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The Musculoskeletal System > Childhood Hip Disorders > Flashcards

Childhood Hip Disorders Flashcards

1
Q

What is DDH?

A

Developmental dysplasia of the hip

(Dislocation or subluxation of the femoral head in the perinatal period which affects joint development)

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2
Q

What are the risk factors for DDH?

A
  1. Being born in breech position
  2. Family history
  3. Girls
  4. First born
  5. Left hip more likely
  6. Down’s syndrome
  7. Presence of other congenital disorders
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3
Q

What may be seen/examined on examination for a baby with DDH?

A
  1. Asymmetry
  2. Clicking/clunking when moving affected hip joint on Barlow/Ortolani instability tests
  3. Check abduction
  4. Decreased leg length
  5. Asymmetric groin/thigh skin creases
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4
Q

Which imaging modality is usedfor babies under 3 months to check for DDH?

A

Ultrasound

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5
Q

In which instances is ultrasound for DDH offered as a routine check?

A
  1. All breech births
  2. Family history
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6
Q

What is the treatment for DDH when diagnosed early?

A

Pavlik harness

(keep hips comfortably flexed and abducted)

This is used for 6 weeks permanently and then at night for a subsequent 6 weeks

It can be used for children up to 4-6 months

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7
Q

What is the treatment for DDH after the point a pavlik harness can be used?

A
  1. Manipulation with dye (as a guide)
  2. Open reduction surgery
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8
Q

What is the treatment for very late diagnoses of DDH?

A

Combined femoral and acetabular surgery

(the patient will never be normal)

This allows the femoral head to be shortened and rotated and the acetabulum to be deepened and reorientated

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9
Q

How may a patient present with a late presentation of DDH?

A
  1. Normal hip movements
  2. No pain
  3. Limp
  4. Tiptoes on one side
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10
Q

What are 3 likely options for a preschool child with a limp no associated with injury?

A
  1. Infection
  2. Transient synovitis
  3. DDH
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11
Q

How can infection in a preschool child with a limp be assessed?

A

Kocher criteria

  1. Temp > 38 degrees
  2. Unable to weight bear
  3. CRP > 20
  4. WCC > 12
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12
Q

What may make a transient synovitis likely for a preschool child with a limp?

A
  1. Slow onset
  2. Generally well
  3. Low grade fever, if any
  4. Reduced movement
  5. Effusion on ultrasound
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13
Q

How can a transient synovitis be treated?

A

Resolves with rest and short course of NSAIDs

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14
Q

How does late DDH present in a preschool child?

A
  1. Painless limp
  2. Short leg
  3. Asymmetric creases on inner thighs
  4. Trendelenberg limp
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15
Q

A 7 year old boy, with pain in his knee, a limp and groin pain is most likely to have which condition?

A

Perthes

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16
Q

What are the characteristic traits of perthes?

A
  1. Affects boys
  2. Age of onset is 4-9
  3. Unsually unilateral
  4. Small and acive children affected
  5. Limp and pain associated
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17
Q

What is perthes?

A

Idiopathic osteochondritis of the femoral head leading to avascular necrosis

This affects bone growth and development

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18
Q

What are the four stages of avascular necrosis associated with perthes?

A
  1. Necrosis/sclerosis
  2. Fragmentation
  3. Reossification
  4. Remodelling
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19
Q

Perthes may result in which other condition later in life?

A

OA

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20
Q

What are the treatment options for perthes?

A
  1. Rest and activity modification
  2. Bracing
  3. Surgery (few patients)
21
Q

Tim, 11, has a three month history of pain around his knee and is unable to weight bear. Which condition are you concerned about?

A

SUFE

(slipped upper femoral epiphises, or SCFE (slipped capital femoral epiphisis))

22
Q

What are the characteristic traits of SUFE?

A
  1. Age of onset 10-16
  2. Mostly occurs within the rapid growth phase in adolescence
  3. Obesity increases risk
  4. Occurs more commonly in males
  5. Black people are more commonly affected
23
Q

What is the pathogenesis os SUFE?

