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Recognizing Adolescent Hip Conditions

Recognizing Adolescent Hip Conditions

by | Aug 21, 2019 | Hip Disorders

Key messages from a presentation by staff orthopedist, David A. Podeszwa, M.D., at Coffee, Kids and Sports Medicine. Article originally published in first quarter, 2018 issue of Pediatric Society of Greater Dallas newsletter. 

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Recognizing Hip Conditions in the Pre-Teen and Teenager

Kids of all ages complain frequently of aches and pains around the hip and it is really easy to brush them
off. I would be lying if I said that I haven’t done it to my own children. For the super-active child/teen who participates in high impact activities year-round, it is easy to explain away complaints of hip pain as simple overuse. The combination of anti-inflammatories, stretching and playing through the pain is a common remedy. At the opposite end of the spectrum is the video gamer or book lover who is more sedentary and less interested in exercise. Their complaints of hip pain are easily attributed to deconditioning and weakness. Becoming more active is the simple remedy. Unfortunately, not all hip pain can be ignored. Missing certain conditions early in their presentation can have significant long-term pain and functional consequences. Below are several important pearls to remember that will help you avoid missing a serious hip condition when evaluating a patient with hip pain.

  1. Hip disorders can present with hip or knee pain. Sorting out the etiology and location starts with a good history and physical exam. Is the chief complaint pain, limp, or decreased motion? Some disorders can present without pain and only a limp. Where does it hurt? Hip disorders can present with hip (anterior, lateral, groin), thigh or knee pain. Complaints of constant pain that does not resolve with rest, is worse with weight bearing, limits hip range of motion, and is not improved with anti-inflammatories should be red flags for a significant underlying condition. Physical exam may demonstrate pain with palpation at the anterior superior iliac spine, iliac crest, and or greater trochanter. Pain with range of motion or significant asymmetry in hip range of motion should also be concerning.
  2. Children and adolescents do not get “groin pulls.” Recurrent limping and/or hip pain (especially groin pain) unresolved with rest is likely to have an underlying etiology. “Groin pull” is an easy answer, but it is never the correct one.
  3. An adolescent limping with his/her foot turned out and complaining of hip or knee pain has a slipped capital femoral epiphysis (SCFE) until proven otherwise by an AP and frog-lateral of both hips. Range of motion of the hip will likely be painful, especially with internal rotation when the hip is flexed. In severe cases, there will be obligate external rotation (and often abduction) when flexing the hip. In addition, any pre-teen or teen who presents with thigh or knee pain should have their hips examined as well. Referred pain is very common. Examining the hips in the face of knee pain will help prevent you from missing a serious hip condition. Delay in diagnosis is very common and is correlated with a more severe deformity and poorer outcomes.
  4. Hyperactive boys under the age of 10 who present with a limp (without pain or with vague complaints of hip, thigh or knee pain) should have an AP pelvis and frog-lateral of the hip to evaluate for Legg-Calve-Perthes disease. Far more common in boys than girls (4:1), this condition is most common between 4 and 10 years of age. The affected child is usually small and young appearing for his/her age. The child is able to bear weight, the pain or limp is usually worse with increased activity and there will not be any systemic signs or symptoms. Early diagnosis and treatment can make a significant difference in outcome. Once diagnosed, please refer to a pediatric orthopedist.
  5. Adolescents with hip pain and fever have septic arthritis of the hip until proven otherwise. Transient synovitis most commonly affects children 4-9 years old. Be very skeptical of this diagnosis in any child outside this age range. If the child is younger than four or older than ten years of age with hip pain and fever, think septic arthritis first. The child with transient synovitis may be able to ambulate and may tolerate gentle passive range of motion of the hip. He/she will commonly be afebrile. The CRP is usually <2 mg/dL, ESR usually <40 mm/hr, and WBC usually <12K cells/mL. A child with either transient synovitis or early septic arthritis will respond to ibuprofen. Ibuprofen should not be used as a diagnostic tool, but as a treatment for transient synovitis once the diagnosis is made. The differential diagnosis includes Lyme disease, gonorrhea, post-streptococcal reactive arthritis and hemophilia. Aspiration of the hip with cell count, gram stain, and cultures is the definitive diagnostic procedure for septic arthritis.

