What is the initial management for hip bursitis in a child?

Initial Management of Hip Bursitis in Children

The initial management for hip bursitis in a child should focus on conservative measures including rest, ice application, activity modification, and nonsteroidal anti-inflammatory drugs (NSAIDs).

Diagnostic Considerations

Before initiating treatment, it's crucial to distinguish hip bursitis from more serious conditions:

1. Rule out septic arthritis/infection: This is an orthopedic emergency requiring prompt intervention

   • Evaluate for Kocher criteria: fever >101.3°F, ESR ≥40 mm/hr, WBC ≥12,000 cells/mm³, inability to bear weight 1
   • Elevated C-reactive protein >2.0 mg/dL is also an accurate predictor of septic arthritis 1

2. Imaging studies:

   • Ultrasound: Quick and accurate for detecting joint effusion and can guide aspiration if infection is suspected 1
   • Radiographs: Limited sensitivity for early diagnosis but helpful to rule out fractures or other bony abnormalities 1
   • MRI: Consider if symptoms persist despite treatment, as it has high sensitivity for detecting inflammatory changes and soft tissue pathology 1

Treatment Algorithm

First-line Management:

1. NSAIDs: Strongly recommended as initial treatment 1, 2

   • Appropriate dosing based on child's weight
   • Monitor for gastrointestinal side effects

2. Physical measures:

   • Rest: Limit activities that aggravate symptoms
   • Ice application: 15-20 minutes several times daily
   • Activity modification: Avoid repetitive hip movements that exacerbate pain

3. Physical therapy: Conditionally recommended for children with or at risk for functional limitations 1

   • Focus on stretching and strengthening exercises for hip abductors
   • Gait training if limping is present

Second-line Management (if no improvement after 2-4 weeks):

1. Consider corticosteroid injection:
   • Local injection may be beneficial for persistent symptoms 2, 3
   • Should be performed by experienced clinicians with appropriate anatomical guidance
   • Note: Use with caution in children and only when conservative measures have failed

Special Considerations

1. Differential diagnosis:

   • Developmental dysplasia of the hip (DDH): More common in infants but can present later 1, 4
   • Juvenile idiopathic arthritis: Consider if multiple joints involved or symptoms persist 1
   • Osteomyelitis: Consider if fever, elevated inflammatory markers present 1
   • Transient synovitis: Common cause of hip pain in children that typically resolves spontaneously

2. Red flags requiring urgent evaluation:

   • Fever
   • Inability to bear weight
   • Night pain
   • Systemic symptoms (weight loss, fatigue)
   • Persistent symptoms despite appropriate management

Follow-up Recommendations

1. Re-evaluate within 1-2 weeks if symptoms persist
2. Consider additional imaging if no improvement with conservative management
3. Refer to pediatric orthopedics if:
   • Symptoms persist beyond 4-6 weeks despite appropriate management
   • Significant functional limitations
   • Diagnostic uncertainty

Common Pitfalls to Avoid

1. Failing to rule out infection or other serious conditions before diagnosing bursitis
2. Prolonged NSAID use without appropriate monitoring
3. Premature return to aggravating activities
4. Overuse of corticosteroid injections in pediatric patients
5. Delayed referral for persistent symptoms

Hip bursitis in children typically responds well to conservative management, with most cases resolving within 4-6 weeks with appropriate treatment.