Cultures of joint and synovial fluid may be needed.Īrthritis is a clinical diagnosis anti-nuclear antibody (ANA), rheumatoid factor and HLA-B27 are helpful in classification and treatment. If infection is suspected, urgent assessment in secondary care is required and FBC, ESR, CRP, blood and joint cultures will form part of the evaluation. Because of the serious nature of many of the underlying causes and the importance of early intervention, urgent referral for specialist assessment is often required.Systemic examination should include temperature and vital signs.Examine the corresponding knee, inguinal canal, abdomen and testes.A complete musculoskeletal examination to look for joint swelling should be done if there is a history of inflammatory symptoms.The lumbar spine, sacroiliac joint joint, knee and abdomen should also be examined.Most causes of hip pain are unilateral, allowing comparison to the unaffected side.Assess for predisposing factors such as excessive stiffness, joint laxity and/or increased or decreased muscle tone.Try to reproduce the patient's pain through gentle palpation and manipulation.Loss of hip abduction can be difficult to assess because children often tilt their pelvis to give a false impression of hip abduction.Restricted internal rotation is the most sensitive marker of hip pathology in children, followed by a lack of abduction.Total angle from full internal to full external rotation should equal 90°: Passive movements: rotation with hip and knee flexed to 90°.Active movements are typically as follows: hip flexion - most children can bring their knee to touch their chest 120-135°.The hip should be moved through active range of motion and then placed through full passive range of motion: Check range of active and passive movement, by comparison to the other side.Swelling of the hip is rarely visible, as the joint is so deep to the soft tissues.Inspect for swelling, redness, deformity, asymmetry, leg length discrepancy:.Careful examination of the hips is essential.Evaluation of gait and manoeuvres such as squatting, single leg hopping, and sit-ups may be helpful. Examine gait (limp, altered weight-bearing).Ask about previous treatments and response (including antibiotics, analgesics, anti-inflammatories, physiotherapy, steroid treatment).Ask about systemic symptoms (fever, irritability) inflammatory symptoms (morning stiffness) neurological symptoms (weakness, altered sensation) and the current level of function of the child.Ask about family history of hip problems.These might suggest developmental or degenerative conditions. Ask about developmental history, particularly noting late onset of walking, unusual gait or clumsiness in very young children.Establish whether there is any possibility of tick exposure.Any other underlying developmental conditions (eg, Down's syndrome). History should include previous injury (acute macrotrauma, repetitive microtrauma), surgery, neurological disorder, inflammatory joint disease or bleeding diathesis, as well as conditions associated with arthropathies, including psoriasis, acute uveitis and inflammatory bowel disease.Hip pathology often causes referred thigh or knee pain.Pain in the hip area may be referred from the knee joint or from structures in the inguinal canal, testis (including torsion) and lower abdomen, or from the lower back.Intra-articular hip pathology is usually localised to the groin. Pain in the hip area may originate from any part of the hip joint or from the femur.If pain is present it is important to determine the origin:.History should include pain characteristics (location, character, onset, duration, change with activity or rest, aggravating and alleviating factors, night pain), together with any mechanical symptoms (catching, clicking, snapping, worse during or after activity).
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