Children’s Orthopaedics – ‘The Big 3’ - DDH, Perthes’ Disease, SUFE Flashcards
in paediatric orthopaedics what are the big three?
DDH - Developmental dysplasia of the hip
Perthes Disease
SUFE - Slipped upper femoral epiphysis
what developmental dysplasia of the hip?
Developmental dysplasia of the hip (DDH) is a condition where the “ball and socket” joint of the hip does not properly form in babies and young children
In DDH, the socket of the hip is too shallow and the femoral head is not held tightly in place, so the hip joint is loose. In severe cases, the femur can come out of the socket (dislocate)
what is the incidence of DDH in different parts of the world?
Northern Europe - 0.7 to 2.2 per 1000
Eastern Europe - 28.7 per 1000
African Neonates - 0
Apaches and Navajos - 5%
Aberdeen - 2.4 per 1000 deaths
what is the incidence between boys and girls
girls 6 to 1
what is the incidence. between the right and left hip?
left hip 3 to 1
there is increased incidence of DDH in who?
First Born
Oligohydramnios (reduced fluid in the uterus)
Breech Presentation - hen the fetus presents buttocks or feet first (rather than head first – a cephalic presentation)
Family History
Other lower limb deformities (not TEV)
Increased weight (>10lb)
what are some clinical features of DDH?
Ortolani’s Sign - positive Ortolani sign is noted if the hip is dislocated, by a characteristic clunk that is felt as the femoral head slides over the posterior rim of the acetabulum and is reduced
Barlow’s Sign - In a positive finding, there is a palpable clunk as the hip reduces back into position
Piston Motion Sign
The hamstring sign
In children can see if one leg is longer
Only pick up 40% of DDH by examination
what is used for early diagnosis?
Babies not x-rayed at birth to look for DDH and this is partly due to x-ray exposure and on average the head of the femur does not ossify until the child is at least 3 months old, use US for early diagnosis
what is the treatment of DDH?
AVN = avascular necrosis and can become arthritis if it becomes a abnormal shape
how is screening for DDH done?
Selective ultrasound screening done in the uk
Legg-Calve-Perthes Disease is also known as what?
Also known as perthes disease
what is perthes disease?
Perthes disease is a rare childhood condition that affects the hip. It occurs when the blood supply to the rounded head of the femur (thighbone) is temporarily disrupted. Without an adequate blood supply, the bone cells die, a process called avascular necrosis
who does perthes disease occur in?
- Male 5:1 Female
- 15% bilat
- Primary school age
what does perthes disease cause?
- Short stature
- Limp
- Knee pain on exercise
- Stiff hip joint
- Systemically well
what is the aetiology of perthes disease?
radiographic appearances can be put into four different waldenstrom stages which are what?
1 - slcerosis and increased joint space
2 - epithysis breaking up
3 - new bone
Avascular necrosis
Fragmentation - Revascularisation (pain)
Reossification - Bony healing
Residual deformity
what are some differential for perthes disease?
Unilateral - Septic hip, JIA, SCFE, Lymphoma
Bilateral - Hypothyroid, Sickle, Epiphyseal dysplasia
what does the prognosis of perthes disease depend upon?
what is the treatment of perthes disease?
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 <9y
Splints, physio, NWB not proven
what is SCFE also known as?
Slipped capital femoral epiphysis – aka SUFE
Slipped upper femoral epiphysis
what is SUFE?
Slipped Upper Femoral Epiphysis is a condition that happens in late childhood/early adolescence where the epiphysis (the growth center) of the femoral head displaces or slips out of alignment from the rest of the femur. As a result, there is a change in shape of the hip joint
who does SUFE occur in?
what are the different classifications of SUFE?
Acute v Chronic (3wks)
Magnitude of slip (angle of proportion)
Stable v unstable (Loder):
- Unstable = unable to weight-bear (poor prognosis)
- Stable = able to weight-bear (good prognosis)
what is the presentation of SUFE and how is it detected?
Pain in hip or knee
Externally rotated posture & gait
Reduced internal rotation, especially in flexion
Plain x-rays - best seen on lateral view
whata re the radiographic fetures and how is the severity classified?
Classify magnitude on the with of the femur relative to the amount of slippage
All relative to width femoral neck on AP film
Mild <1/3
Moderate1/3-1/2
Severe>1/2
what is the pathology of SUFE?
Displacement through hypertrophic zone
Metaphysis moves anterior and proximal
Inferiorly is metaphaseal bone, superior is the epithysis and growth plate in-between
what operative treatment can occur?
Pins to stop slippage occurring
Severe unstable slips consider open reduction but AVN is high risk
what are the outcomes of SUFE?
AVN (high risk of this in unstable slips)
Chondrolysis
Deformity
Early osteoarthritis
Possibility of slip on other side
Limb length discrepancy (younger the child bigger the discrepancy)
Impingement
what is 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
Quiz
Aged 13
Left groin pain 3 months
Short, externally rotated
Painful to weight bear
what is his diagnosis?
SCFE/SUFE
what is the differential?
Painless limp x 2m
Now knee painful
Reduced abduction
Leg lengths equal
Transient synovitis
Infection
SCFE
Missed DDH
JIA
Lymphoma
Perthes
