Developmental Dysplasia of the Hip, Perthes Disease and Slipped Upper Femoral Epiphysis

Question 1

Growth plates in children

Answer 1

Remodelling
Physeal arrest
Displacement
Length discrepancies

Question 2

Bone in children

Answer 2

Collagen
Porosity
Cellularity
Plasticity

Question 3

Periosteum in children

Answer 3

Metabolically active

Thick and strong

Question 4

Ligaments in children

Answer 4

Relatively strong, it is the bone that fails rather than the ligament

Question 5

Cartilage in children

Answer 5

Thicker and stronger

Imaging difficult

Question 6

“normality in children”

Answer 6

Wide variation is normal
Age related physiological and structural changes
Function over form
Avoiding labels

Question 7

Normal lower limb development

Answer 7

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

Question 8

If distance between knees is around 18cm and is symmetric

Answer 8

Physiological varus

GP review at 18 months

Question 9

If the distance between the knees is more than 18 cm

Answer 9

Possible bow legs

Refer to orthopaedic

Question 10

If distance between the knees is 18 or below or the children is older than 7

Answer 10

Refer to orthopaedics, possible knock knee

Question 11

If distance is 18cm and the child is under the age of 7

Answer 11

Physiological valgus have a GP review at 7 years

Question 12

Causes of intoeing

Answer 12

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)

Question 13

What is the normal presenting complaint of intoei

Answer 13

Parents start to notice when the child begins to walk, there will be increased tripping and the feet will go inward

Question 14

Femoral Anteversion test

Answer 14

This will be able to hugely externally rotate. This is usually bilateral.

Question 15

Femoral anteversion

Answer 15

Developmental norm. 40 degrees at birth, there is an increase of 1-2 degrees per year.

Question 16

Internal Tibial Torsion

Answer 16

Increased thigh foot angle

90% spontaneously resolve which splints and wedges

Question 17

Metatarsus Adductus

Answer 17

1/1000 live births

90% resolve by 1 year

Question 18

Flexible Flat feet

Answer 18

Normal at birth 
Diminishes with age 
The arch is absent when standing
The arch reappears on sitting or tip toes 
Treat with insoles

Question 19

5’s in childrens orthopaedics

Answer 19

Symptoms - night pain
Symmetry - lack 
Stiffness - of joints, paralysis
Syndromes - associated features
Systemic illness - pyrexia

Question 20

Incidence of Developmental Displasia of the hip

Answer 20

2.4/1000

Occurs in girls (6:1) and tends to affect the left hip

Question 21

Increased incidence of DDH results from

Answer 21

First Born
Oligohydramnios
Breech Presentation
Family History
Other lower limb deformities
Increased weight

Question 22

Clinical Features of DDH

Answer 22

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)

Question 23

X-ray findings of DDH

Answer 23

May show up too late as the head of the femur doesnt ossify until the child is at least 3 months old

Question 24

Treatment of DDH

Answer 24

< 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

Question 25

Perthes Disease a typical story

Answer 25

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

Question 26

Aetiology of Perthes Disease

Answer 26

Pathalogically avascular necrosis of the hip Pathalogically avascular necrosis of hip Possible relationship to coagulation tendancy Possible relationship to repeated minor trauma Familial tendancy

Question 27

Radiological Stages of Perthes Disease

Answer 27

Initial Stage Fragmentation Stage Reossification Stage Healed Stage

Question 28

Prognosis of Perthes Disease

Answer 28

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)

Question 29

Treatment of Perthes Disease

Answer 29

``` 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) ```

Question 30

SUFE (slipped upper femoris epiphysis)

Answer 30

1 - 10 per 100,000 Teenage boys > girls (9 - 14 yrs) 20% become bilateral Many overweight

Question 31

SUFE classification

Answer 31

``` Acute v Chronic (3wks) Magnitude of slip (angle or proportion) Stable v unstable (Loder) - unstable - unable to weight bear -stable - able to weight bear ```

Question 32

SUFE detection

Answer 32

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

Question 33

Pathology of SUFE

Answer 33

Displacement through hypertrophic zone Metaphysis moves anterior and proximal

Question 34

Operative Treatment of SUFE

Answer 34

Stable pin in situ

Question 35

Possible outcomes of SUFE

Answer 35

``` AVN Chondrolysis Deformity (short, ext rotated, limited flexion) Early osteoarthritis Possibility of slip on other side Limb length discrepancy Impingement ```