What is the best course of treatment for a 16-year-old patient with right hip pain after a high altitude hike, given a history of similar episodes with dehydration or illness and negative hip x-rays?

Acute Management of Suspected Sickle Cell Vaso-Occlusive Crisis

This 16-year-old with recurrent joint pain triggered by dehydration or illness, now presenting with acute hip pain after high-altitude exposure, most likely has sickle cell disease with an acute vaso-occlusive crisis and requires immediate aggressive hydration, pain management, and urgent laboratory evaluation to confirm the diagnosis and prevent complications.

Immediate Clinical Actions

Hydration Protocol

• Initiate aggressive intravenous fluid resuscitation immediately with normal saline or lactated Ringer's solution at 1.5 times maintenance rate 1, 2, 3
• Dehydration at high altitude combined with hypoxia creates the perfect conditions for sickling and vaso-occlusive crisis 1, 4
• Hypohydration significantly increases pain sensitivity and can exacerbate musculoskeletal pain perception 2
• Rehydration therapy alone resolves symptoms in dehydration-related pain syndromes, but in suspected sickle cell crisis, it must be combined with other interventions 3

Pain Management

• Provide multimodal analgesia immediately, starting with NSAIDs (ibuprofen or ketorolac) if not contraindicated 5
• Add opioid analgesia (morphine or hydromorphone) for moderate to severe pain, as vaso-occlusive crises typically require opioid-level pain control
• Acetaminophen can be added as adjunctive therapy 5
• Avoid delaying pain management while awaiting diagnostic workup—pain control should begin immediately upon presentation

Urgent Diagnostic Workup

• Order complete blood count with differential, reticulocyte count, hemoglobin electrophoresis (if not previously diagnosed), and comprehensive metabolic panel immediately
• Obtain blood type and screen given potential transfusion needs
• Check lactate dehydrogenase (LDH) and indirect bilirubin as markers of hemolysis
• Repeat hip radiographs are already negative, but obtain MRI of the right hip urgently to evaluate for avascular necrosis (osteonecrosis of the femoral head), which is a common complication in sickle cell disease and can present similarly 5, 6

High-Altitude and Sickle Cell Considerations

Pathophysiology of High-Altitude Crisis

• High altitude creates hypoxic conditions that promote red blood cell sickling 1
• Dehydration from increased insensible losses at altitude compounds the problem by increasing blood viscosity 1, 4
• The combination of hypoxia, dehydration, and physical exertion (hiking) creates a perfect storm for vaso-occlusive crisis 1, 4

Prevention Counseling for Future

• Patients with sickle cell disease should avoid high-altitude exposure above 1,500-2,000 meters whenever possible 1
• If high-altitude travel is unavoidable, prophylactic measures include: aggressive hydration (3-4 liters daily), gradual ascent, avoiding strenuous activity, and potentially prophylactic transfusion 1
• Acetazolamide, while effective for altitude sickness prevention in healthy individuals, requires careful consideration in sickle cell patients due to its diuretic effects potentially worsening dehydration 1

Differential Diagnosis Considerations

Why This Is Likely Sickle Cell Crisis

• Recurrent episodes of joint pain with dehydration or illness is pathognomonic for sickle cell disease
• The hip is the second most common site for vaso-occlusive pain crises (after the back)
• Age 16 fits the typical presentation pattern for sickle cell complications
• Negative radiographs do not exclude vaso-occlusive crisis or early avascular necrosis 5, 6

Alternative Diagnoses to Consider

• Avascular necrosis of the femoral head: MRI is essential as plain films can be normal in early stages 5, 6
• Septic arthritis: less likely given negative radiographs and typical history, but check inflammatory markers (ESR, CRP) and consider joint aspiration if fever or elevated white count
• Transient synovitis: possible but less likely given the specific triggers and recurrent pattern
• Stress fracture: MRI will identify if present 5, 6

Disposition and Follow-Up

Admission Criteria

• Admit this patient for inpatient management given acute vaso-occlusive crisis requiring IV hydration and pain control
• Consult hematology urgently if sickle cell disease is confirmed or strongly suspected
• Monitor for complications including acute chest syndrome (obtain chest X-ray if any respiratory symptoms develop)

Outpatient Management (If Mild and Confirmed Not Crisis)

• If pain improves rapidly with oral hydration and NSAIDs, and laboratory workup is reassuring, outpatient management may be considered 5
• Physical therapy referral for hip rehabilitation once acute pain resolves 5
• Close follow-up within 24-48 hours to reassess symptoms 6

Critical Pitfalls to Avoid

• Do not assume this is simple musculoskeletal pain from hiking—the history of recurrent episodes with dehydration/illness is a red flag for underlying hematologic disease 2, 3
• Do not rely on negative plain radiographs to exclude serious pathology—MRI is mandatory to evaluate for avascular necrosis and bone marrow infarction 5, 6
• Do not delay hydration and pain management while awaiting diagnostic confirmation 1, 2, 3
• Do not discharge without confirming hemoglobin electrophoresis status—if this patient has undiagnosed sickle cell disease or trait, they need comprehensive hematology follow-up and genetic counseling
• Do not use opioids for chronic management, but acute vaso-occlusive crisis is an appropriate indication for short-term opioid therapy (unlike chronic osteoarthritis) 5