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 Table of Contents  
CASE SERIES
Year : 2018  |  Volume : 4  |  Issue : 2  |  Page : 38-40

Chronic Knee Pain in Children, Must Exclude Hip Pathology


1 Senior Resident, Department of Orthopaedics, IGIMS, Patna, India
2 Associate Professor, Department of Orthopaedics, IGIMS, Patna, India
3 Professor, Department of Orthopaedics, IGIMS, Patna, India

Date of Web Publication10-Dec-2020

Correspondence Address:
Ritesh Runu
Associate Professor, Dept. of Orthopaedics, IGIMS, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Knee pain is one of the commonest orthopaedic complain in paediatric age group. Itis mainly due to hyper mobility and growing pains. It may be due to hip pathology which presents with knee pain. Here we present a case series of children who presented with referred knee pain due to hip pathology.

Keywords: Children, hip pain, knee pain, referred pain


How to cite this article:
Kumar A, Runu R, Sagar V, Kumar D, khemka G, Kumar S. Chronic Knee Pain in Children, Must Exclude Hip Pathology. J Indira Gandhi Inst Med Sci 2018;4:38-40

How to cite this URL:
Kumar A, Runu R, Sagar V, Kumar D, khemka G, Kumar S. Chronic Knee Pain in Children, Must Exclude Hip Pathology. J Indira Gandhi Inst Med Sci [serial online] 2018 [cited 2021 Dec 4];4:38-40. Available from: http://www.jigims.co.in/text.asp?2018/4/2/38/302952




  Introduction: Top


Complaints related to the musculoskeletal system is approx 6.1% in paediatric age group of which 33% is related to knee pathology.[1] In paediatric age the most common cause of knee pain is hyper mobility like playing activity.[2]

Knee pain may have several orthopaedic causes like Sinding-Larsen-Johansson syndrome (SLJ), patellar tendinitis, Osgood-Schlatter syndrome (OSS), patellofemoral syndrome, fat pad syndrome (FPS), plica syndrome, lateral retinacular pain (LRP), iliotibial band syndrome (ITBS), joint mouse, osteochondritis dissecans, meniscus tear, ligament tear, and chondral injuries. Other causes of knee pain may be inflammation such as juvenile rheumatoid arthritis, infectionand neoplasm.

Apart from knee pathology, hip pathology may present with knee joint like Perthes' disease, transient synovitis and slipped capital femoral epiphysis. Here we present a case series of childrenwho presented with referred knee pain due to hip pathology.


  Case Reports: Top


Case 1: A 12 years male child presented with complain of the pain in the left knee for 18 months. It was gradual onset pain localized to proximal part of ipsilateral popliteal fossa and medial aspect of groin. It used to aggravate during daytime and night without any relation to activity or rest. It was relieved with analgesics for few hours. It was not associated with fever, loss of appetite, loss of weight. He was treated with antibiotics, analgesics and neurotropic drugs at several centres without relief. The previous medical history, family historywas unremarkable.

O/E- Patient was conscious, oriented, stable and afebrile. Left lower limb examination was unremarkable except there was significant left thigh wasting of 3cm and left calf wasting of 1cm [Figure 1].
Figure 1: Left thigh wasting of 3cm & left calf wasting of 1cm

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Haemogram showed Hb 11.7gm % , ESR and CRP were within normal limit. X-ray left hip, thigh and knee was normal. [Figure 2].USG of left hip and knee joints. Since all reports were normal hence bone scan was advised to rule out bony pathology. It showed increased uptake of isotope in the subtrochanteric zone and medial aspect of left femoral neck. [Figure 3].
Figure 2: x-ray left hip, thigh & knee

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Figure 3: Bone scan

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Based on bone scan report MRI left hip was advised which showed hypointenselesion on T2/STIR images with adjacent marrow edema at medial aspect of left femoral neck [Figure 4].
Figure 4: MRI

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Previous X-rayswere reviewed and increased sclerosis on the medial aspect of left femoral neck was seen.

On the basis of MRI report and retrospective clinico radiological report we planned to decompress the sclerotic area. [Figure 5]
Figure 5: Under c arm guidance open biopsy & curettage done

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The left proximal femoral lesion was localized under C-arm guidance. Through antero-lateral bony window localized part was drilled and curetted. [Figure 5]



Post operatively pain reduced and analgesics use also reduced. The culture was negative. Histopathological report showed inflammatory cells infiltrate. The patient was put on skin traction for 6 weeks. At 6 weeks post op his ESR and CRP was normal but he complained of low intensity pain for which Tab. Linezolid (300mg) prescribed for 3 weeks. After 3 weeks his pain reduced and analgesic requirement was nil. At 6 months post op the patient was asymptomatic. His final ESR and CRP was also normal. And physically the patient condition improved.

Case 2: 12 year female child presented with left knee pain for 6 months. Her previous knee radiographs were normal. On examination, she had a limping gait, shortening and reduced range of motion of left hip. Hemogram was normal and x ray hip showed changes consistent with Perthes' disease right hip [Figure 6]. After consent and PAC she was operated and valgus osteotomy was done. Her limb length was restored and ROM improved.
Figure 6: Pre -op x-ray (Perthes' disease)

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Case 3. Male 12 years presented with unresolving right knee pain for one year. He had history of fever and pain in right knee on and off. He took multiple consultations without relief. On clinical examination, right thigh 2cm wasting was noted. Right hip and knee range of motion was full and neurovascular status was normal. His hemogram showed elevated ESR and CRP titre. Rest all the reports were normal. X-ray of right knee was normal. X-ray right hip showed lytic area surrounded by sclerotic area in the neck of right femur [Figure 7]. The finding was not prominent hence MRI of right hip done which showed hyper intense lesion in the right femoral neck [Figure 8].
Figure 7: X-ray right hip showing lytic area surrounded by sclerotic area in the neck of right femur.

