Pediatric Hip Pain: Pediatric Hip Pain: Septic Arthritis, Transient Septic Arthritis, Transient Synovitis, and Osteomyelitis Synovitis, and Osteomyelitis Benjamin Easter, MS III Benjamin Easter, MS III Gillian Lieberman, MD Gillian Lieberman, MD Core Radiology Clerkship, BIDMC Core Radiology Clerkship, BIDMC November 16, 2009 November 16, 2009
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Pediatric Hip Pain: Pediatric Hip Pain: Septic Arthritis, Transient Septic Arthritis, Transient
Synovitis, and OsteomyelitisSynovitis, and Osteomyelitis
Benjamin Easter, MS IIIBenjamin Easter, MS IIIGillian Lieberman, MDGillian Lieberman, MD
Patient PresentationPatient PresentationAnatomy ReviewAnatomy ReviewDifferential Diagnosis of Hip Pain/LimpDifferential Diagnosis of Hip Pain/LimpSeptic Arthritis vs. Transient SynovitisSeptic Arthritis vs. Transient SynovitisOsteomyelitisOsteomyelitisDiagnose our PatientDiagnose our Patient
Our Patient Our Patient ––
History and Physical ExamHistory and Physical Exam
HPI:HPI: MB is a 20 month old previously healthy female with 1 day MB is a 20 month old previously healthy female with 1 day history of sudden pain in her L hip. Refuses to walk. No recent history of sudden pain in her L hip. Refuses to walk. No recent falls or trauma. falls or trauma. Further history: Further history: NonNon--contributorycontributoryVitalsVitals: T 37.3, HR 120, BP 105/59, RR 24: T 37.3, HR 120, BP 105/59, RR 24Focused Exam:Focused Exam: L leg was extended and internally rotated. L L leg was extended and internally rotated. L hip tender to palpation. No warmth, tenderness, or erythema of hip tender to palpation. No warmth, tenderness, or erythema of lower extremity, lower back, or SI joint. Knee and ankle can be lower extremity, lower back, or SI joint. Knee and ankle can be manipulated through FROM. Resists manipulation of hip. Will manipulated through FROM. Resists manipulation of hip. Will not bear weight on L. An insect bite was apparent on left calf.not bear weight on L. An insect bite was apparent on left calf.Remainder of exam:Remainder of exam: Benign Benign
Hip AnatomyHip Anatomy
Children’s Hospital of Philadelphia. Available at: http://www.chop.edu/healthinfo/anatomy-of-a-joint.html. Accessed November 12, 2009.
Advanced Technology Hip Surgery. Available at: http://www.hipsurgery.co.il/english/introduction.htm. Accessed November 12, 2009.
Hip Blood SupplyHip Blood Supply
Wheeless’ Textbook of Orthopaedics. Available at: http://www.wheelessonline.com/ortho/blood_supply_to_femoral_head_neck. Accessed November 12, 2009.
Fx of femoral neck can disrupt perfusion through branches of circumflex femoral arteries, leading to avascular necrosis (AVN)
Exhaustive Differential Diagnosis of Exhaustive Differential Diagnosis of Hip Pain/Limp in ChildrenHip Pain/Limp in Children
Mechanical/OrthopedicMechanical/OrthopedicSlipped Capital Femoral Epiphysis (SCFE)Slipped Capital Femoral Epiphysis (SCFE)LeggLegg--CalveCalve--Perthes (LCPD)Perthes (LCPD)Developmental Dysplasia of HipDevelopmental Dysplasia of HipPatellofemoral pain syndromeMyositis ossificans
More Practical, Narrowed More Practical, Narrowed Differential DiagnosisDifferential Diagnosis
Septic ArthritisSeptic Arthritis-- can’t miss due to rapid joint can’t miss due to rapid joint destruction and morbiditydestruction and morbidityToxic SynovitisToxic Synovitis-- most common diagnosis in most common diagnosis in children with limp*children with limp*OsteomyelitisOsteomyelitis-- high morbidity if missedhigh morbidity if missedTraumaTraumaAcquiredAcquired-- LeggLegg--CalveCalve--Perthes Disease (LCPD), Perthes Disease (LCPD), Slipped Capital Femoral Epiphysis (SCFE)Slipped Capital Femoral Epiphysis (SCFE)CancerCancer
*Fischer SU, Beattie TF. The limping child: epidemiology, assessment, and outcome. JBJS Br 1999; 81(6):1029-1034.
