1. Pediatric Hip and Groin Kyle J. Cassas, MD Steadman Hawkins Clinic of the Carolinas

2. Educational Objectives Identify common causes of pediatric hip and groin pain/injury. Formulate differential diagnoses. Describe various prevention and treatment strategies. Employ return to sport recommendations. Disclosures: none

3. Sports and Recreational Activity 38 million children and adolescents 3.2 million ER visits –Children 5-14 Leading cause of ER visits (12-17) www.cdc.gov

4. High School Sports Injuries High School Participation (2005-2006) –7.5 million HS –2 million injuries –500,000 visits –30,000 hospitalizations 2010-2011 1.7/1000 AEs 2010-2011 1.7/1000 AEs 3.6/1000 Comp 3.6/1000 Comp MMWR Sept 29, 2006 www.cdc.gov MMWR Sept 29, 2006 www.cdc.gov www.nfhs.org www.nfhs.org

5. “Kids are not Little Adults” Think Fracture/Physeal Injury –Sprain or contusion Overuse Injuries –½ all injuries (HS and middle school) “Adult” Injuries –ACL Tear –Little League Elbow/Shoulder –Stress Fractures Batson J. 2010 ACSM Annual Meeting

6. Changing Landscape High Intensity Volume of Training Multiple Leagues “Year-Round” Early Specialization Parental Pressures

7. Risk Factors Intrinsic Intrinsic Insufficient Rest Fatigue and Stress Poor Training and Conditioning Nutrition and Hydration Extrinsic ExtrinsicEnvironmental Training Surface Training Load Lack of Protective Equipment

8. Who is Responsible for Prevention? CoachesParentsAthlete Health Care Providers Sports Societies and Organizations

9. Pediatric Limp

10. Common All ages –Septic arthritis –Osteomyelitis –Malignancies

11. Pediatric Limp Under 2 –Toddler’s fracture –DDH –CP Age 3-5 years –Transient Synovitis –Septic Hip –Leukemias

12. Transient Synovitis vs Septic Hip? Differentiating Between Septic Arthritis and Transient Synovitis of the Hip in Children: An Evidence-Based Clinical Prediction Algorithm. Kocher M. The Journal of Bone and Joint Surgery 81:1662-70 (1999)

13. Septic Hip Kocher Criteria Non-WBFeverESR>40 WBC>12,000 mm3 4/4 = 99% 3/4 = 93% 2/4 = 40% 1/4 = 3%

14. Validation of a Clinical Prediction Rule for the Differentiation Between Septic Arthritis and Transient Synovitis of the Hip in Children Kocher M. et al. J Bone Joint Surg Am. 2004;86:1629-1635. Prospective Study: 1997-2002 Septic Arthritis-51 Transient Synovitis-103 “CPR-Very Good Diagnostic Performance”

15. Factors Distinguishing Septic Arthritis from Transient Synovitis of the Hip in Children Caird MS. et al. J Bone Joint Surg Am. 2006;88:1251-1257. Prospective Study: 4 years (2000-2004) 016.9% Oral Temp>38.5°C136% CRP>2mg/dl262% ESR>40mm/hr382% Refusal to WB493% WBC > 12,000/mm 3 597%C “Clinical Judgment” 12%-septic arthritis had 0/1

16. Pediatric Limp Age 5-9 years –Legg-Calve-Perthes Age 11-16 –SCFE –JRA –Tarsal Coalition –Osteochondritis Dessicans

19. DeLee: DeLee and Drez's Orthopaedic Sports Medicine, 2nd ed

20. Legg-Calve-Perthes Disease Etiology? 4-10 y/o M:F 4:1 Caucasians Bilateral 20%

21. Legg-Calve-Perthes Disease PainLimp Limited ROM Thigh atrophy Flexion contracture

23. Treatment Rest Non-weight bearing Activity Restriction Abduction Bracing? Refer!

24. Prognostic Factors GoodPoor Age 8-9 Hip MotionMaintainedStiff Extent 50% X-rayNo subluxSublux

25. Slipped Capital Femoral Epiphysis Adolescent 11-13 (pre-pubescent growth phase) 25-30% Bilateral OverweightAcuteChronic

26. Clinical Findings Insidious Painful limp “Ache” Easily misdiagnosed Loss of abduction/IR ER w/ hip flexion

27. Klein’s Line

28. Slip Severity

29. Complications AVNChondrolysis Varus Deformity Osteoarthritis Risk of contra-lateral slip

30. Surgery

31. Apophyseal Injury

32. Sudden, violent muscle contraction POP ROM Pain and swelling Weakness

33. Apophyseal Injury Relative Rest Activity Modification IceNSAID’sTherapy Surgery ?

34. Snapping Hip Syndrome External –ITB Internal –Iliopsoas Rehab

35. Checklist for Return to Sports SAFE to return with little risk for re-injury Sports specific tests or drills Pain free Educate and Counsel

36. Checklist for Return to Sports 10% Rule Equipment Training Programs Muscle Imbalance/Flexibility Early Detection

37. Summary Injuries Common Age based diagnosis Perthes and SCFE PreventionRTP

38. Resources National SAFE KIDS Campaign –www.safekids.org National Youth Sports Safety Foundation –www.nyssf.org AOSSM Stop Youth Sports Injuries –www.sportsmed.org/stop/ USA Baseball: www.asmi.org

39. THANKS FOR YOUR ATTENTION

40. Kyle J. Cassas MD: kcassas@ghs.org(864) 454-7422