SUMMARY Pediatric Septic Hip Arthritis is an intra-articular infection in children that peaks in the first few years of life. While diagnosis may be suspected by a combination of history, physical exam, imaging, and laboratory studies, confirmation requires a hip aspiration. Considered a surgical emergency and requires prompt recognition and urgent surgical I&D followed by IV antibiotics. EPIDEMIOLOGY Incidence rare affects 4-5 per 100,000 children annually Demographics peaks in the first few years of life 50% of cases occur in children younger than 2 years of age male > female (2:1 ratio) Location hip joint involved in 35% of all cases of septic arthritis knee joint involved in 35% of all cases of septic arthritis Risk factors prematurity (relatively immunocompromised) cesarean section patients treated in the NICU invasive procedures such as umbilical catheterization, venous catheterization, heel puncture may lead to transient bacteremia Etiology Mechanism direct inoculation from trauma or surgery (skin penetration) hematogenous seeding upper respiratory infection precedes about 80% of the cases extension from adjacent bone (osteomyelitis) can develop from contiguous spread of osteomyelitis often from metaphysis common in neonates who have transphyseal vessels that allow spread into the joint joints with intra-articular metaphysis include hip shoulder elbow ankle (NOT the knee) Pathophysiology enzymatic destruction release of proteolytic enzymes (matrix metalloproteinases) from inflammatory and synovial cells, cartilage, and bacteria which may cause articular surface damage within 8 hours increased joint pressure may cause femoral head osteonecrosis if not relieved promptly Microbiology in up to 55% of cases, no organism is identified organisms vary with age (see chart) Microbiology by Organism Group B streptococcus most common in neonates with community-acquired infection exposed during transvaginal delivery Staph aureus most common in children over 2 years of age gram-positive cocci in clusters most common in nosocomial infections of neonates Neisseria gonorrhoeae still the most common organism in adolescents gram negative diplococci, negative Gram stain a majority of the time patients usually have a preceding migratory polyarthralgia, multiple joint involvement, and small red papules may treat with large doses of penicillin alone and usually does not require surgical debridement. Group A beta-hemolytic streptococcus most common organism following varicella infection HACEK organisms Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella fastidious incidence of septic arthritis caused by H influenzae has markedly decreased since the advent of its vaccine Kingella noted to be the most common organism in children < 4 years in some studies (best isolated on blood culture media) Presentation History recent local trauma or infections vaccination history must be obtained, particularly with regard to vaccination against Haemophilus influenzae recent or current antibiotics may mask symptoms Symptoms acute onset of pain presents more acutely than osteomyelitis systemic symptoms often associated with fever and other systemic symptoms causing toxic appearance limp or refusal to bear weight Physical exam vitals temperature and vital signs to rule out hemodynamic instability may show toxicity inspection and palpation localized swelling effusion, tenderness, and warmth hip rests in a position of flexion, abduction, and external rotation (FABER) hip capsular volume is maximized with flexion, abduction, and external rotation and is the position of comfort for hip septic arthritis range of motion severe pain with passive motion severe pain with logrolling of the hip unwillingness to move joint (pseudoparalysis) examine adjacent joints and spine must rule out adjacent joint involvement Imaging Radiographs recommended views AP and frog-leg lateral pelvic x-rays, if hips can be put in frog leg position. findings may be normal, especially in early stages of disease widening of the joint space in infants, prior to ossification of the femoral head, widening of joint space can be seen by lateral displacement of the proximal femur this is a sign of significant pus in joint subluxation dislocation bone lesions may see bone involvement with associated osteomyelitis Ultrasound indications neonate contralateral hip in neonates, ultrasound both hips if any septic joint is found, signs and symptoms of infection are muted in neonates, and a missed infection can be catastrophic. can be used to guide aspiration findings may be helpful to identify effusion cannot differentiate between a septic and a sterile effusion MRI may be difficult to obtain expeditiously identifies a joint effusion and possible adjacent osseous involvement which can guide operative treatment Studies Serum labs WBC is elevated in 30-60% of patients with a left shift in 60% neonates may have leukopenia ESR often elevated but may be normal early in the course of infection CRP may rise as soon as 6-8 hours after injury or infection CRP > 2.0 (mg/dl) is an independent risk factor (not included in studies of the previous 4 criteria) CRP > 2.0 (mg/dl) in combination with refusal to