Septic Arthritis (SA) of the HipSeptic Arthritis (SA) of the Hip
Infancy, 3Infancy, 3--6 year olds6 year oldsStaph, Group B Strep, GonococcalStaph, Group B Strep, GonococcalSpreadSpread
Direct InoculationDirect InoculationLocal SpreadLocal SpreadHematogenous SpreadHematogenous Spread-- 72%*72%*
Benign clinical course that resolves with Benign clinical course that resolves with conservative tx (NSAIDs)conservative tx (NSAIDs)
*Taylor GR, Clarke NM. Management of irritable hip: a review of hospital admission policy. Arch Dis Child 1994;71:59. *Haueisen DC, Weiner DS, Weiner Se. The characterization of “transient synovitis of the hip” in children. J Pediatr Orthop 1986;6:11.
Transient Synovitis and Septic Arthritis Transient Synovitis and Septic Arthritis –– Different Entities, Similar PresentationDifferent Entities, Similar Presentation
atraumatic, acutely irritable hip atraumatic, acutely irritable hip progressive signs of fever progressive signs of fever limp or refusal to bear weight limp or refusal to bear weight limited ROM limited ROM abnormal labsabnormal labs
Because of the morbidity of SA Because of the morbidity of SA and the relatively benign course and the relatively benign course of TS, it is very important to be of TS, it is very important to be
able to distinguish between these able to distinguish between these two entities. What is the role of two entities. What is the role of
imaging in this process?imaging in this process?
Role of Imaging Role of Imaging ––
Plain RadiographsPlain RadiographsBy ACR Appropriateness criteria, plain films of By ACR Appropriateness criteria, plain films of the area of interest are the #1 study in all the area of interest are the #1 study in all limping/hip pain children!*limping/hip pain children!*AdvantagesAdvantages
Rapid overviewRapid overviewRule out certain conditions e.g. fxRule out certain conditions e.g. fxRule in certain conditions e.g. SCFERule in certain conditions e.g. SCFEFast, cheap, readily availableFast, cheap, readily availableAutomatic control from contralateral hipAutomatic control from contralateral hip
*American College of Radiology. ACR Appropriateness Criteria-
Limping Child Ages 0-5 Years. 2007. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonPediatricImaging/Limping
ChildUpdateinProgressDoc6.aspx. Accessed November 10, 2009.
Let’s view some examples of Let’s view some examples of diagnoses that can be made on diagnoses that can be made on
plain film alone. plain film alone.
Toddler’s Fracture on Plain FilmToddler’s Fracture on Plain Film
Gable H. Image Interpretation. Available at: http://www.imageintGable H. Image Interpretation. Available at: http://www.imageinterpretation.co.uk/images/ankle/TODDLERS%20AP.jpg. erpretation.co.uk/images/ankle/TODDLERS%20AP.jpg. Accessed November 12, 2009. Accessed November 12, 2009.
Toddler’s Fracture on frontal radiograph of R lower extremity–
oblique, nondisplaced fx of tibial diaphysis
LeggLegg--CalveCalve--Perthes Disease on Plain FilmPerthes Disease on Plain Film
Legg-Calve-Perthes Disease on frontal radiograph of pelvis -AVN of L femoral head
PACS, CHB
Avulsion Fracture on Plain Film Avulsion Fracture on Plain Film
PACS, CHB
Frontal radiograph of pelvis showing avulsion fx of R ischial tuberosity in 14 yo F athlete
SCFE on Plain FilmSCFE on Plain Film
“Frog leg”/lateral radiograph of pelvis showing R SCFE with “ice cream falling off cone” appearance
PACS, CHB
In review, plain films are the In review, plain films are the initial study of choice in all initial study of choice in all
children with hip pain or limp. children with hip pain or limp. What are the imaging What are the imaging
recommendations for patients recommendations for patients with suspected SA?with suspected SA?
