6 Year old boy with extreme pain - a rare finding that eluded emergency doctors!
Alex was an extremely active 6 year old boy who never walked anywhere, he always ran. He spent an enormous amount of time outside climbing trees, jumping on his trampoline, kicking his footy and very rarely sitting still. On this particular weekend, the family were at a social function and Alex was running around the backyard with a number of his little friends. They spent time in the cubby house, playing make believe, followed by some time shooting hoops and finally they found themselves climbing up and jumping off a retaining wall. One of Alex’s little friends came and got Mum saying that Alex had hurt himself and Mum found Alex sitting next to the retaining wall in tears. He was holding the front of his hip saying it hurt. Given that he had been jumping from a 1.5 metre high retaining wall, Mum presumed he had jarred his hip and suggested that Alex sit inside for a while to let it rest. Dad carried Alex into the lounge room and sat with him. Initially his pain seemed extremely bad and this made Mum and Dad concerned that he might have done some serious damage, but all of a sudden his pain decreased, the tears dried up and Alex said he was okay and wanted to go back to play with his friends. Reluctantly Mum and Dad let Alex get up from the couch and he appeared to be walking without any problems at all. Mum and Dad kept an eye on Alex for the next 10 minutes and he seemed perfectly fine, until he went back onto the trampoline and the pain started up again. Intense pain as soon as he started jumping. At this stage Mum and Dad decided to take Alex home and although this episode of pain lasted longer than the first, it eventually went as quickly as it came.
Alex was fine for the rest of the night with no further exacerbations of his hip pain, although he was not his normal active self, in fact Mum said he was happy to rest on the couch and watch a movie, which is not like him! Mum and Dad decided to let things ride and see how he was in the morning after a good night sleep. Alex woke with his normal energetic zest for life, as if the hip pain of yesterday hadn’t even happened. After breakfast he went outside to kick the footy with Dad and was once again struck down with sudden intense pain in his hip. This episode lasted almost an hour and he began to feel clammy and look pale, so Mum and Dad popped him in the car and took him to the hospital emergency department (it was Sunday mid morning by this stage). By the time they arrived the pain was significantly improved. Dad carried him into the hospital, but while waiting to be triaged Alex got up and walked to the water fountain. He had developed a very slight limp, but said he wasn’t feeling too much pain.
By the time Alex had been taken into a cubicle and was seen by the doctor he was walking without a limp at all and the pain was completely gone. This created a conundrum for Alex’s parents because the doctor looked at them a little like they were wasting his time. The doctor had a feel around his hip and Alex didn’t experience any pain at all, making a diagnosis very difficult. The doctor suggested that they head home and return if it happened again. Alex hopped of the hospital bed to leave and 💥 the pain returned. Luckily the doctor hadn’t left yet and could see it for himself. He went through the examination again and couldn’t find the source of the pain, although it was very apparent that Alex was in a world of pain. His heart rate and blood pressure all went up significantly. The doctor order an x-ray and it came back completely clear. Eventually Alex was sent home with a prescription for anti-inflammatories and Panadol and his parents were told that if this didn’t resolve the issue, that an MRI would be required during the week.
Alex spent much of the night on the couch resting and his parents could see that he was very reluctant to move around for fear of the pain starting again. The following two days were very similar, with Alex not attending school and spending time either in bed or on the couch. He was willing to walk to the bathroom himself, but had a limp as he walked. Given his inactivity, Alex didn’t experience and further flare up’s like before, leading Mum and Dad to believe the anti-inflammatories and Panadol were working. Although a little perplexed as to what was causing the pain in the first place, Mum and Dad felt relieved that the issue appeared to be getting better. Until later on that night, Alex screamed out in pain from his bed. This was the first time the pain came on without any really obvious physical cause. They bundled their son into the car and back to the emergency department. A different doctor attended to Alex this time, but unfortunately was just as confused as the first doctor about the possible cause of Alex’s pain, but insisted an MRI be ordered as soon as possible. The MRI was scheduled for the beginning of the following week and they recommended Alex continue to rest and take anti-inflammatories and gave him some stronger analgesics.
Mum and Dad weren’t willing to sit on their hands and wait for the MRI and decided to bring Alex to me for a Chiropractic assessment. I completed a physical assessment of Alex’s lower back and hip joints, revealing a couple of subluxations (normal for an active child like Alex), but wasn’t convinced that this was the cause the symptoms he was experiencing. I continued to search for answers and the next step was an abdominal examination. Alex’s abdominal examination revealed slight guarding on his lower left and some mild feral loading, but again, nothing consistent with the pain that he was experiencing. Alex’s history revealed that he had stopped using his bowels since taking the stronger analgesic medication, but prior to this was extremely regular. Something for us to deal with, but not the answer to the cause of his pain. The next examination to be performed was a testicular examination. To be honest with you both parents looked at me like I was a little crazy, given they were absolutely convinced that the cause of this injury was a physical cause. Immediately it became apparent that the left testicle was enlarged and needed immediate medical attention. We sent Alex off to the hospital once again, but this time rang ahead and told them he was coming and told them that I suspected he had testicular torsion. He bypassed the triage station and went straight in to see a doctor. Within half an hour Alex was operated on to correct the torsion and was given a favourable prognosis.
Testicular torsion is a medical emergency, as without blood supply the testicle can die within 6 hours. In Alex’s case the torsion wasn’t extreme, which is why the pain would come and go. Every time Alex would jump, it caused the testicle to bounce and exacerbated the condition causing a temporary lack of blood flow to the testicle, but as he rested the testicle would regain blood flow, which is when the pain would subside. I can only presume that when Alex woke in extreme pain over night that he had rolled over and perhaps moved his legs in a way that squashed his torsioned testicle between his legs causing a lack of blood flow again.
It is not uncommon for testicular issues to present as hip pain and for them to cause a limp like in Alex’s cause. If you have a son with intermittent or persistent hip pain, do a quick check below deck. Assessing for testicular pain or swelling can potentially be the difference between your child being able to have his own children or not. Not something to take lightly. Get you son checked by a GP and don’t be too shy to ask the specific question of the doctor as to whether they think it could be coming from the testicles.