bear weight yields a 74% probability of septic arthritis order of sensitivity of above criteria fever > CRP > ESR > refusal to bear weight > WBC Hip aspiration may confirm diagnosis of septic arthritis fluid samples should be sent for WBC count with differential Gram stain, culture, and sensitivities Glucose and protein levels have been recommended by some, but of questionable value A septic joint aspirate will show high WBC count (> 50,000/mm3 with >75% PMNs) PMN percentage more sensitive than total WBC count 85% PMNs correlates with an 88% sensitivity. glucose 50 mg/dl less than serum levels high lactic acid level with infections due to gram positive cocci or gram negative rods Blood cultures should be performed if the patient is febrile, as they are often positive, even when local cultures are negative Lumbar puncture consider in a septic joint caused by H. influenzae due to risk of meningitis IF there are clinical signs of meningitis Differential Key Differential transient synovitis osteomyelitis JRA JIA Additional Differential Lyme Disease SCFE LCP MED Table - Differential diagnosis of Hip Pain in Children Diagnosis Diagnosis made by a combination of history, physical exam, imaging, and laboratory studies while the Kocher Criteria is commonly used, no one algorithm is diagnostic alone Original Kocher Criteria four criteria WBC > 12,000 cells/µl of serum inability to bear weight fever > 101.3° F (38.5° C) ESR > 40 mm/h algorithm probability of septic arthritis may be as high as 99.6% when all four criteria above are present if none of the above predictors are present, probability of having septic arthritis is <0.2% 3% incidence of septic arthritis if 1/4 criteria present, 40% incidence if 2/4 criteria present, 93% incidence if 3/4 criteria present Modified Kocher Criteria additional criteria CRP Treatment Nonoperative antibiotics alone rarely indicated adolescent Neisseria gonorrhoeae infection in some cases can be treated with large doses of penicillin alone and usually does not require surgical debridement Operative urgent surgical I&D followed by IV antibiotics indications standard of care for septic hip joints if possible in septic arthritis it is better to err on the side of surgical drainage considered a surgical emergency in the hip due to chondrolytic effect of pus removes damaging enzymes which are chondrolytic reduces intraarticular pressure and decreases epiphyseal ischemia Techniques Septic Hip Irrigation and Debridement approach most commonly one of the following approaches is utilized anterolateral approach to the hip anterior approach through the Smith-Peterson interval drainage of the shoulder, elbow, knee, and ankle may be open or arthroscopic technique arthrotomy is performed to remove all purulent fluid and to irrigate the joint consider removal of 1cm by 1cm hip capsule to minimize chances of re-accumulation consider synovial culture intra-articular drain placement is recommended antibiotics timing perform joint aspiration, preferably before administration of empiric antibiotics empiric IV antibiotics are started after samples are sent for culture once cultures return follow with IV antibiotics targeting pathogens convert to PO antibiotics once the clinical picture improves and definitive sensitivities are obtained current recommendation is a 2-7 day course of culture-specific IV antibiotics followed by a 2-3 week course of oral antibiotics terminate antibiotics once the CRP or ESR normalizes, and clinical picture returns to normal microbial coverage based on age and medical comorbidities immunization status determines whether empiric antibiotics should cover H influenzae Septic Arthritis Antibiotic Treatment Age Organism Antibiotics < 3 months group B streptococci, s. aureus, and gram-negative bacilli 1st generation cephalosporin 3 months to 5 years S. aureus, Kingella, S. pneumoniae, group A streptococci, H. influenzae 2nd or 3rd generation cephalosporinKingella shown to be resistant to vancomycin and clindamycin 5-12 yrs S. aureus 1st generation cephalosporin 12-18 yrs N. gonorrhoeae, S. aureus 2nd or 3rd generation cephalosporin postoperative care range of motion exercises of the affected joint may be started within the first few days after surgery Complications Femoral head destruction complete destruction of the femoral head and neck, easily visible on x-ray treatment salvage operations exist including varus/valgus proximal femoral osteotomies Femoral neck deformity physeal damage leads to late angular deformity and leg length discrepancy Joint contracture Growth disturbance patients should be followed up for 1-2 years to monitor for physeal arrest Limb-length discrepancy Osteonecrosis Prognosis Overview usually good unless diagnosis is delayed delay in diagnosis may result in permanent joint damage, and long-term disability. Prognostic indicators poor age < 6 months associated osteomyelitis delay >4 days until presentation hip joint (versus knee)
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Irrigation and Debridement of Septic Hip Evan Siegall Eric Shirley Pediatrics - Hip Septic Arthritis - Pediatric
