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paeds > DISORDERS OF THE HIP AND KNEE > Flashcards

DISORDERS OF THE HIP AND KNEE Flashcards

1
Q

What is the term that has replaced the previous name of congenital dislocation of the hip?

A

Developmental dysplasia of the hip

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2
Q

What is the incidence of developmental dysplasia of the hip?

A

1.5 in 1000 births

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3
Q

What is developmental dysplasia of the hip?

A

Represents a spectrum of hip instability ranging from a dislocated hip to hips with various degrees of acetabular dysplasia.

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4
Q

What is acetabular dysplasia?

A

Where the femoral head stay in position but the acetabulum is shallow.

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5
Q

When does developmental dysplasia of the hip occur?

A

Previously thought to be entirely congenital, but it is now known to also occur after birth in previously normal hips.

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6
Q

What are the two types of developmental dysplasia of the hip?

A

Typical - affecting otherwise normal babies

Teratological - associated with neurological and genetic conditions.

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7
Q

What are the risk factors for developmental dysplasia of the hip?

A

Congenital muscular torticollis

Congenital foot abnormalities

Female sex

First baby - squeezed in more tightly

Breech delivery

Family history

Oligohydramnios

Neuromuscular disorders

Birth weight more than 5 kg

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8
Q

What are the warning signs of developmental dysplasia of the hip when it is not diagnosed at birth?

A

Delayed walking

A painless limp

A waddling gait - Trendelenburg gait

Apparent short femur - unequal knee height (Galeazzi sign)

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9
Q

Why are asymmetrical skin creases not a reliable sign of developmental dysplasia of the hip?

A

Because 30% of all babies will have these

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10
Q

How is developmental dysplasia of the hip usually diagnosed or screened for?

A

6 week check:

Barlow manoeuvre - used to screen for DDH

Ortolani manoeuvre - used to confirm Barlow findings to check that hip is actually dislocated

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11
Q

How do you perform the Barlow manoeuvre?

A

Flex knees and hips to 90˚

Line up legs in parallel to each other in line with shoulders

Apply backward pressure to each knee in turn.

A subluxable hip is suspected on the basis of palpable partial or complete displacement using your finger.

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12
Q

How do you perform Ortolani manoeuvre?

A

Flex knee and hips to 90˚

Line up legs in parallel to each other in line with shoulders

Abduct hip whilst applying anterior pressure on the thigh to relocated the hip.

A relocating hip will be felt with your finger on the joint.

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13
Q

What proportion of cases of developmental dysplasia of the hip will be missed by examination alone (Barlow and Ortolani manoeuvre)?

A

40%

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14
Q

What investigation should be done in addition to examination in babies at high risk of developmental dysplasia of the hip?

A

Ultrasound scanning is diagnostic.

X-rays are not useful until after 4-5 months of age when femoral head has ossified.

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15
Q

What is Allis sign?

A

This is when the femur is shortened. Sometimes associated with DDH.

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16
Q

How do we treat developmental dysplasia of the hip?

A

If less than 8 months:
This involves fixing the hip in abduction. This is usually done with a Pavlik or Von Rosen harness. Harness must be adjusted every two weeks for growth and should be kept on at all times.

If more than 8 months old:
Open reduction and derotation femoral osteotomy needs to be performed, followed by Spica case. Often accelerated degenerative changes might necessitate total hip replacement in early adult life.

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17
Q

What is Perthes’ disease?

A

An idiopathic disorder characterised by osteonecrosis of the femoral head. Caused by impaired blood supply to the femoral head, causing bone infarction.

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18
Q

What are the risk factors for developing Perthes’ disease?

A

Five times as common in males than females

Family history

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19
Q

What ages are children mostly affected by Perthes’ disease?

A

Between 2 - 12

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20
Q

What are the clinical features of Perthes’ disease?

A

Limp - insidious onset

Pain in hip, knee or thigh

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21
Q

What proportion of cases of Perthes’ disease are bilateral?

A

20%

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22
Q

What initial investigation would you do for someone in whom you suspected Perthes’ disease?

A

Hip X-rays

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23
Q

What would you see on hip x-ray of someone with Perthes’ disease?

A

Widening of joint space

Epiphyseal destruction - decreased femoral head size

Deformed acetabula

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24
Q

If hip x-ray was normal but a child continued to show signs of Perthes’ disease, what imaging might you send him or her for?

A

Technetium bone scan

OR

MRI

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25
Q

What is the system used to classify severity of Perthes’ disease? What are the different levels?

A

Catterall staging:

Stage 1 - clinical and histological features only

Stage 2 - Sclerosis with or without cystic changes and preservation of the articular surface

Stage 3 - Loss of structural integrity of the femoral head

Stage 4 - Loss of acetabular integrity

26
Q

How do we manage Perthes’ disease?

A

Need to keep femoral head within acetabulum using cast or braces as well as activity restriction.

