Childhood Hip Disorders Flashcards
What is DDH?
Developmental dysplasia of the hip
(Dislocation or subluxation of the femoral head in the perinatal period which affects joint development)
What are the risk factors for DDH?
- Being born in breech position
- Family history
- Girls
- First born
- Left hip more likely
- Down’s syndrome
- Presence of other congenital disorders
What may be seen/examined on examination for a baby with DDH?
- Asymmetry
- Clicking/clunking when moving affected hip joint on Barlow/Ortolani instability tests
- Check abduction
- Decreased leg length
- Asymmetric groin/thigh skin creases
Which imaging modality is usedfor babies under 3 months to check for DDH?
Ultrasound
In which instances is ultrasound for DDH offered as a routine check?
- All breech births
- Family history
What is the treatment for DDH when diagnosed early?
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
What is the treatment for DDH after the point a pavlik harness can be used?
- Manipulation with dye (as a guide)
- Open reduction surgery
What is the treatment for very late diagnoses of DDH?
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
How may a patient present with a late presentation of DDH?
- Normal hip movements
- No pain
- Limp
- Tiptoes on one side
What are 3 likely options for a preschool child with a limp no associated with injury?
- Infection
- Transient synovitis
- DDH
How can infection in a preschool child with a limp be assessed?
Kocher criteria
- Temp > 38 degrees
- Unable to weight bear
- CRP > 20
- WCC > 12
What may make a transient synovitis likely for a preschool child with a limp?
- Slow onset
- Generally well
- Low grade fever, if any
- Reduced movement
- Effusion on ultrasound
How can a transient synovitis be treated?
Resolves with rest and short course of NSAIDs
How does late DDH present in a preschool child?
- Painless limp
- Short leg
- Asymmetric creases on inner thighs
- Trendelenberg limp
A 7 year old boy, with pain in his knee, a limp and groin pain is most likely to have which condition?
Perthes
What are the characteristic traits of perthes?
- Affects boys
- Age of onset is 4-9
- Unsually unilateral
- Small and acive children affected
- Limp and pain associated
What is perthes?
Idiopathic osteochondritis of the femoral head leading to avascular necrosis
This affects bone growth and development
What are the four stages of avascular necrosis associated with perthes?
- Necrosis/sclerosis
- Fragmentation
- Reossification
- Remodelling
Perthes may result in which other condition later in life?
OA
What are the treatment options for perthes?
- Rest and activity modification
- Bracing
- Surgery (few patients)
Tim, 11, has a three month history of pain around his knee and is unable to weight bear. Which condition are you concerned about?
SUFE
(slipped upper femoral epiphises, or SCFE (slipped capital femoral epiphisis))
What are the characteristic traits of SUFE?
- Age of onset 10-16
- Mostly occurs within the rapid growth phase in adolescence
- Obesity increases risk
- Occurs more commonly in males
- Black people are more commonly affected
What is the pathogenesis os SUFE?
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
Which sign can show the classical changes of the femoral head associated with SUFE on X-ray?
Trethowan’s sign
What is Trethowan’s sign?
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)
In patients with SUFE it is important to take a _________ X-ray
Lateral
What is the treatment for SUFE?
Stabilisation of the physis with pins
Why is SUFE a potential worry?
It can lead to avascular necrosis
If left untreated, what will happen in DDH?
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
What is the Ortolani test?
Reducing a dislocated hip with abduction and anterior displacement
What is the Barlow test?
Dislocatable hip with flexion/adduction and posterior displacement
Why can X-rays not be used in the diagnosis of DDH?
The femoral head epiphysis is not yet ossified
(after 4-6 months X-ray is the test of choice)
What is transient synovitis of the hip?
A self-limiting inflammation of the synovium of a joint, which is most common at the hip
What commonly precedes transient synovitis of the hip?
An upper respiratory tract infection which is usually viral
What is the typical age to be affected by transient synovitis of the hip and which sex is more commonly affected?
2-10
Boys
What is the most common cause of hip pain in childhood?
Transient synovitis of the hip
What is the presentation of transient synovitis of the hip?
- Limp
- Reluctance to weight bear on affected side
- Ptential restrcition to range of motion
- Low grade fever
- Not systemically unwell
How can both Perthes disease and septic arthritis be excluded in a child who most likely has transient synovitis of the hip?
Radiograph (X-ray) - excludes Perthes
CRP - Near normal levels exclude septic arthritis
If there is doubt about the diagnosis of transient synovitis of the hip, what could be done?
- Aspiration of the hip
- Open surgical drainage
- MRI can exlcude osteomyelitis
The first two options will limit cartilage damge from potential bacterial infection
Severe cases of Perthes may require what treatment in adolescence?
Hip replacement
What is the first clinical sign of Perthes and which clinical signs follow this?
- Loss of internal rotation (occurs firstly)
- Loss of abduction
- Postive Trendellenburg tests (from gluteal weakness) (occurs last)
What are the treatment options for perthes?
Regular X-ray observation and avoidance of physical activity
Subluxation of the femoral head requires osteotomy of the femur or acetabulum
In SUFE, the growth plate is not ________ _________
Strong enough
(to support the body weight)
Before SUFE occurs what may occur to trigger the condition?
Growth spurt
How do patients with SUFE present?
Pain and limp
Pain can be felt in the groin or potentially just in the knee
What is the reason knee pain may be the only clinical sign of SUFE?
The obturator nerve supplies both the knee and hip joint and may become irritated
What is the first clinical sign of SUFE?
Loss of internal rotation of the hip
What is the treatment for SUFE?
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)
