Balmaseda, Paolo N, MD

Evans, Chelsea, DO

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health Network LVHN Scholarly Works Department of Family Medicine Vague Hip Pain in a 9-Year Old Soccer Player Paolo N. Balmaseda MD Chelsea Evans DO Follow this and additional works at: https://scholarlyworks.lvhn.org/family-medicine  Part of the Sports Medicine Commons This Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org. © 2019 Lehigh Valley Health NetworkCASE PRESENTATIONHISTORY 9-year-old male presented to a primary care sports physician office complaining of right hip pain with antalgic gait. Onset of the symptoms was 2 weeks after URI. He denies any specific inciting injury or trauma but said the day after soccer practice, he woke up with pain in right hip that radiated around the side of his hip. He described the pain as sharp with moderate severity. Pain was aggravated with running and standing. Patient tried NSAID with minimal relief. Parents gave him rest from sports for one week and restarted activity but he had severe pain in groin when walking. PHYSICAL EXAMINATION BP 90/60 | Ht 1.473 m (4’10”) | Wt 40.2 kg (88 lb 9.6 oz)  | Temp 98.6° General: awake, alert, and oriented. Uncomfortable Skin: no rashes, lesions, or lacerations Vascular: good popliteal pulses, skin warm and dry Neuro: no weakness in the L4-S1 nerve distribution Musculoskeletal: right hip exam Inspection: no observable abnormalities. Antalgic gait. Palpation: no tenderness to palpation ROM: hip flexion and extension was moderately limited with significant pain. Signification pain with internal rotation and with external rotation. Not able assess strength due to pain. Special tests: positive FADIR and positive FABER test TESTS AND RESULTS Initial Blood Tests: WBC 7.5, Plt 290. ESR 38. Lyme Ab negativeXR: AP/LAT of the right hip/pelvis resulted normalRepeat Blood Tests (1 week later): WBC 9.2, Plt 363. CRP 12.1 ESR 50. Blood culture negativeMRI: Bone marrow edema in the acetabulum suggests stress reaction versus infection. There is reactive edema in the adjacent obturator internus muscle. Prominent right hip joint effusionDIFFERENTIAL DIAGNOSIS1.  Transient Synovitis 2. Adductor Strain 3.  Legg-Calves  Perth-Disease 4. Septic Arthritis 5. MalignancyFINAL DIAGNOSISOsteomyelitis of right hip acetabulum Vague Hip Pain in a 9-Year Old Soccer PlayerPaolo N. Balmaseda, MD and Chelsea Evans, DOLehigh Valley Health Network, Allentown, PAOUTCOMEPatient was admitted to a children’s hospital with the diagnosis of osteomyelitis. He underwent emergent aspiration, irrigation and debridement surgery. He was started on IV Clindamycin and Linezolid. Cultures from the aspiration results were delayed due to lab errors. The final bacteria culture remained unknown. He was discharged  from the hospital with a PICC line to complete a total course of 7 weeks with IV Clindamycin and Linezolid. Antibiotic effectiveness was followed with serial CRP, which trended down to normal at the end of the antibiotic course.Return to Play: He was placed on limited weight bearing over the next 1–2 weeks. He was transitioned to full weight bearing as tolerated. Patient was referred to PT/OT. He was gradually advanced to return to play. He is now able to fully participate in sports after 12 weeks from initial visit.DISCUSSIONApproximately 1% of inpatient hospitalizations in children are from osteomyelitis. There are 3 categories of osteomyelitis:  1. Acute hematogenous osteomyelitis.  2. Non-hematogenous osteomyelitis.  3. Chronic osteomyelitis.  Acute hematogenous  osteomyelitis (AHO) is the most  common form of osteomyelitis in children, which is mostly likely this case. It results from  hematogenous deposition of bacteria within bone following symptomatic or asymptomatic bacteremia. Staphylococcus aureus, Streptococcus pneu-moniae and Haemophilus influenza type B are most common bacteria. In hematogenous osteomyelitis, 85% of cases are due to S aureus. Nonhematogenous osteomyelitis occurs with direct contamination of bone from trauma, surgery, or spread of infection from an adjacent soft tissue infection.  The earliest sign of osteomyelitis seen on x-ray is swelling of surrounding tissues follow by periosteal reaction however this is not often evident until 1–2 weeks after onset of infection. REFERENCESTetzlaff TR, et al. Oral antibiotic therapy for skeletal infections in children. II. Therapy of osteomyelitis and suppurative arthritis. J Pediatr. 1978;92:485–90.Gonzalez-Lopez JL, et al. Subacute osteomyelitis in children. J Pediatr Orthop. 2001;120:101–104.Rhodes J, et al. Orthopedics. In: Hay, Jr. WW, Levin MJ, Deterding RR, Abzug MJ. eds. Current Diagnosis & Treatment: Pediatrics, 24e New York, NY: McGraw-Hill; . http://accesspediatrics.mhmedical.com/content.aspx?bookid=2390&sectionid=189081789. 

Vague Hip Pain in a 9-Year Old Soccer Player

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=1707&context=family-medicine

Vague Hip Pain in a 9-Year Old Soccer Player

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