Approach to the Paediatric Hip

Question 1

What are the three significant hip conditions in paediatrics?

Answer 1

1.DDH
2. Perthes disease
3. SUFE

Question 2

Describe DDH as a spectrum of disorders.

Answer 2

DDH comprises of a spectrum of disorders:
1. Shallow acetabulum without displacement
2. Shallow acetabulum with subluxation(partial dislocation) of femoral head
3. Frank Dislocation

(NB) It goes from NOT dislocated to PARTIALLY dislocated to TRUE/FRANK dislocation. That is the whole spectrum.

Question 3

What are the risk factors for DDH?

Answer 3

1. Breech
2. Family history
3. Female
4. Multiple pregnancy
5. Oligohydramnios

Question 4

What clinical findings are seen in neonates or infants with DDH?

Also include the relevant exams/tests

Answer 4

• Barlow (attempt to dislocate) and Ortolani(attempt to reduce) tests
• Uneven skin creases
• Limb length discrepancy
• Limited abduction
• Telescoping Test(positive telescoping test means joints laxity or hip dislocation).

Question 5

What clinical findings can be observed in older children with DDH?

Answer 5

• Waddling gait
• Hyperlordosis

Question 6

At what age can X-rays be used to investigate DDH?

Answer 6

From about **5 months

Question 7

What imaging technique can assess the hip before ossification begins?

Answer 7

**Ultrasound

Question 8

What is Broken Shenton’s line in the context of DDH?

Answer 8

Intact on one side and broken on the other.

Shenton’s line is an imaginary line dran from the superior pubic ramus to/along the inferiomedial border of the neck of femur

Interruption of shenton’s line indications (1)DDH (2) Neck Of Femur Fracture.

Question 9

What is the typical management for DDH in children aged 0-6 months?

Answer 9

Pavlik Harness, is a soft brace that holds the baby’s legs in a position that allows their hip jont to be aligned.

Just additional: Children under 6 months should be examined by ultrasonography

Pavlik=derived from Paul= which means SMALL

Question 10

What is the management of DDH for children aged 6-16 months?

Answer 10

Closed reduction under anaesthesia, followed by hip spica and **bduction cast

Question 11

What is the management approach for DDH in children **over 16 months with failed closed reduction?

Answer 11

Open reduction of the hip

Question 12

What age group is most commonly affected by Perthes disease?

Answer 12

Children between **4 and 8 years old

Question 13

What is the main pathology of Perthes disease?

Answer 13

Idiopathic avascular necrosis of the femoral head

Question 14

What are the stages of Perthes disease?

Answer 14

• Stage 1: Initial
• Stage 2: Fragmentation
• Stage 3: Re-ossification
• Stage 4: Healed

Question 15

What are common X-ray findings in Perthes disease during the fragmentation stage?

Answer 15

• Femoral head collapse
• lateral uncovering
• widened medial joint space

Question 16

Describe the Clinical features of Perthes Disease

Answer 16

• Child with antalgic or Trendelenburg gait plus/minus pain
• Intermittent knee, hip, groin or thigh pain.
• Decreased abduction and internal rotation of hip.

Question 17

What is SUFE?

Answer 17

Slipped upper femoral epiphysis

It is type I salter-Harris epiphyseal injury at proximal hip. There is slippage of the femoral head.

Question 18

What is a key misconception about SUFE?

Answer 18

The epiphysis remains in-situ; it is the femoral neck that rotates and shortens

Question 19

What age group is most affected by SUFE?

Answer 19

Children between 10 and 14 years old

Question 20

What are common clinical features of SUFE?

Answer 20

• Hip and/or knee pain
• External rotation of the affected leg
• Trendelenburg gait
• Obligatory external rotation on hip flexion

Question 21

What is Klein’s line in the context of SUFE?

Answer 21

A line drawn along the superior border of the femoral neck that should pass through the femoral head.

Klein’s line is a diagnostic tool for Slipped Upper Femoral Epiphysis. *I(f the femoral head has slipped, Klein’s line will fail to intersect the epiphysis, indicating misalignent)

Question 22

What is the typical management for SUFE?

Answer 22

In-situ pinning of the femoral head

Question 23

What important assessment should be made in children presenting with knee pain?

Answer 23

Assess the hip for pathology

Question 24

What are the possible complications of treatment of DDH?

Answer 24

1. Avascular Necrosis
2. Pressure sores
3. Femoral nerve palsy
   (just to name a few)

Question 25

Describe the management of Perthes disease

Answer 25

1.Physiotherapy (the goal is to preserve ROM)

2. Femoral or pelvic osteotomy

Question 26

Complications of Perthe’s disease.

Answer 26

1. Femoral head deformity
2. Limb length discrepency
3. Early onset osteoarthritis
4. Need for Total Hip Replacement (THR)

Question 27

Describe the difference between Perthe’s disease and Adult AVN

Answer 27

Well, they both involve the loss of blood supply to the femoral head, leading to bone death.

The cause is unknown in perthe’s whereas Adult AVN could be linked to trauma, alcohol consumption, blood clotting disorders etc.

Perthe’s and Adult AVN obviosuly affect different age groups.

Question 28

Discuss the etiology of SUFE

Answer 28

It is multifactorial

Genetic component: Autosomal Dominant, Blacks more commonly affected

Overweight: Mechanical stress

Trauma

Question 29

DISCUSS the complications of SUFE

Answer 29

1. AVN
2. Premature Osteoarthritis
3. Loss of range of movement