QUESTIONS 1 of 28 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ18.56) A 5-year-old female presents to the emergency department with right hip pain. On exam, there is no skin discoloration but motion of the hip appears painful and she refuses to bear any weight on that side. A current radiograph is shown in Figure A. Initial set of vitals shows a body temperature of 37.8 degrees C, and his labs reveal a WBC count of 13K and ESR of 19. How many Kocher criteria are met, what is the corresponding likelihood of infection, and what is most likely causative organism? QID: 212952 FIGURES: A Type & Select Correct Answer 1 1 of 4 Kocher criteria, <10%, Staphylococcus aureus 8% (140/1830) 2 1 of 4 Kocher criteria, 40%, Neisseria gonorrhoeae 0% (5/1830) 3 2 of 4 Kocher criteria, 40%, Staphylococcus aureus 77% (1410/1830) 4 3 of 4 Kocher criteria, 93%, Group A streptococcus 12% (221/1830) 5 3 of 4 Kocher criteria, 99%, Group B streptococcus 2% (39/1830) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ18.57) A 17-year-old male presents with severe right hip pain of several days duration. He reports that he felt a "pop" when playing basketball a few days prior, and the pain intensified. Over the past few weeks, he has had pain in both of his knees and elbows. He currently is having difficulty ambulating and is reporting a history of subjective fevers. Upon further questioning, he denies alcohol, smoking, or drug use. On physical examination, his leg is flexed and externally rotated. He also has a rash over his body. Current imaging is shown in Figures A and B. He is sent for ultrasonagrapy-guided aspiration. Which of the following is the most likely finding when the joint fluid is analyzed? QID: 212953 FIGURES: A B Type & Select Correct Answer 1 Presence of intracellular Gram-negative diplococci 65% (953/1461) 2 Presence of Gram-positive cocci in clusters 6% (93/1461) 3 Presence of rheumatoid factor 7% (98/1461) 4 Normal joint fluid 18% (264/1461) 5 Presence of negatively birefringent crystals 1% (15/1461) L 1 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.108) Which of the following is true regarding matrix metaloproteinases (MMPs)? QID: 4468 Type & Select Correct Answer 1 They are activated by chelating agents 6% (275/4928) 2 They mediate the destruction of cartilage in septic arthritis 76% (3751/4928) 3 Toll-like receptors inhibit the formation of MMPs 7% (321/4928) 4 They have a anabolic effect on cartilage 5% (262/4928) 5 Stromelysin is an indirect antagonist of many MMPs 5% (265/4928) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ12.260) A 3-year-old presents with a 24-hour history of limping and progressive inability to bear weight. The parents recount no history of trauma, but note that he recently had an upper respiratory infection. A clinical photo is shown in Figure A. The patient’s vital signs are stable. Physical exam is limited because of pain. A hip ultrasound is shown in Figure B. Laboratory values are as follows: WBC-15.0 (97% PMN), ESR-120, CRP-5.0. What is the next best step for this patient? QID: 4620 FIGURES: A B Type & Select Correct Answer 1 Admit for observation 5% (176/3563) 2 Repeat hip ultrasound 0% (12/3563) 3 Obtain an MRI 5% (171/3563) 4 Start the patient on IV antibiotics 3% (119/3563) 5 Emergent hip arthrotomy with irrigation and debridement 86% (3060/3563) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ11.21) A 2-year-old child is diagnosed with a septic hip. Initially, no organisms grew on the standard blood agar plate. However, after 1 week, the offending organism was recovered in an aerobic blood culture medium. Which of the following organisms was the most likely cause? QID: 3444 Type & Select Correct Answer 1 Kingella kingae 80% (2415/3012) 2 Mycobacterium tuberculosis 6% (171/3012) 3 Mycobacterium avium 2% (73/3012) 4 Neisseria 7% (197/3012) 5 E-coli 4% (132/3012) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ11.162) A 2-year-old boy is seen for evaluation of a limp. His history is significant for a left knee infection treated with IV antibiotics as a neonate and a family history of cancer. Laboratory testing demonstrates a normal ESR and CRP. The remainder of his workup is negative. An AP pelvis is seen in Figure A. What was the most likely etiology of his condition? QID: 3585 FIGURES: A Type & Select Correct Answer 1 Untreated neonatal hip infection 91% (2822/3086) 2 Chondrosarcoma 1% (34/3086) 3 Legg-Calve-Perthes disease 6% (175/3086) 4 Slipped capital femoral epiphysis 0% (10/3086) 5 Osteosarcoma 1% (26/3086) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ10.243) An 8-day-old infant is admitted to the hospital for septic arthritis of the hip. He went home on day two after an uneventful vaginal birth. Which of the following will most likely be the causative organism by culture? QID: 3342 Type & Select Correct Answer 1 Group B Streptococcus 77% (2663/3437) 2 Staph Aureus 18% (607/3437) 3 Staph Epidermidis 0% (11/3437) 4 Haemophilus Influenzae 2% (83/3437) 5 Neisseria Gonnorhea 1% (49/3437) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ10.255) A 7-year-old boy developed a limp with right leg pain five days ago, and today has trouble bearing weight. On exam, he is lethargic and has chills. His temperature is 38.4 degrees centigrade. He