Irritating hip or rotting femur?

Radiograph of Septic HipA 3 year old boy presents to the Emergency Department with a limp. He has been reluctant to weight bear on his right leg during the day and has a temperature of 37.9°C. Hip examination is painful. What clinical or laboratory tests could help discriminate between septic arthritis and transient synovitis?

Of course, you could just ring up orthopaedics and ask them to take him to theatre and wash out the hip – but you may not win many friends that way. How do you decide there is enough ‘clinical suspicion’ to make the call?

Well, you’re fortunate to have a team of orthopaedic surgeon and paediatrician have answered this question for you. [EDIT – Jan 2009]

If you can’t wait for their answer, you might want to post your own here though … [EDIT – Jan 2009] Or now you can read their thoughts here

(Image from the files of the Royal College of Surgeons, Edinburgh)

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  • Do his inflammatory markers. If they are normal, then you can probably afford to wait a day to see what happens. If they are markedly abnormal, then you will have to go for washout. Somewhere in between is the diagnostic aspirate.

  • Bob Phillips

    Does a CRP of 13 count as abnormal? What about 10, or 18? Is it all just a matter of how brave I’m feeling?

  • faisal subhani

    Orthpods always ask for a inflamatory markers , then if they have time, they will see the patient.
    Rely on your hidtory and clinical judgement,hips are more irritbale then septic.

  • Bob Phillips

    So is there any room for evidence (of a more scientific nature) in this discussion, or should we just rely on he fact that Orthos always ask about the CRP as enough for us? And yes, irritable hips are the majority. Just like the majority of tired, slightly pale kids are viral. Does this mean that the septic (or leukaemic) child doesn’t matter somehow, or that it’s OK to miss/delay the diagnosis?