As I was taught and I often tell trainees, you don’t have to know what’s wrong, just recognize something is not right. Remembering these pearls will help you recognize when hip pain is really a problem.

An Orthopedic Surgeon’s Perspective On Child Obesity

An Orthopedic Surgeon’s Perspective On Child Obesity

by | Apr 17, 2019 | General News

Originally presented by Corey S. Gill, M.D., at the Sports Medicine for Young Athlete: How Do We Keep Our Kids Safe Conference in Frisco.
Childhood obesity is a significant public health problem and significantly increases the risk of developing a number of debilitating medical conditions, such as diabetes and heart disease. The prevalence of childhood obesity nationwide is approximately 15%, but is often much higher in pediatric orthopedic patients. For example, more than one third of my patients who require surgery for orthopedic problems are obese. Obesity may play a causative role in disorders such as slipped capital femoral epiphysis (SCFE) and Blount’s disease, and often increases the severity and complexity of fractures and other orthopedic injuries.

Conditions Often Found in This Population
SCFE is a condition that can develop in the hips of obese children and adolescents. The excess body weight increases the stress across the cartilage growth plate of the femur near the hip joint and can lead to a stress fracture or complete fracture. This condition always requires surgical intervention and may lead to significant long-term damage to the hip joint that necessitates additional surgery or even hip replacements at a young age. This condition is often difficult to diagnose, as the hip pain can be vague or even manifest as knee pain. All obese adolescents with significant hip/knee pain, or a noticeable limp, should be evaluated by a pediatric orthopedic surgeon.

Blount’s disease is another condition correlated with obesity. In this condition, there is severe bowing of the knees that leads to pain, joint damage and a significant visible deformity. Surgical treatment for mild Blount’s disease is called growth modulation. This treatment involves tethering a growth plate near the knee with a metal plate and screws, so that the leg can gradually straighten over approximately one to two years. In more severe cases, larger surgeries are often required to cut and realign the tibia bone, often with an external metal frame attached to the leg for stability.

Fractures or broken bones are relatively common in growing children. Obese children are more likely to sustain arm and leg fractures after a fall compared to normal weight peers. In addition, these fractures are usually more severe and more complicated to fix in obese children. Finally, the excessive soft tissue present in obese limbs makes fractures more difficult to hold in position in a cast. Consequently, many fractures that can be treated nonsurgically in normal weight children require surgical intervention in obese children.

Peri-operative Risks in Obese Children
Overweight and obese children often have medical comorbidities that increase risk of complications during and after surgery, such as anesthesia-related complications, infection and wound problems.  A thorough preoperative evaluation is recommended in obese patients undergoing surgery in order to optimize perioperative care. For example, sleep apnea is found in 85% of patients with Blount’s disease and hypertension is present in 65% of Blount’s and SCFE patients. Oftentimes, these medical comorbidities are undiagnosed at the time of presentation, so orthopedic surgeons play an important role in the recognition and diagnosis of these diseases.

Now What?
Childhood obesity is a difficult problem, and there are no easy solutions to eliminate the epidemic. A multidisciplinary approach with frequent communication between surgeons, pediatricians, nutritionists and other health care providers is mandatory to optimize orthopedic care of the obese patient. The pediatric and orthopedic communities must continue to support initiatives to encourage kids to be active and to eat a healthy balanced diet. Regarding diet, healthy eating habits need to be established at a young age, as studies have shown that obese children as young as 11 are already consuming in excess of 1100 to 1300 extra calories per day. Regarding activity, children and adolescents should be encouraged to participate in at least 60 minutes of physical activity each day. Participation in team sport, or other activities such as walking, running or biking, may decrease obesity rates and promote a lifelong love of a healthy activity.

Learn more about injury prevention and pediatric sports medicine.

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