Hip pain in childhood

Ribeiro, Sariane Coelho; Barreto, Kaline Silva Santos; Alves, Catarina Borges Santana; Almendra Neto, Oswaldo Lima; Nóbrega, Marcel Vieira da; Braga, Leonardo Robert de Carvalho

doi:10.1590/0100-3984.2018.0042

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Pictorial Essay • Radiol Bras 53 (1) • Jan-Feb 2020 • https://doi.org/10.1590/0100-3984.2018.0042 linkcopy

Hip pain in childhood

Authorship SCIMAGO INSTITUTIONS RANKINGS

Hip pain in a child can have infectious, inflammatory, traumatic, neoplastic, or developmental causes, which can make the diagnosis challenging. Meticulous history taking and a detailed clinical examination guide the radiological investigation. In this article, we address some of the main causes of hip pain in childhood and their findings on diagnostic imaging.

Keywords:
Hip joint; Pain/etiology; Arthritis, juvenile; Hip dislocation, congenital; Child, preschool; Child; Adolescent

Authorship

person Sariane Coelho Ribeiro

schoolUDI 24 horas, Teresina, PI, Brazil.UDI 24 horasBrazilTeresina, PI, BrazilUDI 24 horas, Teresina, PI, Brazil. a https://orcid.org/0000-0001-8497-1186;

0000-0001-8497-1186

person Kaline Silva Santos Barreto

schoolUDI 24 horas, Teresina, PI, Brazil.UDI 24 horasBrazilTeresina, PI, BrazilUDI 24 horas, Teresina, PI, Brazil. b https://orcid.org/0000-0003-3818-6106;

0000-0003-3818-6106

person Catarina Borges Santana Alves

schoolUniversidade Ceuma, São Luís, MA, Brazil.Universidade CeumaBrazilSão Luís, MA, BrazilUniversidade Ceuma, São Luís, MA, Brazil. c https://orcid.org/0000-0001-5708-9219;

0000-0001-5708-9219

person Oswaldo Lima Almendra Neto

schoolUDI 24 horas, Teresina, PI, Brazil.UDI 24 horasBrazilTeresina, PI, BrazilUDI 24 horas, Teresina, PI, Brazil. d https://orcid.org/0000-0001-9414-2816;

0000-0001-9414-2816

person Marcel Vieira da Nóbrega

schoolHospital São Carlos, Fortaleza, CE, Brazil.Hospital São CarlosBrazilFortaleza, CE, BrazilHospital São Carlos, Fortaleza, CE, Brazil. e https://orcid.org/0000-0002-6132-1727;

0000-0002-6132-1727

person Leonardo Robert de Carvalho Braga

schoolUDI 24 horas, Teresina, PI, Brazil.UDI 24 horasBrazilTeresina, PI, BrazilUDI 24 horas, Teresina, PI, Brazil. f https://orcid.org/0000-0002-4222-9247.

0000-0002-4222-9247

Correspondence: Dra. Catarina Borges Santana Alves. Universidade Ceuma. Rua Josué Montello, 1, Renascença II. São Luís, MA, Brazil, 65075-120. Email:
medcatarinaborges@gmail.com.

https://orcid.org/0000-0001-8497-1186;

https://orcid.org/0000-0003-3818-6106;

https://orcid.org/0000-0001-5708-9219;

https://orcid.org/0000-0001-9414-2816;

https://orcid.org/0000-0002-6132-1727;

https://orcid.org/0000-0002-4222-9247.

SCIMAGO INSTITUTIONS RANKINGS

UDI 24 horas, Teresina, PI, Brazil.UDI 24 horasBrazilTeresina, PI, BrazilUDI 24 horas, Teresina, PI, Brazil.

Universidade Ceuma, São Luís, MA, Brazil.Universidade CeumaBrazilSão Luís, MA, BrazilUniversidade Ceuma, São Luís, MA, Brazil.

Hospital São Carlos, Fortaleza, CE, Brazil.Hospital São CarlosBrazilFortaleza, CE, BrazilHospital São Carlos, Fortaleza, CE, Brazil.

Figures | Tables

Figures (10)
Tables (2)

Thumbnail

Figure 1 Dysplasia of the right hip in a 4 year-old male. Anteroposterior and frog-leg view X-rays (A and B, respectively), showing asymmetry of the hip joints, with right hip dysplasia. MRI of the right hip. Gadolinium-enhanced coronal, fat-suppressed T1-weighted sequence (C) and STIR sequence (D) showing a loss of sphericity, flattening, and superolateral subluxation of the right femoral head, with enlargement of the femoral neck and acetabular cavity, as well as joint effusion with signs of reactive synovitis.

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Figure 2 A 40-day-old child presenting left hip dysplasia, characterized by a alpha angle < 60º.

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Figure 3 Osteomyelitis in a 9-year-old female. MRI of the right thigh. Coronal fat-suppressed T2-weighted sequence (A) and axial T1-weighted sequence (B) identifying an area in the marrow of the right femoral neck and extending to adjacent muscle planes, with a hypointense signal on the T1-weighted sequence, a hyperintense signal on the T2-weighted sequence, a mild periosteal reaction, and no erosion of cortical bone.

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Figure 4 Pyomyositis in a 12-year-old male patient. Coronal fat-saturated T2-weighted MRI sequence showing joint effusion, osteitis, and edema involving the muscle-adipose planes of the gluteal region and root of the right thigh (A), featuring a voluminous, heterogeneous liquid collection, containing small foci of low signal intensity, likely of an infectious/inflammatory nature, located between the ventral portion of the gluteus medius muscle and that of the gluteus maximus muscle (B).

