Developmental Dysplasia of the Hip, Perthes Disease and Slipped Upper Femoral Epiphysis Flashcards
Growth plates in children
Remodelling
Physeal arrest
Displacement
Length discrepancies
Bone in children
Collagen
Porosity
Cellularity
Plasticity
Periosteum in children
Metabolically active
Thick and strong
Ligaments in children
Relatively strong, it is the bone that fails rather than the ligament
Cartilage in children
Thicker and stronger
Imaging difficult
“normality in children”
Wide variation is normal
Age related physiological and structural changes
Function over form
Avoiding labels
Normal lower limb development
Bow leg is common under the age of 2
Knock-knee is common between the ages of 2 and 7
By the teens the legs shouldve straightened out
If distance between knees is around 18cm and is symmetric
Physiological varus
GP review at 18 months
If the distance between the knees is more than 18 cm
Possible bow legs
Refer to orthopaedic
If distance between the knees is 18 or below or the children is older than 7
Refer to orthopaedics, possible knock knee
If distance is 18cm and the child is under the age of 7
Physiological valgus have a GP review at 7 years
Causes of intoeing
Femoral anteversion (inward twisting of the thigh bone, also known as the femur)
Internal tibial torsion (tibia is internally rotated)
Metatarsus adductus ( metatarsus varus, is a common foot deformity noted at birth that causes the front half of the foot, or forefoot, to turn inward)
What is the normal presenting complaint of intoei
Parents start to notice when the child begins to walk, there will be increased tripping and the feet will go inward
Femoral Anteversion test
This will be able to hugely externally rotate. This is usually bilateral.
Femoral anteversion
Developmental norm. 40 degrees at birth, there is an increase of 1-2 degrees per year.
Internal Tibial Torsion
Increased thigh foot angle
90% spontaneously resolve which splints and wedges
Metatarsus Adductus
1/1000 live births
90% resolve by 1 year
Flexible Flat feet
Normal at birth Diminishes with age The arch is absent when standing The arch reappears on sitting or tip toes Treat with insoles
5’s in childrens orthopaedics
Symptoms - night pain Symmetry - lack Stiffness - of joints, paralysis Syndromes - associated features Systemic illness - pyrexia
Incidence of Developmental Displasia of the hip
2.4/1000
Occurs in girls (6:1) and tends to affect the left hip
Increased incidence of DDH results from
First Born Oligohydramnios Breech Presentation Family History Other lower limb deformities Increased weight
Clinical Features of DDH
Barlow Test - the hips are gently pushed posteriorly to elicit the “exit clunk” of the dislocatable joint and then circumducted with forward pressure over the greater trochanters to produce the entry clunk of the dislocated hip (Ortolanis test)
X-ray findings of DDH
May show up too late as the head of the femur doesnt ossify until the child is at least 3 months old
Treatment of DDH
< 3months 90% respond to simple splint
3 Months to 1 year Closed reduction and spica cast
Over a year open reduction and capsule reefing
Over 18 months open reduction with femoral shortening
Over aged 6 and bilateral leave alone
Over aged 10 and unilateral leave alone
Perthes Disease a typical story
Male Primary school age Short stature Limp Knee pain on exercise Stiff hip joint Systemically well
Aetiology of Perthes Disease
Pathalogically avascular necrosis of the hip
Pathalogically avascular necrosis of hip
Possible relationship to coagulation tendancy
Possible relationship to repeated minor trauma
Familial tendancy
Radiological Stages of Perthes Disease
Initial Stage
Fragmentation Stage
Reossification Stage
Healed Stage
Prognosis of Perthes Disease
Age at presentation : younger do better
Proportion of head involved
Herring grade
Radiographic “head at risk signs” Caterall
The nearer the head is to round, the better the outlook (Stulberg)
Treatment of Perthes Disease
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)
SUFE (slipped upper femoris epiphysis)
1 - 10 per 100,000
Teenage boys > girls (9 - 14 yrs)
20% become bilateral
Many overweight
SUFE classification
Acute v Chronic (3wks) Magnitude of slip (angle or proportion) Stable v unstable (Loder) - unstable - unable to weight bear -stable - able to weight bear
SUFE detection
Pain in hip or knee
Externally rotated posture & gait
Reduced internal rotation, especially in flexion
Plain x-rays
Pathology of SUFE
Displacement through hypertrophic zone
Metaphysis moves anterior and proximal
Operative Treatment of SUFE
Stable pin in situ
Possible outcomes of SUFE
AVN Chondrolysis Deformity (short, ext rotated, limited flexion) Early osteoarthritis Possibility of slip on other side Limb length discrepancy Impingement
