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Updated: Dec 22 2021


Images hip.jpg
  • Snapshot
    • A 9-year-old boy presents to his pediatrician with a limp and hip pain. He denies any inciting trauma or event. On exam, he is noted to have atrophy in his upper thigh, asymmetry in leg lengths, and decreased range of motion in his left hip. Radiograph shows sclerosis in the femoral head. His physician recommends conservative management.
  • Introduction
    • Clinical definition
      • an idiopathic hip disorder characterized by avascular necrosis of the femoral head
  • Epidemiology
    • Demographics
      • male > female
      • affects children ages 3-12 but most commonly between ages 4-8
      • most commonly unilateral
    • Risk factors
      • obesity
      • thrombophilia
        • factor V Leiden mutation
      • South Asian heritage
  • Etiology
    • Unknown but thought to be related to factors that can disrupt bone formation or blood supply to the femoral head, including coagulation abnormalities or trauma
    • Pathogenesis
      • blood flow to the femoral head is disrupted causing ischemic necrosis
      • femoral head begins healing after ~1 year and new subchondral bone develops
      • new bone replaces the old bone in 2-3 years
    • Associated conditions
      • acetabular retroversion
      • inguinal hernia
      • Down syndrome
      • cryptorchidism
  • Presentation
    • Symptoms
      • limping
      • pain in the hip that is worse with activity
      • referred knee pain
    • Physical exam
      • small for age
      • thigh and calf muscle atrophy
      • shortening of the leg (asymmetry)
      • hip stiffness and limited range of motion
        • reduced abduction and internal rotation
      • gait disturbance
        • may have Trendelenburg sign
      • no erythema or swelling
  • Imaging
    • Radiography
      • indication
        • for evaluation of femoral head involvement
      • findings
        • femoral head sclerosis
        • collapse of lateral pillar of femoral head
        • increased width of the femoral neck
    • Magnetic resonance imaging
      • indications
        • for evaluation during early stages of the disease when radiography is unrevealing
        • if the diagnosis is uncertain after radiography
      • findings
        • decreased signal intensity in the femoral head due to sclerosis
    • Technetium bone scan
      • decreased uptake at the epiphysis
  • Studies
    • Labs
      • typically normal erythrocyte sedimentation rate and C-reactive protein
    • Making the diagnosis
      • based on clinical presentation and imaging studies
  • Differential
    • Sickle cell disease
      • distinguishing factors
        • anemia
        • sickle cells on peripheral blood smear
    • Slipped capital femoral epiphysis
      • distinguishing factors
        • in obese adolescents
        • displacement of femoral head relative to the femoral neck on radiography
  • Treatment
    • Management approach
      • treatment is usually conservative but may be treated with surgery
    • Conservative
      • observation and bed rest
        • indication
          • children who were less than 6 years of age at disease onset
      • physical therapy or brace/cast
        • indication
          • for all patients
    • Medical
      • nonsteroidal anti-inflammatory drugs
        • indication
          • pain management
    • Operative
      • surgical treatment
        • indication
          • older children (6 years of age or older) or with more advanced disease
        • surgeries
          • pelvic osteotomy (Salter osteotomy)
          • trochanteric advancement surgery
  • Complications
    • Permanent femoral head deformity and limp
    • Osteoarthritis
      • due to deformity of the femoral head
  • Prognosis
    • Over half heal without surgical intervention
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