points to his right inguinal region as the source of the discomfort. He winces with compression of his pelvis. Lab studies reveal a white blood cell count of 11,400/ul, CRP of 0.9 mg/dL (normal < 1.0 mg/dL), and erythrocyte sedimentation rate of 55 mm/h. A pelvis radiograph is shown in Figure A. Ultrasound guided aspiration of the right hip joint yields 9,000 leukocytes per mL. What is the most appropriate next step in management? QID: 3357 FIGURES: A Type & Select Correct Answer 1 Further imaging of the pelvis 48% (1413/2946) 2 Open drainage and irrigation of the right hip joint 28% (839/2946) 3 Repeat aspiration of the hip joint 3% (101/2946) 4 Percutaneous screw fixation of the proximal femoral physis 1% (18/2946) 5 Nonsteroidal antiinflamatory medications and observation 19% (562/2946) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ09.151) An 18 month-old child has been brought to the emergency room by his mother. He had the sudden onset of hip pain 3 days ago and now won't put weight on the affected limb. The child is febrile and an ultrasound (longitudinal view of the proximal femur) shown in Figure A shows the unaffected hip on the left and affected hip on the right. The patient is taken to the operating room for hip aspiration which reveals 60,000 leukocytes with 95% polymorphonucleocytes. What is the most likely diagnosis? QID: 2964 FIGURES: A Type & Select Correct Answer 1 Traumatic effusion 1% (13/1781) 2 Toxic synovitis 3% (47/1781) 3 Acute rheumatic fever 1% (9/1781) 4 Juvenille rheumatoid arthritis (JRA) 1% (9/1781) 5 Septic arthritis 95% (1690/1781) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ09.158) An 8-month old infant is brought by his parents to your office for fever and malaise. Your inspection of the patient is detailed in Image A. An oral temperature of greater than 38.5 has been found to be the best predictor of this child's condition. What is the second best predictor? QID: 2971 FIGURES: A Type & Select Correct Answer 1 Elevated neutrophil count 7% (181/2649) 2 Elevated ESR 13% (350/2649) 3 Elevated rheumatoid factor 1% (14/2649) 4 Elevated CRP 76% (2003/2649) 5 Presence of bacteria on CSF gram stain 3% (84/2649) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.180) A 3-year-old boy presents with his caregiver with concerns regarding a long-standing gait disturbance. The birth history is unknown except for a prolonged ICU stay for sepsis. A pelvic radiograph is shown in Figure A. What is the most likely cause for this child's limp? QID: 566 FIGURES: A Type & Select Correct Answer 1 Slipped capital femoral epiphysis 1% (32/3558) 2 Legg-Calve-Perthes disease 6% (230/3558) 3 Developmental dysplasia of the hip 6% (230/3558) 4 Residual effects of previous untreated septic hip arthritis 85% (3037/3558) 5 Acute femur fracture secondary to child abuse 0% (7/3558) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ08.68) A 6-week old boy refused to move his left hip. The patient was delivered by C-section 4 weeks premature, but otherwise is healthy. He has been afebrile. Examination reveals some mild, diffuse swelling about the left proximal thigh. Passive motion of the hip elicits discomfort. An AP pelvis radiograph is shown in Figure A. What is the most appropriate next step in management? QID: 454 FIGURES: A Type & Select Correct Answer 1 MRI 21% (317/1545) 2 CT scan 0% (7/1545) 3 Observation 5% (71/1545) 4 Aspiration 53% (822/1545) 5 Pavlik Harness 21% (319/1545) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ06.121) Which of the following Gram stain images most accurately represents the primary causative organism for pediatric osteomyelitis and septic arthritis? QID: 307 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 17% (353/2127) 2 Figure B 2% (41/2127) 3 Figure C 2% (48/2127) 4 Figure D 2% (47/2127) 5 Figure E 76% (1620/2127) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ04.159) In differentiating pediatric septic hip from transient synovitis, an elevated ESR (>40), history of fever, refusal to bear weight and what other finding has been identified as predictive of a septic hip? QID: 1264 Type & Select Correct Answer 1 Elevated absolute neutrophil count 3% (45/1559) 2 Serum white blood cell count > 12,000 cells/cubic millimeter 89% (1389/1559) 3 Positive blood cultures 5% (80/1559) 4 Pain with hip extension 1% (15/1559) 5 Symptoms greater than 3 days 1% (21/1559) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ04.242) A 10-month-old infant is brought to the emergency department for fevers, irritability, and avoidance of motion in the right leg. On physical exam, passive motion of the right hip elicits crying. An AP pelvis and an ultrasound of the right hip are shown in Figures A and B respectively. A hip aspiration yields 82,000 WBC with >80% PMNs. Which of the following is the strongest predictor of a poor prognosis? QID: 1347 FIGURES: A B Type & Select Correct Answer 1 CRP > 5mg/L 4% (39/1027) 2 Delay in treatment >4 days 92% (947/1027) 3 Age > 6 months 1% (8/1027) 4 Absence of associated osteomyelitis 0% (3/1027) 5 ESR > 40mm/hr 2% (22/1027) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic
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