Pediatric Hip and Groin Kyle J. Cassas, MD Steadman Hawkins Clinic of the Carolinas
Educational Objectives Identify common causes of pediatric hip and groin pain/injury. Formulate differential diagnoses. Describe various prevention and treatment strategies. Employ return to sport recommendations. Disclosures: none
Sports and Recreational Activity 38 million children and adolescents 3.2 million ER visits –Children 5-14 Leading cause of ER visits (12-17)
High School Sports Injuries High School Participation ( ) –7.5 million HS –2 million injuries –500,000 visits –30,000 hospitalizations /1000 AEs /1000 AEs 3.6/1000 Comp 3.6/1000 Comp MMWR Sept 29, MMWR Sept 29,
“Kids are not Little Adults” Think Fracture/Physeal Injury –Sprain or contusion Overuse Injuries –½ all injuries (HS and middle school) “Adult” Injuries –ACL Tear –Little League Elbow/Shoulder –Stress Fractures Batson J ACSM Annual Meeting
Changing Landscape High Intensity Volume of Training Multiple Leagues “Year-Round” Early Specialization Parental Pressures
Risk Factors Intrinsic Intrinsic Insufficient Rest Fatigue and Stress Poor Training and Conditioning Nutrition and Hydration Extrinsic ExtrinsicEnvironmental Training Surface Training Load Lack of Protective Equipment
Who is Responsible for Prevention? CoachesParentsAthlete Health Care Providers Sports Societies and Organizations
Pediatric Limp
Common All ages –Septic arthritis –Osteomyelitis –Malignancies
Pediatric Limp Under 2 –Toddler’s fracture –DDH –CP Age 3-5 years –Transient Synovitis –Septic Hip –Leukemias
Transient Synovitis vs Septic Hip? Differentiating Between Septic Arthritis and Transient Synovitis of the Hip in Children: An Evidence-Based Clinical Prediction Algorithm. Kocher M. The Journal of Bone and Joint Surgery 81: (1999)
Septic Hip Kocher Criteria Non-WBFeverESR>40 WBC>12,000 mm3 4/4 = 99% 3/4 = 93% 2/4 = 40% 1/4 = 3%
Validation of a Clinical Prediction Rule for the Differentiation Between Septic Arthritis and Transient Synovitis of the Hip in Children Kocher M. et al. J Bone Joint Surg Am. 2004;86: Prospective Study: Septic Arthritis-51 Transient Synovitis-103 “CPR-Very Good Diagnostic Performance”
Factors Distinguishing Septic Arthritis from Transient Synovitis of the Hip in Children Caird MS. et al. J Bone Joint Surg Am. 2006;88: Prospective Study: 4 years ( ) 016.9% Oral Temp>38.5°C136% CRP>2mg/dl262% ESR>40mm/hr382% Refusal to WB493% WBC > 12,000/mm 3 597%C “Clinical Judgment” 12%-septic arthritis had 0/1
Pediatric Limp Age 5-9 years –Legg-Calve-Perthes Age –SCFE –JRA –Tarsal Coalition –Osteochondritis Dessicans
DeLee: DeLee and Drez's Orthopaedic Sports Medicine, 2nd ed
Legg-Calve-Perthes Disease Etiology? 4-10 y/o M:F 4:1 Caucasians Bilateral 20%
Legg-Calve-Perthes Disease PainLimp Limited ROM Thigh atrophy Flexion contracture
Treatment Rest Non-weight bearing Activity Restriction Abduction Bracing? Refer!
Prognostic Factors GoodPoor Age 8-9 Hip MotionMaintainedStiff Extent 50% X-rayNo subluxSublux
Slipped Capital Femoral Epiphysis Adolescent (pre-pubescent growth phase) 25-30% Bilateral OverweightAcuteChronic
Clinical Findings Insidious Painful limp “Ache” Easily misdiagnosed Loss of abduction/IR ER w/ hip flexion
Klein’s Line
Slip Severity
Complications AVNChondrolysis Varus Deformity Osteoarthritis Risk of contra-lateral slip
Surgery
Apophyseal Injury
Sudden, violent muscle contraction POP ROM Pain and swelling Weakness
Apophyseal Injury Relative Rest Activity Modification IceNSAID’sTherapy Surgery ?
Snapping Hip Syndrome External –ITB Internal –Iliopsoas Rehab
Checklist for Return to Sports SAFE to return with little risk for re-injury Sports specific tests or drills Pain free Educate and Counsel
Checklist for Return to Sports 10% Rule Equipment Training Programs Muscle Imbalance/Flexibility Early Detection
Summary Injuries Common Age based diagnosis Perthes and SCFE PreventionRTP
Resources National SAFE KIDS Campaign – National Youth Sports Safety Foundation – AOSSM Stop Youth Sports Injuries – USA Baseball:
THANKS FOR YOUR ATTENTION
Kyle J. Cassas MD: