Childhood Hip and Knee Conditions Flashcards
What is DDH?
Involves dislocation/subluxation of the femoral head during the perinatal period which affects the subsequent development of the hip
What can DDH cause in the long term?
Severe arthritis at a young age, gait/mobility may be severely affected
What are some risk factors for DDH?
Breech position, family history, other MSK or congenital conditions, Down’s syndrome, female, first born
Most cases of DDH are in which hip?
Left, though 20% are bilateral
Do all cases of DDH have apparent risk factors?
No (60% do not)
What are some features to look for to suggest DDH?
Extra skin fold, asymmetry, decreased leg length
What is the most important movement to check when assessing for DDH?
Abduction, one will be stiffer than the other
Describe the Barlow test?
Abduct the hip and apply pressure on the knees, you will dislocate the hip
Describe the Ortolani test?
Flex and adduct the hip, put pressure on the greater trochanter and you will reduce the dislocated hip
If Ortolani and Barlow tests are positive for DDH, what test should be done next?
Ultrasound
What is the main investigation for assessing DDH in children < 6 months of age?
Ultrasound
What is the main investigation for assessing DDH in children > 6 months of age?
X-ray
Which babies should have a routine ultrasound to image the hip at birth?
Breech position or positive family history
How should you manage mild cases of DDH, with a shallow acetabulum and a mildly dislocatable but reduced hip?
Close examination and regular US scans
If there is an early diagnosis of severe DDH, how should this be managed? What are the outcomes like?
Pavlik harness to keep the hip in flexion/abduction and hence reduced, really good outcomes
Overflexion/abduction of the hip can lead to what?
AVN
If there is a late diagnosis of DDH, how is it managed? What are the outcomes?
Surgical open reduction, the joint will probably never be normal
If a child is diagnosed with DDH over 2 years old, how is this managed?
Combined femoral and acetabular surgery (breaking and reattaching)
How long is a Pavlik harness used for? What ages can it be used for?
6 weeks continuous, 6 weeks part-time. Used up to 4-6 months of age.
Those with late diagnosed DDH will go on to have what problems?
Early onset arthritis and hip replacement
If the hip joint is infected, when will there be pain?
At rest and on movement, the child will be resistant to movement
What is transient synovitis?
Self-limiting inflammation of the synovial (commonly hip)
When is transient synovitis more common?
Following a viral URTI
Which age and sex are more likely to have transient synovitis?
Boys, aged between 2 and 10
What are some pathologies that need to be excluded in a child with possible transient synovitis?
Septic arthritis, rheumatoid arthritis, juvenile idiopathic arthritis
How does a child with transient synovitis usually present?
A limp, or reluctance to bear weight on the affected side. Range of motion may be restricted slightly.
Will the child be systemically unwell in transient synovitis?
No, except a possible low grade fever
What test is used to exclude Perthes in a child with transient synovitis?
X-ray
What test can be used to exclude septic arthritis in a child with transient synovitis? What should be done if there is any doubt of this?
CRP (if there is any doubt the hip can be aspirated and drained)
What is the treatment for transient synovitis?
Exclude a more serious cause, short course of NSAIDs
What is the onset of transient synovitis?
Insidious
When should patients with transient synovitis be seen again if the pain has not gone?
A few weeks
What is Perthes disease?
Idiopathic osteochondritis of the femoral head
Who does Perthes disease typically occur in?
Between ages 4-9, more common in small boys who are hyperactive
How does Perthes disease usually present?
Pain and a limp (though can be painless)
Can Perthes be bilateral?
Yes, but usually not at the same time
If Perthes occurs in both hips at the same time, what can this suggest?
Underlying skeletal dysplasia
What happens to the femoral head in Perthes?
It gradually loses its blood supply, resulting in necrosis with subsequent abnormal growth
What are indicators of a worse prognosis in Perthes?
Older age, AVN
What will an incongruent joint as a result of Perthes lead to?
Early onset arthritis and possible hip replacement at a young age
What is the general treatment for Perthes disease?
X-ray monitoring and avoidance of activity
What position is it best for the hip to be in in Perthes?
Abduction
Onset below what age implies a better prognosis in Perthes?
< 7
Who does SUFE tend to affect?
Pre-pubertal adolescent boys (10-16) who are overweight
What happens in SUFE?
The femoral head epiphysis slips inferiorly in relation to the femoral neck
Pain is the main feature of SUFE, where can this pain be?
In the groin, or sometimes only in the knee
SUFE causing pain in the hip and knee is due to nerve supply from where?
Obturator nerve
What movement is the first to be lost in SUFE?
Internal rotation
What may precede the onset of SUFE? What may not have occurred?
May be precede by a growth spurt, often puberty is delayed
Can SUFE be bilateral?
Yes, about a third of cases. Treat for both even if not present.
What ethnic group is SUFE more common in?
Black children
What other conditions may predispose to SUFE?
Hypothyroidism and renal disease
What imaging is essential in SUFE?
Lateral x-ray
SUFE can tear vessels can cause a risk of what?
AVN
Is AVN in SUFE reversible?
No, if not caught then the hip can die
What is the management for SUFE?
Pinning of the physis in situ (bilateral)
Can stable slips become unstable in SUFE?
Yes
An adolescent who cannot weight bear has what until proven otherwise?
SUFE
If you suspect emergency SUFE, what should be done?
Immediate x-ray (including lateral) and do not weight bear
What implies a worse prognosis in SUFE?
The greater the degree of the slip
What can SUFE result in in the long term?
Early hip replacement
What should always be checked in a young person presenting with knee pain?
Hips for SUFE
What makes knee extensor mechanism problems common in adolescence?
Increased weight and more sporting activities
What is a specific type of knee extensor mechanism problem which may occur in adolescence and is self limiting but ay require physio?
Patellar tendonitis
Anterior knee pain is more common in which sex?
Females
What are some reasons the anterior knee pain is more common in girls?
Muscle imbalance, ligamentous laxity, skeletal predisposition
What is the treatment of anterior knee pain?
Self-Limiting, physio may help
What may very rare, resistant cases of anterior knee pain require?
Surgery (tibial tubercle transfer)
What types of meniscal tears are children and young people more likely to get?
Peripheral or bucket handle tears
Do young people with meniscal tears have a good recovery rate?
Yes
