Children's Orthopaedics - The Big 3 - DDH, Perthes, SUFE Flashcards
Is developmental dysplasia of the hip (DDH) more common in boys or girls
Girls 6:1
Risk factors for DDH
- First born
- Beach presentation
- Oligohydramnios
- FHx
- Other LL deformities
- Increased weight
Clinical features of DDH
- Ortolani’s sign
- Barlow’s sign
- Piston motion sign
- The hamstring sign
Why are x-rays not great at detecting DDH
- On average the head of the femur doesn’t ossify until 3 months
- Which is too late
Rx of DDH
- <3mth simple splint (90% respond)
- 3-12mth closed reduction + spica cast
- > 1yr open reduction + capsule reefing
- > 18mth open reduction + femoral shortening
- > 6yr + bilateral leave alone
- > 10yr + unilateral leave alone
Older the child the poorer the results
How to screen for DDH
- Clinical exam (only picks up 40%)
- US (universal or selective)
Typical presentation of Perthes disease
- Boy
- Primary school age
- Short stature
- Limp
- Knee pain on exercise
- Stiff hip joint
- Systemically well
Aetiology of Perthes disease
- Pathological avascular necrosis of the hip
- Possible relationship w/ coagulation tendency + repeated minor trauma
- FHx
- Classically low social class
4 stages of Perthes disease seen on a radiograph
4 Waldenstorm stages
- Initial stage
- Fragmentation stage
- Reossification stage
- Healed stage
Prognosis of Perthes disease
- Younger do better
- Proportion of head involved
- Herring grade
- The nearing the head is to the round the better the outlook (Stulberg)
Rx of Perthes disease
- Analgesia
- Restrict painful activities
- Splints + physio
- Consider osteotomy in children >7yrs
What is slipped upper femoral epiphysis (SUFE)
- Usually presents after minor trauma
- There is displacement through the growth plate, with the epiphysis always slipping down and back
Risk factors for SUFE
-Male
-Overweight
-
Typical presentation of SUFE
- Boy
- 10-16yrs
- Overweight
- Limp
- Pain groin, knee or ant. thigh
Externally rotated posture + gait
Reduced IR, especially in flexion
How to classify SUFE
- Chronic vs acute
- Magnitude of slip (angle or proportion)
- Stable vs unstable
Chronic vs acute SUFE
> 3 weeks = chronic
Stable vs unstable SUFE
- Stable (90%) = able to bear weight (good prognosis)
- Unstable (10%) = unable to bear weight (bad prognosis)
Investigations for SUFE
- AP radiograph
- Frog-leg lateral radiograph
Of both hips
What can delayed diagnosis of SUFE lead to
- Progression of slip w/ increased risk of early OA
- Stable lesions becoming unstable
- AVN of femoral head
Rx of SUFE
- Early internal fixation (to stabilise any slippage + encourage physeal closure)
- Prophylactic fixation remains controversial and is assessed on a case by case basis
What types of SUFE have low and high risk of AVN
- Stable = Low risk
- Unstable = High risk
Why should one have a high index of suspicion for SUFE in 10-16yrs
- Correct age group for SUFE
- Symptoms often mild
- Severe outcomes if missed
If a child has symptoms similar to SUFE but is <10yrs/>16yrs what should be considered
-Endocrinopathy e.g. hypothyroidism or growth hormone imbalance
Possible outcomes of SUFE
- AVN
- Chondrolysis
- Deformity (short, ext. rotated, limited flexion)
- Early OA
- Limb length discrepancy
- Impingement
- Possibility of slip on other side
