Children’s Orthopaedics – ‘The Big 3’ - DDH, Perthes’ Disease, SUFE Flashcards
What are the 3 most common childhood hip problems?
- DDH: developmental dysplasia of the hip
- Perthes disease
- SUFE: slipped upper femoral epiphysis
Who tends to get DDH? Which hip is most commonly affected? When is the condition usually identified?
- More common in girls & first borns
- Usually left hip
- Usually identified during the newborn, 6 week or 8 month baby checks
Risk factors for DDH?
- First born / high birth weight
- Oligohydramnios (reduced fluid w/in uterus)
- Breech presentation (feet / buttocks of baby closest to cervix)
- Family history
- Other lower limb deformities (not TEV)
Clinical signs of DDH?
- Ortolani’s Test (neonates): abduction of hip causes joint reduction with a clunk
- Barlow’s Test (neonates): gentle posterior pressure with legs adducted causes dislocation / subluxation
- Hamstring sign: thigh flexed up onto abdomen and knee extended, knee shouldn’t extend fully unless hip is dislocated
Symptoms / signs of DDH?
- One leg appears longer than the other
- Abnormal gait / limp
- Pain if detected late on
Investigations for suspected DDH?
- Ultrasound**
- X-Ray if late on, but not useful until after a year in some children as ossification of the head of the femur has yet to occur
Treatment of DDH?
- If child < 3 months old: 90% resolve with splintage. Most common splint is Pavlik Harness
- 3 months - 1 yr old: reduction under anaesthetic and spika plaster cast
- Over 1 yr: surgical reduction + capsule reefing
- Over 18 months: open reduction with femoral shortening +/- periactetabular osteotomy
When is DDH left untreated? Which condition can develop from DDH and often has poor prognosis?
- If diagnosis is make past age 6 and the DDH is bilateral
- If diagnosis is made past age 10 in unilateral cases
- Avascular necrosis of head of femur (Usually requires surgical intervention)
How are babies screened for DDH in the UK?
Selective ultrasound screening
- Every baby examined at birth, if any question of hip deformity progress to ultrasound screening
- High birth weight babies and those with other lower limb deformities are often also given ultrasounds
What is Perthes disease known as in the USA?
Legg - Calve - Perthes Disease
Who tends to get Perthes Disease?
- Males
- Primary school age (3 - 12 years)
- Family history
- Classically occurs in low-socially economic status
What is Perthes disease?
Avascular necrosis of the femoral head of unknown aetiology
Signs / symptoms of Perthes disease?
- Short stature
- Limp
- Knee pain on exercise
- Stiff hip joint
- Systemically well
Radiological signs of Perthes disease?
- Increased joint space
- Sclerosis
- Altered shape of femoral head
- Osteophytes
What are the Waldenstrom stages of Perthes disease?
Classification of radiographic appearances
- Initial stage
- Fragmentation stage
- Reossification stage
- Healed stage
What factors affect the prognosis of Perthes disease?
- Younger age at presentation leads to better prognosis
- Proportion of femoral head involved
- How round the femur re-ossifies
- Herring grade (grade given to hip based on height to which the collapse of the femur extends)
Treatment of Perthes disease?
- Maintain hip motion, analgesia & restrict painful movements
- “supervised neglect” in most cases
- Consider osteotomy in selected groups of older children (> 7 yrs)
Who tends to get SUFE (slipped upper femoral epiphysis)? Is the injury usually uni or bilateral?
- Boys aged 10-15
- Usually obese
- 20% bilateral
Symptoms of slipped upper femoral epiphysis?
- Hip / groin pain (better with rest)
- Referred pain in KNEE
- Pain on weight bearing
- Affected leg appears shorter & externally rotated
What’s another name for slipped upper femoral epiphysis?
- Slipped capital femoral epiphysis
What are some different ways in which SUFE is classified?
- Acute vs Chronic (3 wks)
- Magnitude of slip (angle / proportion)
- Stable vs unstable (can the child weight bear?)
Investigations for SUFE? Common radiological findings?
X-Ray (often better seen from lateral angle)
- Femoral epiphysis in abnormal (slipped) position in relation to femoral neck.
- Trethowan’s sign: line drawn parallel to neck of femur should evenly divide epiphysis. If line is superior to epiphysis on either side: slip
Which part of the femur is actually displaced in a slipped upper femoral epiphysis?
The metaphysis
Metaphysis moves anterior and proximal, puts the epiphysis and the neck out of line
Treatment of SUFE?
Screw fixation through metaphysis to fix joint alignment
Possible late complications of SUFE?
- Limb length discrepancy
- Early osteoarthritis
