Irritable hip in a child refers to an atraumatic limp, hip pain, or reluctance to use one leg. The following algorithm is intended to allow many children to be managed as an outpatient, to limit needle aspiration to a high risk group, and to limit X-rays to those with persistent symptoms.
Management of Children <= 18 Months
These children should be carefully investigated at presentation. Children with irritable hip in this age group are:
(1) more likely to have sepsis than older children
(2) at risk for having neuroblastoma
Algorithm for Children > 18 Months
Step 1: Exclude leukemia and sickle cell disease.
Step 2: Determine risk of sepsis using the sepsis risk score.
Step 3: If patient is identified as high risk, then perform ultrasonography with needle aspiration of any effusion.
(3a) If there is evidence of septic arthritis, then admit and treat with antibiotics.
(3b) If there is no evidence of septic arthritis, then discharge.
(3c) Review in 48 hours. Consider bone scan if osteomyelitis suspected.
Step 4: If the patient is identified as low risk, then discharge.
Step 5: If symptoms persist for 1 week, re-examine with X-ray.
Sepsis Risk Score
Parameters:
(1) pain
(2) tenderness
(3) temperature
(4) erythrocyte sedimentation rate (ESR)
|
Parameter |
Finding |
Points |
|
pain |
absent |
0 |
|
|
present |
1 |
|
tenderness |
absent |
0 |
|
|
present |
1 |
|
temperature |
<= 38°C |
0 |
|
|
> 38°C |
1 |
|
erythrocyte sedimentation rate (ESR) |
<= 20 mm/h |
0 |
|
|
> 20 mm h |
1 |
where:
• These criteria are similar to those of Taylor and Clark (see below). These authors used (1) temperature < 38°C and >= 38°C, (2) severe hip pain or spasm.
sepsis risk score =
= SUM(points for the 4 parameters)
Interpretation:
• minimum risk score: 0
• maximum risk score: 4
• A sepsis risk score of 0 or 1 indicates low risk for sepsis.
• A sepsis risk score of >= 2 indicates high risk for sepsis.
• A C-reactive protein may be helpful in questionable cases. See Eich et al (below) for cutoff.
Specialty: Surgery, orthopedic, Pedatrics