Analgesia

Revascularization and reossification occurs with resumption of growth - cycle takes 3-4 years

Surgery may be need if there is deformity

27
Q

What is the prognosis following diagnosis of Perthes’ disease?

A

Usually good especially if under 6 years old.

In older children and those where more than half the epiphysis is involved, femoral deformity occurs in 40% resulting in early arthritis.

28
Q

What are the complications of Perthes’ disease?

A

Permanent deformity

Earlier degenerative arthritis

29
Q

What is the most common cause of hip pain in children?

A

Transient synovitis of the hip (irritable hip)

30
Q

What age are children affected by transient synovitis of the hip?

A

2 - 12 years old

31
Q

What is the aetiology of transient synovitis of the hip?

A

Largely unknown but associated with viral infection

32
Q

What are the clinical features of transient synovitis of the hip?

A

Sudden onset of hip pain

No pain at rest

Limp

Refusal to bear weight on the affected side

Limited passive abduction and rotation on examination

Afebrile, otherwise well child

33
Q

What is the main differential diagnosis to exclude when someone presents with the signs and symptoms of transient synovitis of the hip?

A

Septic arthritis

34
Q

What investigations would you do in a child that presents with signs and symptoms of transient synovitis of the hip?

A

FBC - looking at WCC

CRP

ESR

Blood cultures

If there is doubt, the joint should be aspirated for culture followed by prompt administration of IV antibiotics

35
Q

How do we treat confirmed transient synovitis of the hip?

A

Analgesia

Avoid strenuous activity

36
Q

What is the prognosis for transient synovitis of the hip?

A

It will resolve within 2 weeks

37
Q

What is slipped upper femoral epiphysis?

A

Displacement of the femoral head epiphysis in a medial postero-inferior direction.

38
Q

What is the typical age of children affected by slipped upper femoral epiphysis?

A

10 -15 years old - occurs during the growth spurt

39
Q

What are the risk factors for slipped upper femoral epiphysis?

A

Male

Obesity

Black

Associated with delayed skeletal maturation and endocrine disorders such as hypothyroidism, hypopituitarism and renal osteodystrophy

40
Q

What are the clinical features of slipped upper femoral epiphysis?

A

Limp

Hip or referred knee/distal thigh pain

Can be acute following trauma but more often chronic

Waddling gait

Loss of internal rotation, as well as as reduced abduction and flexion.

41
Q

What percentage of cases are found to have bilateral slipped upper femoral epiphysis?

A

20%

42
Q

How do we diagnose slipped upper femoral epiphysis?

A

X-ray - The Southwick angle gives indication of disease severity

43
Q

How do we manage slipped upper femoral epiphysis?

A

Unstable hips are an orthopaedic emergency

Femoral head needs to be pinned percutaneously or osteotomy

Non-surgical treatment is ineffective

44
Q

What are the complications of slipped upper femoral epiphysis?

A

Avascular necrosis

Premature fusion of epiphysis

45
Q

What is the other name for Osgood-Schlatter disease?

A

Tibial apophysitis

46
Q

What is Osgood-Schlatter disease?

A

Osteochondritis of the patellar tendon insertion at the knee.

47
Q

Who tends to be affected by Osgood-Schlatter disease?

A

Adolescent males who play sport particularly football or basketball

48
Q

What are the clinical features of Osgood-Schlatter disease?

A

Knee pain after exercise

Localised tenderness

Swelling over the tibial tuberosity

Hamstring tightness

Bilateral in 25-50%

49
Q

How do we treat Osgood-Schlatter disease of the knee?

A

Most resolve with rest. Knee immobiliser splint may be helpful

May need physiotherapy to strengthen quadriceps and stretch hamstring

Occasionally orthotics are required.

50
Q

Who tends to be affected by chondromalacia patellae?

A

Adolescent females

51
Q

What is chrondomalacia patellae?

A

Softening of the articular cartilage of the patella

52
Q

What are the clinical features of chondromalacia patellae?

A

Pain when patella is tightly apposed eg when standing from prolonged sitting or walking up and down stairs

53
Q

What features is chondromalacia patellae associated with?

A

Hypermobility

Flat feet

54
Q

How do we manage someone with chondromalacia patellae?

A

Rest

Physiotherapy for quadricep muscle strengthening

55
Q

What is the other name for osteochondritis dissecans?

A

Segmental avascular necrosis of the subchondral bone

56
Q

Who is most likely to suffer from osteochondritis dissecans?

A

Very active adolescents

57
Q

What causes the pain associated with osteochondritis dissecans?

A

Separation of the bone and cartilage from the medical condyle following avascular necrosis.

58
Q

What are the clinical features of osteochondritis dissecans?

A

Pain after exercise

Knee locking or giving way

59
Q

How do we manage osteochondritis dissecans?

A

Rest

Physiotherapy to strengthen quadriceps

Sometimes arthroscopic surgery is required`

60
Q

What are the features of subluxation of the patella?

A

Medial knee pain

Knee may give way

paeds (41 decks)

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