Review for the generalist: evaluation of pediatric hip pain

Abstract

Hip pathology may cause groin pain, referred thigh or knee pain, refusal to bear weight or altered gait in the absence of pain. A young child with an irritable hip poses a diagnostic challenge. Transient synovitis, one of the most common causes of hip pain in children, must be differentiated from septic arthritis. Hip pain may be caused by conditions unique to the growing pediatric skeleton including Perthes disease, slipped capital femoral epiphysis and apophyseal avulsion fractures of the pelvis. Hip pain may also be referred from low back or pelvic pathology. Evaluation and management requires a thorough history and physical exam, and understanding of the pediatric skeleton. This article will review common causes of hip and pelvic musculoskeletal pain in the pediatric population.

Figure 1

Hip and Pelvis Anatomy. 1 = Iliac crest (abdominal muscle attachment), 2 = Anterior superior iliac spine (sartorius attachment), 3 = Anterior inferior iliac spine (rectus femoris attachment), 4 = Greater trochanter (gluteal attachment), 5 = Lesser trochanter (psoas attachment), 6 = Ischial tuberosity (hamstring attachment), 7 = pubic symphysis and inferior pubis ramus (gracilis and adductor attachments).

Figure 2

Klein's line in normal situation versus in slipped capital femoral epiphysis [13]. Klein's line is drawn along the radiographic border of the neck of the femur. This line should intersect the epiphysis. A, Klein's line in normal situation. B, Alignment of Klein's line with slip: the epiphysis is out of alignment.