Reid Phillips – Thomas Jefferson Univ

HPI: Mom noticed limp 2 days ago. Boy indicated groin pain at that time. Boy is 14 days s/p admission for asthma exacerbation secondary to URI. Mom is primary caretaker, denies trauma. PMH: asthma with prior intubation Meds: albuterol and corticosteroid inhalers FH: hemophilia A, RA PE: T P 100 BP 100/60 RR 18 No pelvic assymmetry. No skin findings. Right leg is flexed and externally rotated while patient is supine. Right hip with markedly reduced ROM due to pain. Left hip normal ROM. Right hip nontender to palpation. Normal strength and sensation distally. Patient refuses to walk.

Vascular Avascular Necrosis Infectious Septic Arthritis Lyme Arthritis Transient Synovitis Osteomyelitis Inflammatory Reactive Arthritis Juvenile Rheumatic Disease Neoplastic Bone tumor Leukemia Deficiency Vitamin D Collagen Iatrogenic Steroids Intoxication Heavy Metals Congenital/Developmental Legg-Calve-Perthes Developmental Dysplasia Slipped Capital Femoral Epiphysis Sickle Cell Disease Hemophilia Automimmune/Allergic Psoriasis Trauma Fracture Soft Tissue Injury Hemearthrosis

Labs CBC ESR/CRP Blood Culture Coags Radiographs AP Frog leg Negative or +Effusion (20% sensitive for effusion) Fracture Avascular Necrosis SCFE LCPD Other Ultrasound Effusion Transient Synovitis Septic Arthritis Osteomyelitis H + P

Relative to radiology 85% sensitive 93% Specific 92% PPV 88% NPV Cannot differentiate between causes of effusion Vieira RL, Levy JA. Bedside ultrasonography to identify hip effusions in pediatric patients. Ann Emerg Med. 2010;55:284–289.

Patient supine, legs extended, Hip in question externally rotated Linear transducer 5-10MHz Transducer long axis aligned parallel to femoral neck

Capsular-Synovial Thickness measured from the concave aspect of femoral neck to the posterior iliopsoas Measure both hips Effusion = Capsular-Synovial Thickness > 5 mm or > 2mm larger than asymptomatic hip

Transient Synovitis Ages :1 male Recent viral syndrome Lack of fever Can be polyarticular Full ROM Can last 2 weeks No serious LT sequlae Infectious Arthritis 50% <2 years old Fever 90% monoarticular Joint tender Erythema and swelling ROM severely limited Serious LT sequelae (sepsis, arthritis, growth disturbance, synovitis, joint stiffness) VS

Risk of Septic Arthritis (Kocher 1999, 2004) 0 criteria 0.2% 1 criteria 3% 2 criteria 40% 3 criteria 93% 4 criteria 99.6% Luhmann criteria 59% Kocher criteria 1. failure to bear weight 2. fever 3. ESR > WBC > 12,000

Contraindications Overlying skin infection Coagulation disorder Technique Consider procedural anesthesia, restraints Clean locally for sterility In-plane technique 22-gauge needle is inserted from distal to joint Target junction of the femoral head and neck Identify and avoid the circumflex femoral vessels using color Doppler Risks Infection, bleeding, local damage, pain

“As in adult patients, emergencyultrasound in children can be lifesaving, timesaving, increase procedural efficiency and maximize patient safety.” (American College of Emergency Physicians) ED physician US has NPV of 88% for hip effusion but should probably not be relied upon to rule out effusion given risks associated with missing the diagnosis of septic joint. Order confirmatory study. High percentages of children with transient synovitis have joint effusions (86% in one study). Effusion does not indicate septic joint and depending on clinical suspicion does not demand arthrocentesis.

1.Martin J et al (2014). Focus On: Pediatric Hip Ultrasound. ACME Online CME. Accessed January 14, 2016 at Medical-Education-(CME)/Focus-On/Focus-On--Pediatric-Hip-Ultrasound/ 2.Plumb J et al (2015). The role of ultrasound in the emergency department evaluation of the acutely painful pediatric hip. Pediatric Emergency Care CME Review Article, 31: Tsung JW et al (2008). Emergency department diagnosis of pediatric hip effusion and guided arthrocentesis using point-of-care ultrasound. Clinical Communications: Pediatrics 35, 4: Minardi JJ et al (2012). Septic hip arthritis: Diagnosis and arthrocentesis using bedside ultrasound. Ultrasound in Emergency Medicine 43, 2: Itai S et al (2006). Sonography of the hip joint by the emergency physician It’s role in the evaluation of children presenting with acute limp. Pediatric Emergency Care 22, 8: Freeman K et al (2007). Ultrasound-guided hip arthrocentesis in the ED. American Journal of Emergency Medicine 25, Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am. 1999;81:1662–1670.

8. Kocher MS, Mandiga R, Zurakowski D, et al. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am. 2004;86-A: 1629– Luhmann SJ, Jones A, Schootman M, et al. Differentiation between septic arthritis and transient synovitis of the hip in children with clinical prediction algorithms. J Bone Joint Surg Am. 2004;86-A:956– Goldberg DL et al (2015). Septic arthritis in adults. Up To Date. Accessed January 17, 2016 at adults?source=machineLearning&search=septic+joint+arthrocentesis& selectedTitle=8~150&sectionRank=3&anchor=H10#H10