Hip Disorders -Warren Flashcards
What is the difference between dysplasia and dislocation?
Dysplasia is a hip that can be dislocated or relocated
dislocation is an un-reducable hip
What are some risk factors for hip dysplasia?
- 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%
How do pts with hip dysplasia normally present?
Asymptomatic!
can also present with pain upon diaper changes and limpness
What are the 2 physical exam techniques used to find hip dysplasia in infants?
- 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
What is the Geleazzi Test?
pt lay supine with knees bent and determine if there is a difference in knee height –> could indicate hip dysplasia
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?
-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
What is the Hilgenreiner line? What is a normal value for this?
used to assess the angle of the hip to determine whether a pt has hip dysplasia
normal =18-20 degrees
What is the treatment for a + Barlow or a + Ortolani in a pt?
orthopedic referral
no need for US or X-ray
What is the best treatment for a baby with + risk factors for hip dysplasia?
US at 4-6 weeks old
What should you do if there is a soft click found upon PE or asymmetric gluteal folds?
repeat PE in 2 weeks:
if same==> ortho consult or US
if resolved==> no further management
if + clunk: Ortho referral
What are the treatments for hip dysplasia from birth to 6 months?
- Triple-diaper technique
2. pavlik harness
What are the indications for using a Pavlik harness? How long should it be left on?
- 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
When is a Pavlik harness considered to have failed?
How is it treated then?
if the hip is not stabilized in 6-8 weeks
treat with traction and closed reduction (surgical intervention)
What are some long term complications for DDH? (developmental dysplasia of the hip)
- Pain (arthritis, avascular necrosis, scarring)
- Limb length discrepancy
- Abnormal gait/limp
- Decreased agility - limited range of motion
- Avascular necrosis of hip
- Early osteoarthritis
What is Legg-Calve-Perthes Disease?
- 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
How will pts with Legg-Calve-Perthes Disease present?
- Limp or hip pain
- 30% cases – pain initially at knee or thigh
- Decreased hip mobility
What are the 4 Waldenstrom radiographic stages?
1) Initial stage
2) Fragmentation stage
3) Reossification stage
4) Healed stage
What are some good prognosis factors of Legg-Calve-Perthes Disease?
- < 6 years old at onset of symptoms
- <50% femoral head involved
- No stiffness or shortening on exam
-No treatment or non-surgical management normally
What are the non-operative treatment options for Legg-Calve-Perthes Disease?
-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
What are some factors for poor prognosis for Legg-Calve-Perthes Disease?
- > 7 yo at onset of symptoms
- > 50% of femoral head involved
- significant stiffness or shortening on exam
need containment or corrective osteotomy
What are some late effects of Legg-Calve-Perthes Disease?
- Physeal arrest patterns –> leg length discrepancy
- Irregular head formation
- Osteochondritis dessicans – pain and swelling
What is the pathogenesis of Slipped Capital Femoral Epiphysis?
stress fracture upper femoral growth plate -> slip of femoral head over femoral neck -> limb shortens and externally rotates
What are the risk factors for Slipped Capital Femoral Epiphysis?
- males > females = 2:1
- bilateral 30%
- positive family history
- obesity
- hypogonadism
- hypothyroidism
- hypopituitarism
What is the typical presentation of a Slipped Capital Femoral Epiphysis?
- Adolescent
- Limp and hip or groin pain
- 30% cases pain at knee or thigh
- Hip externally rotated and flexed
What is Klein’s line? What is it used to determine?
Line drawn superior border of femoral neck should cross at least a portion of the femoral epiphysis
can indicate a slipped capital femora epiphysis
What is the treatment for Slipped Capital Femoral Epiphysis?
- Surgical
- Internal fixation with pinning of screw
- Prophylactic fixation of unaffected hip
What is considered to be a stable slip?
able to bear weight on affected limb and slip angle <30 degrees
-excellent prognosis
What is an unstable slip? What are some complications of this?
unstable slip=unable to bear weight on the affected limp===> bad prognosis
-complications:
avascular necrosis, severe deformity, stiffness, early osteoarthritis, cartilage necrosis (chondrolysis)
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
d. Arrange for an orthopedic consultation
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
a. developmental dysplasia of the hip
