Children’s Orthopaedics – "The Big 3" Flashcards
What are the 3 main childhood hip problems?
- Developmental dysplasia of the hip (DDH)
- Perthes disease
- Slipped upper femoral epiphysis (SUFE)
How common is DDH?
- Aberdeen - 2.4 per 1000 births
- F:M 6:1
- LH:RH 3:1
What are the risk factors for DDH?
- First Born
- Oligohydramnios
- Breech Presentation
- Family History
- Other lower limb deformities (Not TEV)
- Increased weight (>10 lb)
What are the clinical features of DDH?
- Ortolani’s Sign
- Barlow’s Sign
- Piston Motion Sign
- The Hamstring Sign
What imaging do you use to identify DDH?
- X-ray may show signs too late
* Use ultrasound for early diagnosis
How is DDH treated in <3 months?
90% resppond to a simple splint
How is DDH treated in 3 months - 1 year?
Closed reduction and spica cast
How is DDH treated in >1 year?
Open reduction and capsule reefing
How is DDH treated in >18 months?
Open reduction with femoral shortening ± peri-acetabular osteotomy
How is DDH treated in >6 years when bilateral?
Leave alone
How is DDH treated in >10 years when unilateral?
- Leave alone
- The older the child the poorer the result
- Worst results are associated with AVN of head
What are the requirements to use examination to screen for DDH?
- Baby relaxed and examined early
* Examiner experienced and has time
Why is examination less useful when screening for DDH?
•Does not identify all dysplastic hips
Why is universal ultrasound useful when screening for DDH?
•Eliminates number of late presenters
Why is universal ultrasound less useful when screening for DDH?
- May not be cost effective
- Time consuming/massive workload
- Difficulty with compliance and follow-up
Why is selective ultrasound useful when screening for DDH?
- Work-load manageable
* Reduces late presentation
Why is selective ultrasound less useful when screening for DDH?
Late presentation will still occur
How does Perthes disease present?
- Short stature
- Limp
- Knee pain on exercise
- Stiff hip joint
- Systemically well
Who gets Perthes disease?
- Males
* Primary school age
What is the pathology of Perthes?
- Avascular necrosis o the hip
- Possible relationship to coagulation tendency
- Possible relationship to repeated minor trauma
- Familial tendency
- Classically low social status
What are the 4 Waldenstrom stages used to describe the radiographic appearance of Perthes?
- Initial stage
- Fragmentation stage
- Reossification stage
- Healed stage
What affects the prognosis of Perthes?
- Age at presentation - younger do better
- Proportion of head involved
- Herring grade (lateral Pillar classification)
- Radiographic “head at risk signs” Caterall
- The nearer the head is to round, the better the outlook (Stulberg)
How is Perthes treated?
- Maintain hip motion
- Analgesia
- Restrict painful activities
- Splints, physio, NWB not proven
- “Supervised neglect” in most cases
- Consider osteotomy in selected groups of older children (>7)
- 10% bilateral
How does slipped upper femoral epiphysis (SUFE) present?
- Pain in hip or knee
- Externally rotated posture & gait
- Reduced internal rotation, especially in flexion
- Painful to weight bear
Who gets SUFE?
- Teenage boys > girls (9 - 14 yrs)
- 20% become bilateral
- Many overweight
- Small proportion endocrine abnormalities
What 3 factors are used to classify SUFE?
•Acute v Chronic (3wks)
•Magnitude of slip (angle or proportion)
•Stable v unstable (Loder)
-Unstable = unable to weight-bear (poor prognosis)
-Stable = Able to weight-bear (good prognosis)
What imaging is used to investigate SUFE?
Plain x-rays
What radiographic features indicate severity of SUFE?
- Mild <1/3
- Moderate 1/3-1/2
- Severe >1/2
All relative to width femoral neck on AP film
What is the pathology of SUFE?
- Displacement through hypertrophic zone
* Metaphysis moves anterior and proximal
How is SUFE treated?
SURGICALLY
•Stable slips - usually pinned in situ
•Severe unstable slips - consider open reduction but AVN high risk
What is Klein’s line?
Line drawn along superior border of femoral neck should cross at least a portion of the femoral epiphysis
What sign is used to help identify SUFE on an AP film?
Trethowan’s
What are the potential complications of SUFE?
- AVN
- Chondrolysis
- Deformity (short, ext. rotated, limited flexion)
- Early osteoarthritis
- Possibility of slip on other side
- Limb length discrepancy
- Impingement
How does the nature of the slip affect the risk of AVN in SUFE?
- Stable slips (able to bear weight) have a low risk of AVN.
* Unstable slips (unable to bear weight) have a high risk of AVN.
