Chapter 2 Index

A. Evaluation by system:

1. General

2. HEENT

3. Cardiopulmonary

4. GI

5. GU

6. Orthopedics
--Common Orthopedic Findings
--Growing Pains - Commonly Asked Questions
--DDH: Developmental Dysplasia of the Hips

Hip Limp: Transient Synovitis vs. Legg Perthes Disease - How do we distinguish them?

Transient Synovitis:

Typical Presentation: 3 year old who had URI one week ago, gets up in AM unable to bear weight on his left leg.  On Physical Exam, hip rotation may be guarded or normal. The child seems well except for hesitation of gait.  If child walks, affected leg is externally rotated. This is the first limping episode for this child.

What is the differential diagnosis?

• Legg-Perthes s disease (see below)
• Septic joint: in this situation child is usually quite ill, has a high fever; often hip will be held in a flexed, abducted and laterally rotated position. Diagnosis is made by scan followed by aspiration of joint fluid. X-ray evaluation is less helpful.
• Osteomyelitis: same as septic joint in symptoms and workup
• Slipped epiphysis, trauma, osteoid osteoma, rheumatologic disease, tumor, leukemia

What should workup, treatment, and follow-up be if your diagnosis is toxic synovitis?

1. workup: you may choose to do none; if done, x-rays, CBC, ESR, joint aspiration are all normal. Ultrasound can show fluid in the hip joint.
2. treatment: anti-inflammatory agents (ibuprofen) x 3 days.  If no better, return. Long-term follow-up of patients with toxic synovitis: most have no recurrences, and no joint problems later.  A few progress on to Legg-Perthes disease. 

Should a more extensive workup be done if child returns at any time with a 2nd episode of limp?
Absolutely. A full workup including CBC, ESR, x-ray, ultrasound and possibly scan.

Legg-Perthes disease: avascular necrosis of the femoral head

Etiology: unknown, although trauma has been implicated. 

Incidence: 1:1000 to 1: 5000 in the general population but strong genetic influence. Males: females 5:1; bilateral in 20%. Onseet 2-12 years of age: mean 7 years old.

Symptoms: painless limp but may be antalgic; PE: muscle spasm with restriction of motion. Especially abduction and internal rotation; proximal thigh atrophy; short stature.

Key x-ray findings:

1. Plain x-rays: may show a wide articular cartilage space; subchondral fraction; resorption or fragmentation; then reossification and healing.
2. delayed bone age: this is almost always found and can be a prognostic indicator.  More delayed the better.
3. Bone scan: in early avascular stage shows decreased uptake; in later: increased uptake.
4. MRI can show necrosis

Treatment: recent evidence shows that braces may not be helpful, but that surgery is helpful

Prognosis: only fair.  Joint replacements, as adults are not uncommon in the children diagnosed with Legg-Perthes. Prognosis worse as age of diagnosis increases.

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Department of Pediatrics  |  Medical College of Georgia
Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004