more aggressive approach. An experienced clinician will decide which approach and which techniques are good for individual patients. I found Mulligan’s techniques very very helpful.

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