Imaging of Suspected Septic Arthritis Imaging of Suspected Septic Arthritis -- ACR Appropriateness Criteria and Score*ACR Appropriateness Criteria and Score*
Plain Films Plain Films –– 9 9 Early ChangesEarly Changes-- effusion, soft effusion, soft tissue swellingtissue swellingLate ChangesLate Changes-- cortical cortical destruction, periosteal reactiondestruction, periosteal reaction
Ultrasound of Hip Ultrasound of Hip –– 88Detect effusionDetect effusionGuide aspiration (provides Guide aspiration (provides definitive diagnosis)definitive diagnosis)
TcTc--99m bone scan of lower 99m bone scan of lower extremity extremity –– 77
Good for nonfocal physical examsGood for nonfocal physical exams54% of patients with no diagnosis 54% of patients with no diagnosis after clinical, laboratory, and after clinical, laboratory, and radiographic evaluation had radiographic evaluation had abnormal bone scans+abnormal bone scans+
MRI of area of interest MRI of area of interest –– 77Detect effusion, synovial Detect effusion, synovial inflammationinflammationNonspecific changesNonspecific changes
*American College of Radiology, 2007.+Aronson J, Garvin K, Seibert J, et al. Efficiency of the bone scan for occult limping toddlers. J Pediatr Orthop
1992;12(1):38-44.
Let’s look at our patient’s Let’s look at our patient’s initial imaging…initial imaging…
Our Patient’s Plain FilmsOur Patient’s Plain Films
All Images-
PACS, CHB
FrontalRadiographs of Pelvis and Left Lower Extremity
LateralRadiographs of Pelvis and Left Lower Extremity
Frog leg position (femur abducted, externally rotated) provides lateral view of femoral heads
Detect joint effusionDetect joint effusionGuide aspiration of effusion which provides only definitive diagGuide aspiration of effusion which provides only definitive diagnosis of SAnosis of SA
Because TS is most common cause of limp, some algorithms use U/SBecause TS is most common cause of limp, some algorithms use U/Sbefore plain films in evaluation of these children*before plain films in evaluation of these children*
PACS, CHB
Normal joint space-anechoic, concave
Iliopsoas Tendon
Femoral Head
Femoral Metaphysis
Sagittal Ultrasound of MB’s hips
*
Joint Effusion-increased size, convex shape
* Fischer, 1999
What’s the problem with Ultrasound?What’s the problem with Ultrasound?
Both SA and TS present with joint effusion, so Both SA and TS present with joint effusion, so ultrasound can’t make this allultrasound can’t make this all--important important distinctiondistinctionOptions for distinguishing SA from TSOptions for distinguishing SA from TS
Kocher Criteria* for Kocher Criteria* for Differentiating SA and TSDifferentiating SA and TS
1.1.
FeverFever
2.2.
NonNon--weight bearingweight bearing
3.3.
ESR>40 mm/hrESR>40 mm/hr
4.4.
WBC>12,000/mmWBC>12,000/mm33
Prospective Prospective ConfirmationConfirmation
Only 59% chance of Only 59% chance of SA if all 4 criteria metSA if all 4 criteria met++
*Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic Arthritis and transient synovitis of the hip in children. JBJS (Am)
1999;81(12):1662-70. +Luhmann SJ, Jones A, Schutmann M, et al. Differentiation Between Septic Arthritis and Transient Synovitis of the Hip in Children with Clinical Prediction Algorithms. JBJS
She meets 3 of the Kocher criteria, so her chance of SA is 93%If her chance were lower, we could stop here93% chance of SA requires us to proceed with arthrocentesis
Option 2 Option 2 ––
ArthrocentesisArthrocentesisAspiration provides Aspiration provides definitive diagnosis and definitive diagnosis and fluid can be sent for fluid can be sent for culture and sensitivityculture and sensitivityBut aspiration is invasive, But aspiration is invasive, so we don’t want to do it so we don’t want to do it in setting of low clinical in setting of low clinical suspicion for SAsuspicion for SAMB’s Kocher criteria MB’s Kocher criteria gave us a high suspicion gave us a high suspicion for SA, so we decided for SA, so we decided that aspiration was that aspiration was appropriateappropriate
Companion PatientSagittal Ultrasound-Guided Aspiration of Hip
* Effusion
Femur
Needle
PACS, CHB
MB’s parents did not MB’s parents did not consent to arthrocentesis consent to arthrocentesis
(they felt her clinical status (they felt her clinical status had improved). So we can’t had improved). So we can’t
definitively say what she definitively say what she had, but let’s look at some had, but let’s look at some
other patients with SA.other patients with SA.