A

An imbalance in thyroid hormone, growth hormone or sex hormones as well as renal disease can cause a weakened physis causing the femoral head epiphysis to slip inferiorly in relation to the femoral neck

24
Q

Which sign can show the classical changes of the femoral head associated with SUFE on X-ray?

A

Trethowan’s sign

25
Q

What is Trethowan’s sign?

A

In a postive Trethowan’s sign, the line of Klein passes above the femoral head rather than through it as it normall would.

(the line of Klein is a line along the superior edge of the neck of the femur which should intersect with the lateral part of the superior femoral epiphysis)

26
Q

In patients with SUFE it is important to take a _________ X-ray

A

Lateral

27
Q

What is the treatment for SUFE?

A

Stabilisation of the physis with pins

28
Q

Why is SUFE a potential worry?

A

It can lead to avascular necrosis

29
Q

If left untreated, what will happen in DDH?

A

The acetabulum becomes very shallow

In severe cases, a false acetabulum occurs proximally

Both of which result in a shorter limb

Severe arthritis can occur due to reduced surface area of the joint and gait may be impacted

30
Q

What is the Ortolani test?

A

Reducing a dislocated hip with abduction and anterior displacement

31
Q

What is the Barlow test?

A

Dislocatable hip with flexion/adduction and posterior displacement

32
Q

Why can X-rays not be used in the diagnosis of DDH?

A

The femoral head epiphysis is not yet ossified

(after 4-6 months X-ray is the test of choice)

33
Q

What is transient synovitis of the hip?

A

A self-limiting inflammation of the synovium of a joint, which is most common at the hip

34
Q

What commonly precedes transient synovitis of the hip?

A

An upper respiratory tract infection which is usually viral

35
Q

What is the typical age to be affected by transient synovitis of the hip and which sex is more commonly affected?

A

2-10

Boys

36
Q

What is the most common cause of hip pain in childhood?

A

Transient synovitis of the hip

37
Q

What is the presentation of transient synovitis of the hip?

A
  1. Limp
  2. Reluctance to weight bear on affected side
  3. Ptential restrcition to range of motion
  4. Low grade fever
  5. Not systemically unwell
38
Q

How can both Perthes disease and septic arthritis be excluded in a child who most likely has transient synovitis of the hip?

A

Radiograph (X-ray) - excludes Perthes

CRP - Near normal levels exclude septic arthritis

39
Q

If there is doubt about the diagnosis of transient synovitis of the hip, what could be done?

A
  1. Aspiration of the hip
  2. Open surgical drainage
  3. MRI can exlcude osteomyelitis

The first two options will limit cartilage damge from potential bacterial infection

40
Q

Severe cases of Perthes may require what treatment in adolescence?

A

Hip replacement

41
Q

What is the first clinical sign of Perthes and which clinical signs follow this?

A
  1. Loss of internal rotation (occurs firstly)
  2. Loss of abduction
  3. Postive Trendellenburg tests (from gluteal weakness) (occurs last)
42
Q

What are the treatment options for perthes?

A

Regular X-ray observation and avoidance of physical activity

Subluxation of the femoral head requires osteotomy of the femur or acetabulum

43
Q

In SUFE, the growth plate is not ________ _________

A

Strong enough

(to support the body weight)

44
Q

Before SUFE occurs what may occur to trigger the condition?

A

Growth spurt

45
Q

How do patients with SUFE present?

A

Pain and limp

Pain can be felt in the groin or potentially just in the knee

46
Q

What is the reason knee pain may be the only clinical sign of SUFE?

A

The obturator nerve supplies both the knee and hip joint and may become irritated

47
Q

What is the first clinical sign of SUFE?

A

Loss of internal rotation of the hip

48
Q

What is the treatment for SUFE?

A

Urgent surgery to pin the femoral head

In severe cases hip replacement is required

(severe acute slips can have gentle manipulation, but this risks AVN)

The Musculoskeletal System (58 decks)

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