#82 - Vascular/Mechanical Dysfunction of bones - Hip disorders.

Question 1

What is DDH?

Answer 1

Developmental Dysplasia of the hip. It is an abnormal formation of one or both hips during the gestational period (in utero).

Question 2

What are the 5 risk factors (5F’s) for DDH?

Which is the most important

Answer 2

• Female (joint laxity)
• First born (small uterus)
• Family history - (maternal pelvis shape)
• Frank Breech
• Foot deformities and other packaging issues (torticollis, etc.)

Question 3

What is the barlow test?

Answer 3

• Test for DDH.
• Sublux the hip –> hip gets popped out of the acetabulum with this maneuver

Pneumonic - BAR = We are going out tonight! = hip gets popped out.

Question 4

What is the ortolani test?

Answer 4

Test for DDH, done after the barlow test dislocates the hip.
-Reduces the hip back into it’s position after the barlow test.

B before O, after going out, time to go home.

Question 5

What is the galeazzi test?

Answer 5

test for knee height difference in newborns - will detect possible DDH. Affected hip will be shorter. It is useful from 3 to 12 months.

Question 6

Which two newborn tests are only useful in the first 3 months of life?

Answer 6

Barlow and ortolani.

Question 7

Which tests for DDH are useful after 12 months?

Answer 7

Tredelenburg sign is seen (gluteus medius lurch)

• short leg limp.
• stiff legs.

Question 8

Positive Barlow/ Ortolani. How do you confirm DDH?

Answer 8

Ultrasound used to confirm in newborns.

Question 9

Positive galeazzi on a newborn 9 months old

Answer 9

X ray. X ray needed to confirm if older than 6 months (Structures no longer cartilaginous, ultrasound no good)

Question 10

Treatment for DDH in young vs. older children vs. adult

Answer 10

Young: Pavlik harness (presses hip into acetabulum)

Older: open/closed reduction in the OR

Adult: hip replacement.

Question 11

10 month female walks with her toes on the left. She has dislocated hip on x ray and DDH. What is her prognosis?

Answer 11

With open reduction, very good. There is excellent remodeling potential at this age.

Question 12

What is the natural history of DDH, left untreated?

Answer 12

-Eventually, the person will develop pseudoacetabulum in a different part of the hip. This will cause severe degenerative changes, and they will need an early joint replacement.

Question 13

What is Legg-Calve-Perthes disease, aka Perthes?

Answer 13

It is an idiopathic avascular necrosis of the femoral head.

Question 14

Who gets Perthes?

Answer 14

males, age 4-10

Question 15

What will an x-ray look like of a boy with Perthes?

Answer 15

The hip may be in one of 3 stages. If both hips are affected (10-15%) of cases, The two hips will ALWAYS be in different stages. If they are in the same stage think something different.

Question 16

3 stages of disease in Perthes.

Answer 16

Avascular necrosis –> Fragmentation/resorption –> re-ossification

Question 17

Goal of treatment in Perthes.

Answer 17

They cannot stop the stages from happening. The goal is to maintain a round head and joint during remodeling.

Question 18

What is the treatment for Perthes?

Answer 18

no agreed upon treatment - Huge variability. (traction beds, etc have been used in the past.

Question 19

If a child is in this age range at the time of presentation with Perthes,, they may receive intervention (surgery)

Answer 19

6-8 years old.

Under 6 do really well, above 8 do very poorly w/ or w/o treatment.

Question 20

If younger than 6 at presentation with Perthes, prognosis is (good/bad)

Answer 20

good - nearly all make it to 50 without treatment

Question 21

If older than 8 at presentation with Perthes, prognosis is (good/bad)

Answer 21

bad - nearly all get degenerative joint disease before age 40

Question 22

What is SCFE?

Answer 22

Slipped Capital Femoral Epiphysis. “Ice cream slipped off the cone” It is a displacement of the proximal femoral metaphysis through the growth plate. Common in obese males nearing the end of skeletal maturity.

Question 23

What is the cause of a SCFE?

Answer 23

it is due to an abnormally wide zone of hypertrophy?

Question 24

Which moves in SCFE: the femoral head, or the metaphysis (long bone)

Answer 24

the metaphysis moves, while the head stays put.hence the name (Slipped Capital Femoral Epiphysis.) is a misnomer

Question 25

Who is at risk for SCFE?

Answer 25

-obese (50% of patients are >95% for weight)

-females 10-14
males 10-16.
more males.
minorities

Question 26

T/F SCFE is related to endocrine changes

Answer 26

True. 80% occur during growth spurt.

Question 27

How is SCFE diagnosed?

Answer 27

Pt has pain in one leg standing
CAN BE KNEE PAIN(referred)
-limping gait
-lack of hip internal rotation compared to other side
-“obligate” external rotation with hip flexion.

Question 28

Which SCFE patients are good candidates for a prphylactic screw in the non-affected hip?

Answer 28

Those who present really young (10 years old) - high risk to get it in the other hip..

Question 29

What is the treatment for SCFE?

Answer 29

If mild/moderate, screw to prevent the head from slipping any further. If more than 2/3 slipped, you can do an open reduction, but it’s risky.

Question 30

What is a stable vs. unstable SCFE?

Answer 30

stable = patient is able to walk with (or without) crutches

unstable = patient unable to walk even without crutches.

Question 31

T/F SCFE Is a surgical emergency.

Answer 31

True

Question 32

T/F SCFE patients should undergo a period of physical therapy before surgery.

Answer 32

NO! Do not let the child walk. Weight bearing can worsen the slippage!!

Question 33

Natural history of SCFE

Answer 33

avascular necrosis of the femoral head–> degenerative joint changes necessitating joint replacement.