Updated: 10/22/2017

Psoas Abscess - Pediatric

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Questions
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Evidence
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Introduction
  • A form of infection that must be considered when evaluating hip pain in children
  • Epidemiology
    • demographics
      • more common in tropics
  • Pathophysiology
    • may spread to hip joint causing septic arthritis because of
      • indirect passage via psoas bursa
        • lies between hip joint and psoas
        • connects psoas directly to hip joint in 15% of cadavers
    • direct passage between the iliofemoral and iliopubic ligaments
  • Microbiology
    • Staph aureus
      • most common organism
  • Associated conditions
    • septic hip - pediatric 
    • tuberculous spondylitis 
Presentation
  • Symptoms
    • presents like hip septic arthritis
      • fever
      • hip pain
      • limp or refusal to bear weight
  • Physical exam
    • inspection
      • hip rests in a position of flexion
    • palpation
      • may have tender mass in iliac fossa
    • provovative tests
      • psoas sign
        • pain caused by extension and internal rotation of the limb
Imaging
  • Radiographs
    • recommended views
      • AP and frog-leg lateral pelvic x-rays to rule out septic hip
    • findings
      • may show loss of definition or enlargment of psoas muscle shadow 
  • Ultrasound
    • diagnostic imaging study of choice 
  • Bone scan
    • helpful in diagnosis 
  • CT scan with contrast
    • indications
      • can confirm diagnosis when ultrasound or MRI not available
      • avoid if possible due to radiation exposure
    • findings
      • include the presence of a mass and local attenuation within the involved musclee, with ring enhancement
      • may be negative in early stages
  • MRI
    • indications
      • can confirm diagnosis if ultrasound not available
      • difficult to obtain expeditiously
    • findings
      • will show changes early in the disease process 
Treatment
  • Nonoperative
    • percutaneous ultrasound or CT-guided drainage
      • indications
        • treatment of choice in most cases
  • Operative
    • open drainage
      • indications
        • useful for secondary psoas abscess e.g. spread from the bowel
          • can simultaneously address intraabdominal source
Complications
  • Septic arthritis
    • psoas abscess can spread to hip joint
  • Sepsis
 

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Questions (1)

(OBQ13.94) A 17-month-old girl presents with intermittent fever, hip pain and irritability for 2 weeks. She walks with a limp. On examination, temperature is 38°C, and her hip is held in flexion. Passive hip extension, internal rotation, and abduction causes severe pain. WBC is 29,300 cells/microliter. ESR is 66 mm/h. Radiograph, bone scan and CT scan are shown in Figures A through C. What is the diagnosis? Review Topic

QID: 4729
FIGURES:
1

Septic arthritis

21%

(640/3081)

2

Psoas abscess

73%

(2241/3081)

3

Sacroiliitis

1%

(31/3081)

4

Transient synovitis

4%

(119/3081)

5

Osteomyelitis

1%

(35/3081)

ML 2

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