Children's orthopaedics - The Big 3

Question 1

Which ethnicities have highest incidence of DDH?

Answer 1

Inuits (eskimo) 25%

Apaches and navajo 5%

Question 2

What are some risk factors for DDH?

Answer 2

First Born
Oligohydramnios
Breech Presentation
Family History
Other lower limb deformities (Not TEV)
Increased weight (>10 lb)

Question 3

What are some signs to test for in DDH?

Answer 3

Ortolani’s Sign
Barlow’s Sign
Piston Motion Sign
The Hamstring Sign

Question 4

What is Ortolani’s sign?

Answer 4

Examiner abducts hip and applies anterior force to reduce hip joint
Palpable sensation of the femoral head slipping into the acetabulum

Question 5

What is Barlow’s sign?

Answer 5

Examiner adducts hip and applies posterior force to promote dislocation
Used identify unstable hip which can be passively dislocated

Question 6

What is a good test for DDH?

Answer 6

USS should be used for early diagnosis

X-rays may show too late as femur does not ossify until about 3 months

Question 7

How would an infant <3 months with DDH be treated?

Answer 7

90% respond to simple splint

Question 8

How is a 3-12 month old child treated for DDH?

Answer 8

Closed reduction and spica cast

Question 9

How is a 12-18 month old child treated for DDH?

Answer 9

Open reduction with femoral shortening

Peri-acetabular osteotomy

Question 10

How are children over 6 years treated for DDH?

Answer 10

Nada

Question 11

How does Perthe’s disease usually present?

Answer 11

Male
Primary school age
Short stature
Limp
Knee pain on exercise
Stiff hip
Systemically well

Question 12

What are some possible causes of DDH?

Answer 12

Avascular necrosis of hip
Coagulation tendency
Repeated minor trauma
Family history
Often low social status

Question 13

What are the 4 Waldenstrom stages of DDH radiographic appearance?

Answer 13

Initial
Fragmentation
Reossification
Healed

Question 14

What are some significant factors in prognosis for DDH?

Answer 14

Younger do better
Proportion of head involved
Herring grade
We want head as round as possible for good prognosis

Question 15

How is DDH managed?

Answer 15

Maintain hip motion
Analgesia
Restrict painful activity
Splints
Physio
Consider osteotomy for older children >7

Question 16

What is SUFE?

Answer 16

Slipped Upper Femoral Epiphysis

Question 17

What are some risk factors for SUFE?

Answer 17

Many overweight
Small proportion endocrine abnormalities
Teenage boys 9-14

Question 18

How does SUFE present?

Answer 18

Pain in hip or knee
Externally rotated posture and gait
Reduced internal rotation, especially in flexion
Plain x-rays

Question 19

What is the pathology of SUFE?

Answer 19

Displacement through hypertrophic zone

Metaphysis moves anterior and proximal

Question 20

How is SUFE treated surgically?

Answer 20

Usually pinned in situ

Maybe open reduction if unstable

Question 21

What is Trethowan’s sign?

Answer 21

Used to diagnose slipped capital femoral epiphysis (also called slipped upper femoral epiphysis)
In this sign, the line of Klein passes above the femoral head

Question 22

How might SUFE progress?

Answer 22

AVN
Chondrolysis
Deformity
Early osteoarthritis
Possibility of slip on other side
Limb length discrepancy
Impingement

Question 23

What are some possible deformities from SUFE?

Answer 23

Short
Externally rotated
Limited flexion

Question 24

What is AVN?

Answer 24

Avascular necrosis

Question 25

Is AVN more likely in stable or unstable SUFE slips?

Answer 25

Unstable