Approach to Septic Hip in Infant
Diagnosis often clinical one
Usually between 2-3 years of age
Can spread from contiguous femoral metaphyseal osteomyelitis
Be suspicious in any child who comes in with a painful limp or who will not bear weight on that side
Do not depend on systemic signs – these may be variable. Often they are febrile, often they are sick, but don’t count on the presence of these – you’ll get burned!
Look for fever, warmth and swelling in surrounding soft tissues, and markedly restricted painful motion of hip
Get X-rays – look for soft tissue swelling, look for metaphyseal osteo, look for joint widening/subluxation
– usually NORMAL
Get bloodwork – CBC, ESR, CRP (most useful)
Then culture EVERYTHING – blood culture, urine, sputum if coughing – must try to make a bacteriologic Dx\
If rapid, you can try to get an ultrasound to document fluid within the hip – can try to aspirate the hip
Or do aspiration under fluoroscopy
But if you are suspicious enough that the results of aspiration or ultrasound will not change your management, the kid goes to the OR immediately for incision and drainage.
Pt is supine with bump under bum.
Vertical incision down from ASIS; can curve it up onto the crest slightly as well.
Watch for the lateral cutaneous femoral nerve
Find the deep fascia and identify the interval between tensor fascia lata laterally and sartorius medially. Incise the fascia and enter this plane bluntly.
Deep to this, you may encounter the ascending branch of the lateral femoral circumflex artery – should be ligated. It steers you in between gluteus medius laterally and rectus medially.
By developing this plane, you end up on the anterior capsule; may have to mobilize the reflected head of rectus just abit to get exposure.
Make a sharp capsulotomy – drain the pus: send for stat gram stain, C&S, fungus, AFB if not already asprirated
Begin antibiotics: empirically start on IV Ceftriaxone; can switch to 1st generation cephalosporin once organisms is identified to be gram positive.
Irrigate the joint with 6 L saline, install penrose drain, close.
Plan to keep on Abx IV until responds. May begin moving joint immediately.