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Benjamin Easter, MS III Gillian Lieberman, MD Core Radiology Clerkship, BIDMC November 16, 2009
Agenda
Patient Presentation Anatomy Review Differential Diagnosis of Hip Pain/Limp Septic Arthritis vs. Transient Synovitis Osteomyelitis Diagnose our Patient
Hip Anatomy
Advanced Technology Hip Surgery. Available at: http://www.hipsurgery.co.il/english/introduction.htm. Accessed November 12, 2009.
Childrens Hospital of Philadelphia. Available at: http://www.chop.edu/healthinfo/anatomy-of-a-joint.html. Accessed November 12, 2009.
Fx of femoral neck can disrupt perfusion through branches of circumflex femoral arteries, leading to avascular necrosis (AVN)
Wheeless Textbook of Orthopaedics. Available at: http://www.wheelessonline.com/ortho/blood_supply_to_femoral_head_neck. Accessed November 12, 2009.
Neoplastic
Osteoid Osteoma Osteogenic Sarcoma Ewing Sarcoma Leukemia Spinal Cord Tumors Leukemia Lymphoma
Inflammatory
Toxic/Transient Synovitis Juvenile Rheumatoid Arthritis Spondyloarthropathy Kawasaki Disease Dermatomyositis Polyarteritis nodosa Henoch Schonlein Purpura Systemic Lupus Erythematosus
Mechanical/Orthopedic
Slipped Capital Femoral Epiphysis (SCFE) Legg-Calve-Perthes (LCPD) Developmental Dysplasia of Hip Patellofemoral pain syndrome Myositis ossificans
Trauma
Sprains, Strains, Contusions Fracture (fx)- Toddlers, stress, other
*Morgan DS, Fisher D, Marianos A, Currie BJ. An 18 year clinical review of septic arthritis from tropical Australia. Epidemiol Infect 1996; 117:423.
Because of the morbidity of SA and the relatively benign course of TS, it is very important to be able to distinguish between these two entities. What is the role of imaging in this process?
Lets view some examples of diagnoses that can be made on plain film alone.
Toddlers Fracture on frontal radiograph of R lower extremity oblique, nondisplaced fx of tibial diaphysis
Gable H. Image Interpretation. Available at: http://www.imageinterpretation.co.uk/images/ankle/TODDLERS%20AP.jpg. Accessed November 12, 2009.
PACS, CHB
PACS, CHB
PACS, CHB
In review, plain films are the initial study of choice in all children with hip pain or limp. What are the imaging recommendations for patients with suspected SA?
Ultrasound of Hip 8
Detect effusion Guide aspiration (provides definitive diagnosis)
*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.
Frog leg position (femur abducted, externally rotated) provides lateral view of femoral heads
Because TS is most common cause of limp, some algorithms use U/S before plain films in evaluation of these children* * Fischer, 1999 Sagittal Ultrasound of MBs hips
Iliopsoas Tendon Femoral Head Femoral Metaphysis Normal joint spaceanechoic, concave
PACS, CHB
*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 2004;86:956-962.
She meets 3 of the Kocher criteria, so her chance of SA is 93% If her chance were lower, we could stop here 93% chance of SA requires us to proceed with arthrocentesis
Option 2 Arthrocentesis
Aspiration provides definitive diagnosis and fluid can be sent for culture and sensitivity But aspiration is invasive, so we dont want to do it in setting of low clinical suspicion for SA MBs Kocher criteria gave us a high suspicion for SA, so we decided that aspiration was appropriate
Companion Patient Sagittal Ultrasound-Guided Aspiration of Hip
Needle
* Effusion Femur
PACS, CHB
MBs parents did not consent to arthrocentesis (they felt her clinical status had improved). So we cant definitively say what she had, but lets look at some other patients with SA.
XR AP Pelvis, Companion Patient Effusion bulging fat pads Gluteal and Iliopsoas *
*
Manaster BJ. Chronic Hip Pain: Radiographic Evaluation Radiographics 2000;20:S3-S25
In this patient, septic arthritis was confirmed by aspiration, but transient synovitis could have had identical imaging.
Septic Arthritis Companion Patient #2 11 yo M p/w 3 day history of refusal to bear weight, fevers, chills
Plain films at outside hospital read as normal The now familiar ultrasound
Sagittal Ultrasound of Hips
Joint space shows effusion * Layering and echogenicity consistent with debris PACS, CHB
PACS, CHB
PACS, CHB Hyperintense collections showing joint effusion and surrounding edema
PACS, CHB
Septic Arthritis Companion Patient #2 What Happened? Septic Arthritis Joint Effusion Tamponade of Vascular Supply to Femoral Head Avascular Necrosis of Femoral Head
Osteomyelitis
Proximal femur is most common site in children Pelvic osteomyelitis may also occur (notably children will allow careful examination of hip) Menu of Imaging
Plain Film- more sensitive in later stages, shows bone destruction (if >30%) and effusion* Bone Scan- can detect multifocal disease in children with suspected osteomyelitis MRI- useful if plain films negative, detect bone marrow edema and effusion
*Myers MT, Thompson GH. Imaging the Child with a Limp. Pediatric Clinics of North America 1997;44(3): 637-658.
PACS, CHB
PACS, CHB
* * *
PACS, CHB Hyperintensity on Fluid Sensitive Sequence showing Marrow Edema and Abscess
No Evidence of Osteomyelitis
PACS, CHB
Imaging results not specific for TS TS is a clinical diagnosis that requires ruling out SA by aspiration if suspicion high
Review/Conclusions
DDx of hip pain/limp in children is very broad ACR Appropriateness Criteria
Everyone should get plain films U/S, MRI, Tc-99m Bone Scan all have a role Little role for CT- limited to trauma, pre-op planning
Viewed radiographic appearance of Toddlers fx, LCPD, avulsion fx, SCFE Viewed characteristics of SA, TS, and osteomyelitis on various imaging modalities TS vs. SA is a hard and all-important decision
Imaging not very helpful until late in disease process Kocher Criteria can help Arthrocentesis provides definitive diagnosis
Acknowledgements
Thank you!
Adam Jeffers, MD Sarah Bixby, MD Diana Rodriguez, MD Iva Petkovska, MD Gillian Lieberman, MD Maria Levantakis
References
Advanced Technology Hip Surgery. Available at: http://www.hipsurgery.co.il/english/introduction.htm. Accessed November 12, 2009. 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/ExpertPanelonPediatric Imaging/LimpingChildUpdateinProgressDoc6.aspx. Accessed November 10, 2009. Childrens Hospital of Philadelphia. Available at: http://www.chop.edu/healthinfo/anatomy-of-a-joint.html. Accessed November 12, 2009. Fischer SU, Beattie TF. The limping child: epidemiology, assessment, and outcome. JBJS Br 1999; 81(6):10291034. Haueisen DC, Weiner DS, Weiner Se. The characterization of transient synovitis of the hip in children. J Pediatr Orthop 1986;6:11. 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 2004;86:956-962. Myers MT, Thompson GH. Imaging the Child with a Limp. Pediatric Clinics of North America 1997;44(3): 637658. Morgan, DS, Fisher, D, Marianos, A, Currie BJ. An 18 year clinical review of septic arthritis from tropical Australia. Epidemiol Infect 1996; 117:423. Taylor GR, Clarke NM. Management of irritable hip: a review of hospital admission policy. Arch Dis Child 1994;71:59. Wheeless Textbook of Orthopaedics. Available at: http://www.wheelessonline.com/ortho/blood_supply_to_femoral_head_neck. Accessed November 12, 2009.