Childhood problems Flashcards
what are normal deformities seen in children?
up to 2 years bowing of legs is normal (Genu Vara)
from 3-4 knee-knoking is normal (Genu Valgus)
adopt correct adult alignment by age of 9
in toeing is more normal in children
what is SUFE?
slipped upper femoral epiphysis
the femoral epiphysis and head slips in the posterior inferior direction with respect to the metaphysis and shaft (i.e. metaphysis in superior anterior direction).
this is due to a pathological fracture straight through the physeal plate (Salter Harris class I)
most commonly seen in teens and pre-teens who are still growing.
who is SUFE most likely to affect?
most common in boys
children during rapid growth phase e.g. boys at 13 and girls at 11
What are the symptoms of SUFE?
usually gradual onset of:
- hip, groin, medial thigh and knee pain
- abnormal gait or unable to walk if unstable
- unstable presents as shortened and externally rotated.
- stiffness and instability
- reduced range of movement particularly abduction and internal rotation
- may be history of trauma
- on examination muscle spasms/ guarding.
what are the different types of SUFE?
Stable: able to walk on affected hip
Unstable: unable to weight bear due to more severe slipping. more uncommon but requires urgent treatment
Pre slip: wide epiphyseal but no slip
acute: sudden slipping
Acute on chronic
chronic: gradual slipping. most common
what investigations are necessary if you suspect SUFE?
Xrays - AP and frog leg lateral view
bloods to rule out septic arthritis
what are the causes and risk factors for SUFE?
caused by abnormal cartilage in physeal plate
OR by excess forces through plate (obesity)
risk factors: obesity, FHx, trauma, septic arthritis, endocrine problem (GH and Vit D deficiency, hyperthyroid)
what is the sign seen on XRAY in SUFE?
may be able to see the displacement
Classic sign: Trethowans sign:
- draw a line along superior femoral neck surface (Klein line) and in normal hip this should intersect part of the femoral head. If there is slippage it does not intersect.
also check Xray for any underlying abnormalities e.g. renal osteodystrophy or rickets.
How is SUFE managed?
for best outcome early diagnosis and treatment
surgery required to prevent any further slipping. If already displaced considerable then reduction is also required.
- in situ fixation requiring metal screw through femoral growth plate.
- if displaced femoral neck osteotomy and reduction too.
surgery within 24-48 hours
what are the complications of SUFE?
malunion - can lead to AVN
AVN - risk of damage to vessels with severe slipping (unstable) leading to osteonecrosis
both malunion and AVN can lead to early OA
Chondrolysis - articular cartilage degenerates rapidly leading to pain, deformity and loss of motion in that hip. rare but needs aggressive treatment with NSAIDs and physio
contralateral slip
Coxa Vara: angle between head and shaft of femur >120 degrees
how can SUFE be classified by severity?
mild: <33% displaced
moderate: 33-50%
severe: >50%
what is Perthes disease?
A rare childhood condition whereby there is temporary disruption of blood supply to femoral head resulting in AVN.
describe the pathogenesis behind Perthes disease?
in children (3-7yrs) the lateral epiphyseal vessles of the retinacular arteries are the main supply to femoral head
most likely there is stretching of these vessels or compression by effusion due to injury/synovial inflammation.
This causes ischaemia and partial necrosis of femoral head.
blood supply eventually returns and the necrotic bone is remoced and replaced by soft bone (weak and at risk of breaking). After 2 yrs fully ossified and stronger.
How does Perthes disease present?
changes in walking/ running e.g. limp pain in hip/ groin or knees pain worse with activity reduced abduction and internal rotation on examination may find atrophy or quads or possibly positive trendenburg (due to pain in gluteus medius)
who does Perthes most commonly affect?
most commonly children between 4 and 8
what investigations can be done if Perthes disease is suspected?
bloods: rule out septic arthritis (FBC)
Xray -
- early signs: joint effusion, widening of joint space
- late signs: flattening of femoral head and eventual displacement and collapse
how do we treat mild - moderate Perthes disease?
perthes does heal by itself however we need to ensure this occurs with minimal deformity. Therefore in cases where there is only mild disease:
- bed rest initially (no weight bearing)
- NSAIDs
- wear a petrie cast (keep legs far apart, abducted and internally rotated) for 4-6 weeks
- physio
- eventually light exercise but avoid jumping/running
- regular Xrays to ensure progression in correct direction
how do we treat moderate - severe perthes disease?
may require surgery to reduce the femoral head to a good posion
osteotomy and fixation - cut bone into place and fix with plates/screws that can later be removed
cased 6-8 weeks + physio
What is the outcome of Perthes disease?
Most children heal and go into adulthood with no hip problems -
sometimes deformity leads to OA, limb shortening and pain/loss of function
can lead to osteochondritis dissicans.
what predicts outcome of Perthes disease?
The degree of damage to femoral head and the healing process determines future deformity.
The younger the child the better the outcome
when is surgery indicated in perthes disease?
> 8yrs (associated with deformity)
50% of femoral head damage
failed conservative treatment
what is transient synovitis of the hip?
the most common cause of hip pain in children.
who does transient synovitis of the hip mainly affect?
children aged 4-8
what are the symptoms of transient synovitis of the hip?
acute onset:
- mild/absent fever
- pain in groin/thigh
- worse on awakening and improves
- hip in FABER position
improvements within 48 hours and resolved within a week
how would you investigate and manage transient synovitis of the hip?
high ESR/CRP
need to rule out septic arthritis so take FBC and use the Kochers criteria to assess likelihood.
Xrays - AP , lateral , frog leg.
if < or = 2 - NSAIDS (likely to be transient synovitis of the hip)
>2 - aspirate to check
4 or more - treat as septic arthritis
what is congenital hip dislocation/dysplasia?
A condition whereby the hip does not develop properly and remains loose in the acetabulum resulting in instability ranging from dislocation, to dislocatable to subluxation
what are the risk factors for congenital hip dislocation/dysplasia?
female family history breached birth first born child oligiohydramnios
what are the symptoms of congenital hip dislocation/dysplasia?
usually present at birth but can develop up to 1 yrs
reduced abduction
instability
altered gait: limping, toe walking, waddling
leg length discrepancy
what investigations should be carried out for congenital hip dislocation/dysplasia?
usually screen babies especially if FHx or born breached.
under 3 months - Ortolani test or Barlow test
3-6 months: Galeazzis test and look for asymmetry in skin folds
USS of hip at less than 25 weeks
Xray if suspected - look for femoral head not fitting properly into acetabulum. use shenton and perkins lines to help
what treatment is available for congenital hip dislocation/dysplasia?
usually treated with a Pavlik harness for 1-2 months which holds the femoral head in the acetabulum to promote normal development
sometimes closed reduction under GA is required followed by a body cast (Spica cast) for 2-3 months
sometimes surgery is required involving acetabular osteotomy and attachment of the labrum. (usually surgery required when child has started walking)
physio and NSAIDs
what are the complications of congenital hip dislocation/dysplasia (including complications of treatment)?
Complications of disease:
- If not picked up early can lead to early onset OA
- Osteonecrosis
from treatment:
- Pavlik harness can cause skin irritation
- Spica cast delays walking.
what is the ortolani’s test?
Apply anterior pressure to femoral head to feel it relocating. test for congenital hip dislocation/dysplasia