Septic Arthritis Septic Arthritis ––
Companion Patient #1 Companion Patient #1 7 yo M presenting with R hip pain7 yo M presenting with R hip painSagittal Ultrasound of Hip
T2 Fat Sat Axial MRI
PACS, CHB
Femoral heads with normal bone marrow signal
Hyperintense fluid within joint space consistent with effusion
Manaster BJ. Chronic Hip Pain: Radiographic Evaluation Radiographics 2000;20:S3-S25
Septic Arthritis Septic Arthritis ––
Companion Patient #1 Companion Patient #1 7 yo M presenting with R hip pain7 yo M presenting with R hip pain
In this patient, septic arthritis was confirmed
by aspiration, but transient synovitis
could have had identical imaging.
Septic Arthritis Septic Arthritis ––
Companion Patient #2Companion Patient #2 11 yo M p/w 3 day history of 11 yo M p/w 3 day history of
refusal to bear weight, fevers, chillsrefusal to bear weight, fevers, chillsPlain films at outside hospital read as normalPlain films at outside hospital read as normalThe now familiar ultrasound…The now familiar ultrasound…
PACS, CHB
*
Joint space shows effusion
Sagittal Ultrasound of Hips
Layering and echogenicity consistent with debris
Septic Arthritis Septic Arthritis ––
Companion Patient #2Companion Patient #2 11 yo M Continued11 yo M Continued
Tc-99m Bone Scan of Anterior Pelvis
PACS, CHB
Diminished tracer uptake/photopenia in R capital femoral epiphysis indicating lack of perfusion
What’s the story?
Septic Arthritis Septic Arthritis ––
Companion Patient #2Companion Patient #2 11 yo M Continued11 yo M Continued
Hyperintense collections showing joint effusion and surrounding edema
PACS, CHB
Lack of enhancement of R capital femoral epiphysis compared to L suggests avascular necrosis
PACS, CHB
Septic Arthritis Septic Arthritis ––
Companion Patient #2 Companion Patient #2 What Happened?What Happened?
Septic Arthritis Septic Arthritis Joint Effusion Joint Effusion Tamponade of Tamponade of
Vascular Supply to Vascular Supply to Femoral Head Femoral Head
Avascular Necrosis of Avascular Necrosis of Femoral Head Femoral Head
Imaging of Septic Arthritis Imaging of Septic Arthritis -- ConclusionConclusion
Imaging can distinguish between Imaging can distinguish between SA and TS, but generally only late SA and TS, but generally only late in the disease process when there is in the disease process when there is already bone involvement/AVN.already bone involvement/AVN.
Back to Our Patient Back to Our Patient ––
Hospital CourseHospital Course
Day 2Day 2Spiked fever Spiked fever Now partially weight bearingNow partially weight bearingRepeat U/S showed Repeat U/S showed resolution of effusionresolution of effusionResolving U/S and partial Resolving U/S and partial weight bearing reduce weight bearing reduce suspicion for SAsuspicion for SASpiking fevers and hip pain Spiking fevers and hip pain increase suspicion for increase suspicion for osteomyelitisosteomyelitis PACS, CHB
Increased echogenicity along femur is thickened synovium, but effusion has largely resolved compared to above image
*
*
Sagittal Ultrasounds of our Patient’s L Hip-Admission (Above) and Hospital Day 2 (Below)
PACS, CHB
OsteomyelitisOsteomyelitis
Proximal femur is most common site in childrenProximal femur is most common site in childrenPelvic osteomyelitis may also occur (notably Pelvic osteomyelitis may also occur (notably children will allow careful examination of hip)children will allow careful examination of hip)Menu of ImagingMenu of Imaging
Plain FilmPlain Film-- more sensitive in later stages, shows more sensitive in later stages, shows bone destruction (if >30%) and effusion*bone destruction (if >30%) and effusion*Bone ScanBone Scan-- can detect multifocal disease in children can detect multifocal disease in children with suspected osteomyelitiswith suspected osteomyelitisMRIMRI-- useful if plain films negative, detect bone useful if plain films negative, detect bone marrow edema and effusionmarrow edema and effusion
*Myers MT, Thompson GH. Imaging the Child with a Limp. Pediatric Clinics of North America
1997;44(3): 637-658.