Thumbnail

Figure 5 MRI of the hip. STIR coronal sequence showing mild effusion in the right hip joint, with synovial thickening and hyperintense signal/edema in the adjacent planes of the capsule of the muscle. Note the irregular lesion, with a hyperintense signal in a T2-weighted sequence, in the right femoral head and neck, which is suggestive of a focus of osteomyelitis/intraosseous abscess.

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Figure 6 Ultrasound of the hip identifying joint effusion.

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Figure 7 A 12-year-old male patient. Sagittal fat-saturated T2-weighted MRI sequence showing moderate intra-articular effusion in the right hip joint.

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Figure 8 MRI of the hip. STIR coronal sequence showing signs of pronounced epiphysiolysis. Note the moderate joint effusion.

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Figure 9 MRI of the hip. Contrast-enhanced, coronal, fat-saturated T1-weighted sequence showing complete destruction/resorption of the femoral head, accompanied by severe deformity of the femoral neck and acetabulum.

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Figure 10 A 14-year-old male. Axial proton density-weighted fat-saturated MRI showing bone edema in the right anteroinferior iliac spine.

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Table 1 Causes of isolated hip pain in children.

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Table 2 Imaging methods for the diagnosis of hip pain in children.

imageFigure 1 Dysplasia of the right hip in a 4 year-old male. Anteroposterior and frog-leg view X-rays (A and B, respectively), showing asymmetry of the hip joints, with right hip dysplasia. MRI of the right hip. Gadolinium-enhanced coronal, fat-suppressed T1-weighted sequence (C) and STIR sequence (D) showing a loss of sphericity, flattening, and superolateral subluxation of the right femoral head, with enlargement of the femoral neck and acetabular cavity, as well as joint effusion with signs of reactive synovitis. open_in_new

imageFigure 2 A 40-day-old child presenting left hip dysplasia, characterized by a alpha angle < 60º. open_in_new

imageFigure 3 Osteomyelitis in a 9-year-old female. MRI of the right thigh. Coronal fat-suppressed T2-weighted sequence (A) and axial T1-weighted sequence (B) identifying an area in the marrow of the right femoral neck and extending to adjacent muscle planes, with a hypointense signal on the T1-weighted sequence, a hyperintense signal on the T2-weighted sequence, a mild periosteal reaction, and no erosion of cortical bone. open_in_new

imageFigure 4 Pyomyositis in a 12-year-old male patient. Coronal fat-saturated T2-weighted MRI sequence showing joint effusion, osteitis, and edema involving the muscle-adipose planes of the gluteal region and root of the right thigh (A), featuring a voluminous, heterogeneous liquid collection, containing small foci of low signal intensity, likely of an infectious/inflammatory nature, located between the ventral portion of the gluteus medius muscle and that of the gluteus maximus muscle (B). open_in_new

imageFigure 5 MRI of the hip. STIR coronal sequence showing mild effusion in the right hip joint, with synovial thickening and hyperintense signal/edema in the adjacent planes of the capsule of the muscle. Note the irregular lesion, with a hyperintense signal in a T2-weighted sequence, in the right femoral head and neck, which is suggestive of a focus of osteomyelitis/intraosseous abscess. open_in_new

imageFigure 6 Ultrasound of the hip identifying joint effusion. open_in_new

imageFigure 7 A 12-year-old male patient. Sagittal fat-saturated T2-weighted MRI sequence showing moderate intra-articular effusion in the right hip joint. open_in_new

imageFigure 8 MRI of the hip. STIR coronal sequence showing signs of pronounced epiphysiolysis. Note the moderate joint effusion. open_in_new

imageFigure 9 MRI of the hip. Contrast-enhanced, coronal, fat-saturated T1-weighted sequence showing complete destruction/resorption of the femoral head, accompanied by severe deformity of the femoral neck and acetabulum. open_in_new

imageFigure 10 A 14-year-old male. Axial proton density-weighted fat-saturated MRI showing bone edema in the right anteroinferior iliac spine. open_in_new

table_chartTable 1 Causes of isolated hip pain in children.

Type		Disorder
Congenital*		Hip dysplasia
Infectious		Osteomyelitis‡
		Pyomyositis
		Septic arthritis*
Inflammatory		Transient synovitis of the hip*
		'Juvenile inflammatory arthritis
Traumatic/mechanical†		Epiphysiolysis
		Apophysitis
		Stress fracture
Neoplastic	Benign†	Osteoid osteoma
		Osteochondroma
		Eosinophilic granuloma
		Unicameral bone cyst
		Aneurysmal bone cyst
	Malignant	Metastases‡
		Ewing sarcoma†
		Leukemia, lymphoma†

^*
Typically present in children under 10 years of age.
^†
Typically present in older children or adolescents (≥ 10 years of age).
^‡
Present in children of any age.

table_chartTable 2 Imaging methods for the diagnosis of hip pain in children.

X-ray	Initial method for evaluation of bone diseases
Ultrasound	Complementary to X-ray for better assessment of soft tissues and detection of joint effusion; useful for guiding punctures
Magnetic resonance imaging (MRI)	Evaluation of complications, prolonged complaints, and extent of disease; better joint detailing; and evaluation of the physeal cartilage, subchondral bone, periosteum, synovia, and bone marrow
Computed tomography (CT)	When there is suspicion of osteoid osteoma and for evaluation of the bone contours
Bone scintigraphy	When there is suspicion of osteomyelitis and the primary site is unknown; for the assessment of multifocal disease; and for detection of osseous lesions caused by stress/failure

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[TFN1] ^*
Typically present in children under 10 years of age.

[TFN2] ^†
Typically present in older children or adolescents (≥ 10 years of age).

[TFN3] ^‡
Present in children of any age.