Hip pain is common in children and adolescents and has a broad range of causes, ranging from the benign to the potentially devastating. Transient synovitis, one of the most common causes of hip pain in children, must be differentiated from septic arthritis. Hip pain may be caused by conditions unique to the growing paediatric skeleton including Perthes, slipped capital femoral epiphysis and apophyseal avulsion fractures of the pelvis as well as growth related disorders.
Paediatric red flags
Children presenting with red flags, indicating the possibility of more serious underlying pathology, warrant urgent assessment, with some cases requiring referral directly to the Emergency Department or CAU.
- Unremitting pain
- Night pain (Pain that awakens the child from sleep)
- Systemic symptoms; fever, malaise, unexplained weight loss, sickness
- Changes in bladder and bowel habit
- Hot, swollen and inflamed joint(s)
- Early morning stiffness (may indicate JIA) with persistent swelling
- Painful guarded movement/ muscle spasm/ significant loss of range of motion, in absence of trauma
- Regression of development / loss or deterioration of function
- Antalgic gait / inability to weight bear / gait disturbance / lower limb asymmetry
- Sensation changes (pins and needles/ numbness), absent or exaggerated reflexes, unexplained muscle weakness
This list is not exhaustive nor a diagnostic tool, but areas to consider
Action: Key assessment points
- Assess gait and function
- Check posture, leg length, symmetry
- Check hip range of movement; hip rotation and abduction should be full and symmetrical if there is no pathology
- pGALS: Check spine
- Temperature/observations
Action: Initial GP management
Action: Refer to Paediatric Physiotherapy
- Tight/weak muscles/poor core stability/Persisting or chronic pain
- Reduced weight bearing or gait changes
- Lateral hip pain / ‘snapping hip’ syndrome
- Reduced function/activity levels due to pain, e.g. running, jumping, PE
- Rehab following a period of inactivity/post-surgery
Action: Refer to ED/Acute Paediatricians urgently via the Children’s Assessment Unit (CAU)
- Acute limp or obviously painful or restricted hip movements
- Unable to weight bear
- A fever and/or red flags suggesting serious pathology
- Severe pain, agitated, reduced peripheral pulses or muscle weakness which may indicate neurovascular compromise/ compartment syndrome
- Suspicion of accidental injury
Action: Refer for x-ray
- Urgent X-ray for a limping child, history of trauma or reduced hip ROM
- Routine x-ray for patients with mildly reduced hip range of motion, leg length difference or hip pain indicating pathology such as DDH
Action: Refer to Paediatric Orthopaedics
- A well child with a working diagnosis of transient synovitis but the symptoms fail to resolve within 1 week of onset or for follow-up
- A child presents with limp on multiple different occasions
- There is uncertainty about the diagnosis
- Diagnosis of Perthes/Avascular necrosis/DDH confirmed on x-ray
Action: Refer to Podiatry or Orthotics
- Flat feet/calcaneo-valgus foot posture is accentuating lower limb position, causing hip pain, rubbing or uneven shoe wear
