Hip Disorders -Warren

Question 1

What is the difference between dysplasia and dislocation?

Answer 1

Dysplasia is a hip that can be dislocated or relocated

dislocation is an un-reducable hip

Question 2

What are some risk factors for hip dysplasia?

Answer 2

• Breech (frank) (come out butt first)
• oligohydraminos (not enough fluid)
• first born
• family hx –> 10%
• associated msk pathology
• Native American
• F>M 9:1

Breech presenting girl is the most common –> 12%

Question 3

How do pts with hip dysplasia normally present?

Answer 3

Asymptomatic!

can also present with pain upon diaper changes and limpness

Question 4

What are the 2 physical exam techniques used to find hip dysplasia in infants?

Answer 4

• Barlow: internally rotate hip and apply pressure to see if can dislocate the hip posteriorly
• Ortolani: finger pads on the lateral side of the femur and rotate externally and see if can hear and feel a clunk as the hip moves back into place

Question 5

What is the Geleazzi Test?

Answer 5

pt lay supine with knees bent and determine if there is a difference in knee height –> could indicate hip dysplasia

Question 6

What is the best imaging tool for screening newborns?

What imaging tool is useful when the femoral head starts to ossify? At what age does this occur?

Answer 6

-Ultrasound –> use as a dynamic study with stress maneuvering

-Radiographs 3-6 months
also good for monitoring avascular necrosis and assessment of flexion in the Pavlik harness

Question 7

What is the Hilgenreiner line? What is a normal value for this?

Answer 7

used to assess the angle of the hip to determine whether a pt has hip dysplasia

normal =18-20 degrees

Question 8

What is the treatment for a + Barlow or a + Ortolani in a pt?

Answer 8

orthopedic referral

no need for US or X-ray

Question 9

What is the best treatment for a baby with + risk factors for hip dysplasia?

Answer 9

US at 4-6 weeks old

Question 10

What should you do if there is a soft click found upon PE or asymmetric gluteal folds?

Answer 10

repeat PE in 2 weeks:

if same==> ortho consult or US

if resolved==> no further management

if + clunk: Ortho referral

Question 11

What are the treatments for hip dysplasia from birth to 6 months?

Answer 11

1. Triple-diaper technique

2. pavlik harness

Question 12

What are the indications for using a Pavlik harness? How long should it be left on?

Answer 12

• fully reducible hip
• child not attempting to stand
• family
• regular follow-up (1-2 weeks) –> for adjustments

duration: childs age at hip stability + 3 months

Question 13

When is a Pavlik harness considered to have failed?

How is it treated then?

Answer 13

if the hip is not stabilized in 6-8 weeks

treat with traction and closed reduction (surgical intervention)

Question 14

What are some long term complications for DDH? (developmental dysplasia of the hip)

Answer 14

• Pain (arthritis, avascular necrosis, scarring)
• Limb length discrepancy
• Abnormal gait/limp
• Decreased agility - limited range of motion
• Avascular necrosis of hip
• Early osteoarthritis

Question 15

What is Legg-Calve-Perthes Disease?

Answer 15

• disorder of hip in young children involving avascular necrosis of the femoral head –> collapse–> fragmentation–> progressive deformity of the hip
• Boys: girls= 4-5:1
• usually 4-8 yo

Question 16

How will pts with Legg-Calve-Perthes Disease present?

Answer 16

• Limp or hip pain
• 30% cases – pain initially at knee or thigh
• Decreased hip mobility

Question 17

What are the 4 Waldenstrom radiographic stages?

Answer 17

1) Initial stage
2) Fragmentation stage
3) Reossification stage
4) Healed stage

Question 18

What are some good prognosis factors of Legg-Calve-Perthes Disease?

Answer 18

• < 6 years old at onset of symptoms
• <50% femoral head involved
• No stiffness or shortening on exam

-No treatment or non-surgical management normally

Question 19

What are the non-operative treatment options for Legg-Calve-Perthes Disease?

Answer 19

-Check serial radiographs 
(Every 3-4 mos with ROM testing)
-Continue bracing until:
Lateral column ossifies
Sclerotic areas in epiphysis gone
-Cast/brace uninvolved side

Question 20

What are some factors for poor prognosis for Legg-Calve-Perthes Disease?

Answer 20

• > 7 yo at onset of symptoms
• > 50% of femoral head involved
• significant stiffness or shortening on exam

need containment or corrective osteotomy

Question 21

What are some late effects of Legg-Calve-Perthes Disease?

Answer 21

• Physeal arrest patterns –> leg length discrepancy
• Irregular head formation
• Osteochondritis dessicans – pain and swelling

Question 22

What is the pathogenesis of Slipped Capital Femoral Epiphysis?

Answer 22

stress fracture upper femoral growth plate -> slip of femoral head over femoral neck -> limb shortens and externally rotates

Question 23

What are the risk factors for Slipped Capital Femoral Epiphysis?

Answer 23

• males > females = 2:1
• bilateral 30%
• positive family history
• obesity
• hypogonadism
• hypothyroidism
• hypopituitarism

Question 24

What is the typical presentation of a Slipped Capital Femoral Epiphysis?

Answer 24

• Adolescent
• Limp and hip or groin pain
• 30% cases pain at knee or thigh
• Hip externally rotated and flexed

Question 25

What is Klein’s line? What is it used to determine?

Answer 25

Line drawn superior border of femoral neck should cross at least a portion of the femoral epiphysis

can indicate a slipped capital femora epiphysis

Question 26

What is the treatment for Slipped Capital Femoral Epiphysis?

Answer 26

• Surgical
• Internal fixation with pinning of screw
• Prophylactic fixation of unaffected hip

Question 27

What is considered to be a stable slip?

Answer 27

able to bear weight on affected limb and slip angle <30 degrees

-excellent prognosis

Question 28

What is an unstable slip? What are some complications of this?

Answer 28

unstable slip=unable to bear weight on the affected limp===> bad prognosis

-complications:
avascular necrosis, severe deformity, stiffness, early osteoarthritis, cartilage necrosis (chondrolysis)

Question 29

A 13 year old adolescent male presents to the clinic for one week of limping and knee pain. On the growth curve, it is noted he is in the 95% for his weight. His exam is remarkable for acanthosis and normal knee exam. His hip examination demonstrates diminished ability to flex and internally rotate his right femur.

Which is the best next step in the management of this pt?

a. Instruct the patient to rest and apply ice
b. Prescribe daily nonsteroidal anti-inflammatory drugs until the pain resolves
c. Order MRI of the hip and knee
d. Arrange for an orthopedic consultation

Answer 29

d. Arrange for an orthopedic consultation

Question 30

You are evaluating a 3 month old female in the clinic. The parents comment that her legs appear uneven since birth. Otherwise she has no other symptoms. On physical exam, the infant is happy and nontoxic appearing. She is asymptomatic except for a + Barlow and + Galeazzi sign. Her most likely diagnosis is:

a. developmental dysplasia of the hip
b. tibial bowing
c. septic arthritis
d. Legg-calve-perthes disease

Answer 30

a. developmental dysplasia of the hip