5. Childhood Hip Disorders

Question 1

developmental dysplasia of the hip

Answer 1

invovles dislocation or subluxation of the femoral head during the perinatal period which affects the subsequent development of the joint

Question 2

which hip is DDH most common in

Answer 2

left

20% cases bilateral

Question 3

risk factors for DDH

Answer 3

girls

first born

FH

breech position in utero or at delivery

down syndrome

other MSK - Torticollis (crick in neck) or club foot

Question 4

what can DDH lead to if untreated

Answer 4

shallow acetabulum - and in severe cases a false acetabulum appeats proximal to the original one with a shortened limb

severe arthritis due to reduced contact area

gait/mobility severely affected

Question 5

CF of DDH

Answer 5

shortening

asymmetry

extra groin/thigh crease on one side

clink/clunk on Ortolani or Barlow manouevres

Question 6

ortolani manouevre

Answer 6

relocates a subluxed or partially dislocated hip

Question 7

barlow manouevre

Answer 7

sublux or dislocate an unstable hip

Question 8

to which age are ortolani and barlow manoeuvres useful to

Answer 8

6 weeks

Question 9

when will ortolani and barlow manouevres both be ==negative

Answer 9

irreducible dislocated hip - use other tests

Question 10

what is important about diagnosis in DDH

Answer 10

early! if appropriately aligned in the first few months of life a dysplastic hip may normalise

all high risk infants have US at 2-4 weeks

all babies have hips examined on day 1 and week 6

Question 11

investigations of DDH

Answer 11

US

Xray cannot be used until after 4-6 months as the femoral head epiphysis is unossified until then

Question 12

treatment of DDH

Answer 12

mild - monitor with examination and US

pavlik harness

persistent dislocation over 18 months - open reduction to clear soft tissue and osteotomy to shorten and rotate femur or deepen and re orientate acetabulum in pelvis

Question 13

transient synovitis of the hip

Answer 13

self limiting inflammation of the synovium of a joint,commonly the hip

Question 14

causes of TSH

Answer 14

commonly occurs after an URT infection

can be idiopathic

Question 15

epidemiology of TSH

Answer 15

age between 2 and 10

boys

Question 16

what is the most common cause of hip pain in childhood

Answer 16

TSH

arthritis or RA must be excluded

Question 17

presentation of TSH

Answer 17

limp or reluctance to weight bear on affected side

restricted range of motion

low grade fever

resolves with rest

Question 18

investigations for TSH

Answer 18

radiograph to exclude Perthes

near normal CRP - exclude septic arthritis

US reveals effusion

aspirate hip if suspected bacterial infection

Question 19

what is useful in an equivocal case of TSH

Answer 19

MRI

DD is osteomyelitis

Question 20

treatment of TSH

Answer 20

short course of NSAIDs

rest

should resolve within few weeks, if not consider DD

Question 21

what is perthes disease also called

Answer 21

legg calve perthes disease

Question 22

Perthes Disease

Answer 22

idiopathic osteochondritis of the femoral head that typically affects boys between 4 and 9

occurs when the blood supply to the femoral head is temporarily disrupted - AVN

Question 23

classical Perthes Disease patient

Answer 23

very active boys of short stature

Question 24

Perthes Disease - disease progression

Answer 24

disease process likely secondary to avascular necrosis of the developing femoral head - osteonecrosis

fragmentation of the femoral head may occur causing it to collapse

subsequent remodelling occurs - abnormal growth

(the shape of the femoral head and incongruence of the joints determined by age of onset and amount of collapse)

OA

Question 25

Perthes Disease: what may an incongruent joint lead to

Answer 25

early onset arthritis and severe cases may require hip replacement

Question 26

Perthes Disease: presentation

Answer 26

pain and limp

most cases are unilateral, bilateral indicates underlying skeletal dysplasia or thrombophilia

loss of internal rotation is usually the first clinical sign

positive Trendelenburg test - when weight on affected side, normal hip drops

Question 27

investigation of Perthes

Answer 27

X ray

Question 28

Perthes Disease: treatment

Answer 28

• regular x ray
• avoidance of physical activity
• pain management
• brace
• surgery

Question 29

what are the indications for surgery on Perthes disease

Answer 29

• child >8
• over 50% femoral head lost
• femoral head subluxed
• surgery is osteotomy

Question 30

slipped upper femoral epiphysis

Answer 30

Condition affecting mainly overweight pre-pubertal adolescent boys where there is a fracture through the growth plate which causes the femoral head epiphysis to slip inferiorly in relation to the femoral neck.

Question 31

who is more likely to get SUFE

Answer 31

boys - overweight pre pubertal teens

hypothyroidism or renal disease may predispose

Question 32

pathogenesis of SUFE

Answer 32

growth plate is not strong enough to support the body weight adn the femoral epiphysis fractures and slips due to the strain

Question 33

SUFE - uni or bilateral

Answer 33

1/3 cases bilateral

Question 34

effect of growth spurt and puberty on SUFE

Answer 34

growth spurt may preclude the onset

puberty may be delayed

Question 35

presentation of SUFE

Answer 35

pain and limp

patients can present wtih pain purely in the knee

loss of internal rotation

Question 36

classification of SUFE

Answer 36

acute, acute on chronic, chronic

Question 37

why can patients present with pain purely in the knee in SUFE

Answer 37

obturator nerve supplies the knee and hip joint

Question 38

SUFE investigations

Answer 38

x ray - lateral view required

Trethowan’s sign on x ray

Question 39

SUFE: treatment

Answer 39

urgent surgery to pin femoral head to prevent further slippage (the greater the degree of slippage the worse the prognosis)

may require hip replacement

severe acute slips: gentle manipulation

chronic severe slips: osteotomy