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| Acute Severe Hip and Thigh Pain in a Five-Year-Old Girl1 | ||
| A five-year-old girl presented with a twenty-four-hour history of severe pain in the left hip and thigh. The patient had had a single day of fever that had resolved spontaneously one week prior to admission. She was not diabetic, and there was no recent history of injury or injection in the region of the left buttock, hip, or thigh. There was no history of chicken pox or steroid intake. | ||
| Although she was febrile (39.5°C) and dehydrated, the vital signs were initially stable (pulse, 120 bpm; blood pressure, 100/50 mm Hg). The pain in the left limb prevented walking, and muscle spasm markedly limited the range of motion of the hip. The hip could be flexed passively to only 20°; other directions of movement were virtually impossible. Although no abnormalities of the overlying skin were evident, the left hip and thigh were diffusely swollen, with extreme tenderness without crepitus on deep palpation of the buttocks. The patient was attached to a cardiac monitor, and the blood pressure was checked every fifteen minutes. | ||
| Laboratory investigation revealed a white blood-cell count of 22.3 109/L (leukocytosis), a hemoglobin level of 120 g/L, and a platelet count of 321 109/L; both the erythrocyte sedimentation rate and the C-reactive protein level were elevated (to 80 mm/hr and 20 mg/L, respectively). The prothrombin time (16.6 sec), activated partial thromboplastin time (49.5 sec), and international normalized ratio (1.6) were all prolonged. | ||
| A conventional anteroposterior pelvic radiograph revealed marked soft-tissue swelling around the left hip but no soft-tissue gas. A magnetic resonance imaging scan was made emergently within one hour after admission. | ||
 Fig. 1 | Fig. 1. A T2-weighted fat-suppressed magnetic resonance image, showing that the left gluteus medius and gluteus minimus muscles were markedly swollen with relative sparing of the gluteus maximus. Heterogeneous high-intensity signals within both muscles and stranding of the overlying subcutaneous soft tissues were evident. For larger view, click on image |
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 Fig. 2 | Fig. 2. A T1-weighted fat-suppressed image, made after administration of gadolinium contrast medium, showing heterogeneous contrast enhancement within the gluteus medius and gluteus minimus muscles. No effusion in the left hip joint was noted. For larger view, click on image |
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| Following magnetic resonance imaging, the patient's condition deteriorated and she became hypotensive (blood pressure, 70/30 mm Hg), and she required vasopressor support. Surgery was performed under general anesthesia within two hours after admission, through a lateral approach to the left hip. | ||
| What is the diagnosis? | ||
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