Osteomyelitis Osteomyelitis ––
Companion Patient #3Companion Patient #3 11 yo F fever, L hip pain, MSSA bacteremia11 yo F fever, L hip pain, MSSA bacteremia
PACS, CHB
Note LACK of effusion
*
Tc-99m Bone Scan
Increased tracer uptake in L ischium and acetabulum
PACS, CHB
Sagittal Ultrasound of L Hip
Osteomyelitis Osteomyelitis ––
Companion Patient #3 Companion Patient #3 11 yo F fever, L hip pain, MSSA bacteremia11 yo F fever, L hip pain, MSSA bacteremia
MR Axial T2/Fluid Sensitive Sequences-
Inferior on Left and Superior on Right
Hyperintensity on Fluid Sensitive Sequence showing Marrow Edema
and Abscess
**
PACS, CHB
*
Osteomyelitis Osteomyelitis ––
Companion Patient #3 Companion Patient #3 11 yo F fever, L hip pain, MSSA bacteremia11 yo F fever, L hip pain, MSSA bacteremia
MR Coronal T1 Pre-Contrast (Left) and Post-Contrast (Right)
PACS, CHB
Enhancement of L ischium with contrast suggests increased perfusion to infected bone
Our Patient Our Patient ––
MR ImagesMR ImagesT1 Coronal MRI of Pelvis T2 Coronal MRI of Pelvis
Normal bone marrow intensity bilaterally without surrounding fluid
No difference in signal intensity or appearance between R and L femurs
No Evidence of Osteomyelitis
PACS, CHB
Our Patient Our Patient ––
A ReviewA Review
20 month old female with pain in L hip and 20 month old female with pain in L hip and refusal to walkrefusal to walkPlain FilmsPlain Films-- NormalNormalU/SU/S-- Significant effusion in L hipSignificant effusion in L hipNo aspiration per parent’s requestNo aspiration per parent’s request2 days later2 days later-- resolving effusion and spiking resolving effusion and spiking feversfeversMRMR-- No evidence of osteomyelitisNo evidence of osteomyelitis
Our Patient’s DiagnosisOur Patient’s Diagnosis--
Transient SynovitisTransient Synovitis
Pain and limited ROM in hipPain and limited ROM in hipNo clear precipitantNo clear precipitantRole of Imaging in TSRole of Imaging in TS
Plain FilmsPlain Films-- exclude bony abnormalities, may be normal exclude bony abnormalities, may be normal or show effusionor show effusionU/SU/S-- shows effusion and may guide arthrocentesisshows effusion and may guide arthrocentesisMRIMRI-- may show joint effusion and synovial may show joint effusion and synovial inflammation, exclude osteomyelitisinflammation, exclude osteomyelitis
Imaging results not specific for TSImaging results not specific for TSTS is a clinical diagnosis that requires ruling out SA TS is a clinical diagnosis that requires ruling out SA by aspiration if suspicion highby aspiration if suspicion high
Review/ConclusionsReview/ConclusionsDDx of hip pain/limp in children is very broadDDx of hip pain/limp in children is very broadACR Appropriateness CriteriaACR Appropriateness Criteria
Everyone should get plain filmsEveryone should get plain filmsU/S, MRI, TcU/S, MRI, Tc--99m Bone Scan all have a role99m Bone Scan all have a roleLittle role for CTLittle role for CT-- limited to trauma, prelimited to trauma, pre--op planningop planning
Viewed radiographic appearance of Toddler’s fx, LCPD, Viewed radiographic appearance of Toddler’s fx, LCPD, avulsion fx, SCFEavulsion fx, SCFEViewed characteristics of SA, TS, and osteomyelitis on Viewed characteristics of SA, TS, and osteomyelitis on various imaging modalitiesvarious imaging modalitiesTS vs. SA is a hard and allTS vs. SA is a hard and all--important decisionimportant decision
