Children orthopaedics: big three - DDH, Perthes', SUFE

Question 1

What are risk factors for DDH?

Answer 1

First born, oligohydramnios, breech presentation, FH, other LL deformities. Girls 6:1.

Question 2

What is the clinical signs of developmental dysplasia of the hip (DDH)?

Answer 2

Ortolani’s sign
Barlow’s sign
Piston Motion sign

Question 3

Describe Ortolani’s sign

Answer 3

if hip is dislocated, characteristic clunk felt as femoral head slides over posterior rim of acetabulum and is reduced.

Question 4

Describe Barlow’s sign

Answer 4

examiner grasps infant’s thigh near hip and with gentle posterior/lateral pressure, attempts to dislocate the femoral head from acetabulum;
normally no motion in this direction;
if hip is passively dislocatable (Aka unstable), a distinct ‘clunk’ may be felt as femoral head pops out joint.

Question 5

What are the treatments for DDH?

Answer 5

Pavlik harness

Open/closed reduction surgery

Question 6

What are complications of DDH?

Answer 6

Developing a limp
Hip pain – esp during teenage years
Painful and stiff joints (OA)

Question 7

What is Perthes’ disease?

Answer 7

Occurs when blood supply to femoral head is disrupted, bone can die (osteonecrosis or AVN) and stop growing. M 5:1. 15% bilateral.

Question 8

How does Perthes’ disease present?

Answer 8

Primary school age
Short stature
Limp 
Knee pain on exercise
Stiff hip joint 
Systematically well

Question 9

How do you manage Perthes’ disease?

Answer 9

Maintain hip motion 
Analgesia
Restrict painful activities 
‘Supervised neglect’ in most cases 
‘Containment’ – consider osteotomy in selected groups of older children (>7) 
Prognosis good onset <9 years

Question 10

What are the complications of Perthes’ disease?

Answer 10

Avascular necrosis 
OA
Shortening of limb on affected side
Stiffness and loss of rotation
Deformed femoral head

Question 11

What is slipped upper femoral epiphysis (SUFE)?

Answer 11

Head of femur slips off the neck in backward motion. Teenage B>G, 20% become bilateral.

Question 12

How does SUFE present?

Answer 12

Pain in hip or knee
Externally rotated posture + gait
Reduced internal rotation, especially in flexion

Question 13

How do you manage stable SUFE?

Answer 13

Stable (still able to WB):

• In situ fixation (1st line)
• Open reduction + internal fixation with surgical hip dislocation (2nd line)
• Bone graft epiphysiodesis (3rd line)
• Prophylactic fixation of contralateral hip

Question 14

How do you manage unstable SUFE?

Answer 14

In situ screw fixation/urgent surgical repair

Prophylactic fixation of contralateral hip

Question 15

What are the complications of SUFE?

Answer 15

Avascular necrosis (unstable slips have higher risk)
Chrondrolysis (progressive loss of articular cartilage)
Deformity
Early OA