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Figure 8: MRI of right hip showed hyper intense lesion in the right femoral neck.

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After informed consent, the lesion was decompressed through anterior window and thorough curettage was done. Sample was sent for culture and sensitivity. Report was unremarkable. But the patient was symptomfree after the decompression. He was kept on IV antibiotics for two weeks and then oral antibiotics for four weeks. Now at one year follow up the patient is asymptomatic.


  Discussion: Top


Knee pain in children is common entity. The pain due to hip pathology is not uncommon but it presents as diagnostic dillemma. In our case series, there was no predilection of age and sex. Both male and female child presented with this condition.

Yilmaz et al. concluded that thorough examination should be done to rule out hip pathology in knee pain. Focal cortical defect is one of the reason of knee pain and hip pain.[1] Most of the case reports are related to slipped capital femoral epiphysis. Matava et al. highlighted that 15% of slipped capital femoral epiphysis presents with knee pain and causes delayed diagnosis.[2],[3] Brodies abscess in femoral neck also presents with knee pain.[4],[5]

In a clinical settng when a child presents with chronic knee pain the first investigation is directed to the knee joint. This situation becomes more difficult for the clinician when knee joint has no localising signs and associated hemogram is normal. As we had in our first case. Once the investigation of knee joint is clear then hip joint is investigated. This leads to missed diagnosis and delay in diagnosis. Ledwith reported 29% missed diagnosis in cases of slipped capital femoral epiphysis.[3]

As an initial investigation x ray of hip and knee both should be done as the chances of delay in diagnosis is high with one x ray.[6],[7] As we saw in our case no 2. The patient presented with knee pain. Simultaneous hip and knee x ray was done. Hip x ray showed Perthes' disease and was treated accordingly.

Hemogram as initial investigation is very essential for diagnosis. Raised ESR and CRP titre are indicator of inflammatory and infective process.[8],[9] As we had in case no 3. Suspicion of infection lead to further investigation with bone scan.

Bone scan is very informative tool for localisation of lesion in bone and leads to further management.[10] Case no 1 the bone scan showed incresed uptake in proximal femur and subsequent MRI showed the sclerotic lesion like brodies abscess


  Conclusion: Top


  • In case of isolated knee pain, hip must be examine. As referred pain of knee due to proximal femur.
  • Thigh Muscle wasting is significant finding of hip and knee pathology.
  • Through investigation like X-ray, MRI, Bone Scan along with blood test should be done in such undiagnosed cases.




 
  References Top

1.
Ayse Esra Yilmaz,Hakan Atalar,Tugba Tag,Meki Bilici, Semra Kara. Knee Joint Pain May Be an Indicator for a Hip Joint Problem in Children: A Case Report. Malays J Med Sci. 2011 Jan-Mar; 18(1): 79-82.  Back to cited text no. 1
    
2.
Matava MJ, Patton CM, Luhmann S, Gordon JE, Schoenecker PL. Knee pain as the initial symptom of slipped capital femoral epiphysis: an analysis of initial presentation and treatment. J Pediatr Orthop.1999 Jul-Aug;19(4):455-60.  Back to cited text no. 2
    
3.
Ledwith CA, Fleisher GR. Slipped capital femoral epiphysis without hip pain leads to missed diagnosis. Paediatrics 1992 Apr;89:660-2.  Back to cited text no. 3
    
4.
Yash GULATI, Aditya V. MAHESHWARI. Brodie's abscess of the femoral neck simulating osteoid osteoma. Acta Orthop. Belg., 2007, 73, 648-652.  Back to cited text no. 4
    
5.
Pranshu Agrawal and Anshul Sobti. A Brodie's Abscess of Femoral Neck Mimicking Osteoid Osteoma: Diagnostic Approach and Management Strategy. Ethiop J Health Sci. 2016 Jan; 26(1): 81-84.  Back to cited text no. 5
    
6.
Coffey D, Hudson-Phillips SP, Radha SS, Ball S. Leg length discrepancy: the importance of a complete history and examination. BMJ Case Rep. 2017 Dec 2;2017.  Back to cited text no. 6
    
7.
Seo SG, Sung KH, Chung CY, Lee KM, Lee SY, Choi Yet al. Incidental findings on knee radiographs in children and adolescents. Clin Orthop Surg. 2014 Sep;6(3):305-11.  Back to cited text no. 7
    
8.
Stephens MM, MacAuley P. Brodie's abscess. A long-term review. Clin Orthop Relat Res. 1988 Sep;(234):211-6.  Back to cited text no. 8
    
9.
Julie Desimpel, Magdalena Posadzy, FilipVanhoenacker. The Many Faces of Osteomyelitis: A Pictorial Review. Journal of the Belgian Society of Radiology,2017; 101(1): 24.  Back to cited text no. 9
    
10.
Seung Hyeon Shin,Seong Jang Kim. Bone scintigraphy in patients with pain. Korean J Pain. 2017 Jul; 30(3): 165-175.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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