Imaging not very helpful until late in disease processImaging not very helpful until late in disease processKocher Criteria can helpKocher Criteria can helpArthrocentesis provides definitive diagnosisArthrocentesis provides definitive diagnosis
ReferencesReferencesAdvanced Technology Hip Surgery. Available at: http://www.hipsuAdvanced Technology Hip Surgery. Available at: http://www.hipsurgery.co.il/english/introduction.htm. rgery.co.il/english/introduction.htm. Accessed November 12, 2009.Accessed November 12, 2009.American College of Radiology. ACR Appropriateness CriteriaAmerican College of Radiology. ACR Appropriateness Criteria-- Limping Child Ages 0Limping Child Ages 0--5 Years. 2007. Available 5 Years. 2007. Available at: at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/aphttp://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonPediatricp_criteria/pdf/ExpertPanelonPediatricImaging/LimpingChildUpdateinProgressDoc6.aspx. Accessed NovemberImaging/LimpingChildUpdateinProgressDoc6.aspx. Accessed November 10, 2009. 10, 2009. Children’s Hospital of Philadelphia. Available at: http://www.chChildren’s Hospital of Philadelphia. Available at: http://www.chop.edu/healthinfo/anatomyop.edu/healthinfo/anatomy--ofof--aa--joint.html. joint.html. Accessed November 12, 2009. Accessed November 12, 2009. Fischer SU, Beattie TF. The limping child: epidemiology, assessmFischer SU, Beattie TF. The limping child: epidemiology, assessment, and outcome. ent, and outcome. JBJS Br JBJS Br 1999; 81(6):10291999; 81(6):1029--1034. 1034. Haueisen DC, Weiner DS, Weiner Se. The characterization of “tranHaueisen DC, Weiner DS, Weiner Se. The characterization of “transient synovitis of the hip” in children. J sient synovitis of the hip” in children. J Pediatr Orthop 1986;6:11. Pediatr Orthop 1986;6:11. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septKocher MS, Zurakowski D, Kasser JR. Differentiating between septic Arthritis and transient synovitis of the ic Arthritis and transient synovitis of the hip in children. hip in children. JBJS (Am)JBJS (Am) 1999;81(12):16621999;81(12):1662--70. 70. Luhmann SJ, Jones A, Schutmann M, et al. Differentiation BetweenLuhmann SJ, Jones A, Schutmann M, et al. Differentiation Between Septic Arthritis and Transient Synovitis of Septic Arthritis and Transient Synovitis of the Hip in Children with Clinical Prediction Algorithms. the Hip in Children with Clinical Prediction Algorithms. JBJSJBJS 2004;86:9562004;86:956--962.962.Myers MT, Thompson GH. Imaging the Child with a Limp. Myers MT, Thompson GH. Imaging the Child with a Limp. Pediatric Clinics of North AmericaPediatric Clinics of North America 1997;44(3): 6371997;44(3): 637--658.658.Morgan, DS, Fisher, D, Marianos, A, Currie BJ. An 18 year clinicMorgan, DS, Fisher, D, Marianos, A, Currie BJ. An 18 year clinical review of septic arthritis from tropical al review of septic arthritis from tropical Australia. Epidemiol Infect 1996; 117:423. Australia. Epidemiol Infect 1996; 117:423. Taylor GR, Clarke NM. Management of irritable hip: a review of hTaylor GR, Clarke NM. Management of irritable hip: a review of hospital admission policy. Arch Dis Child ospital admission policy. Arch Dis Child 1994;71:59. 1994;71:59. Wheeless’ Textbook of Orthopaedics. Available at: Wheeless’ Textbook of Orthopaedics. Available at: http://www.wheelessonline.com/ortho/blood_supply_to_femoral_headhttp://www.wheelessonline.com/ortho/blood_supply_to_femoral_head_neck. Accessed November 12, 2009. _neck. Accessed November 12, 2009.