Hip Pathologies (mainly paediatric)

Question 1

Transient synovitis presentation

Answer 1

Diagnosis of exclusion, most common hip pain in children 2-10
Hip pain following viral URTI/autoimmune
Worry about septic arthritis/juvenile idiopathic arthritis if other joints involved

Question 2

Transient synovitis treatment

Answer 2

Self-limiting with rest + analgesia

Question 3

Perthes’ Disease pathology

Answer 3

Idiopathic avascular necrosis of femoral head, 10% of cases bilateral
Ischaemia is self-healing but remodelling of bone distorts epiphysis -> abnormal ossification

Question 4

Perthes’ Disease presentation

Answer 4

3-11 years, 4x more likely in boys
Hip pain progressively over weeks
Limp, stiffness+reduced ROM in hip

Question 5

Perthes’ Disease diagnosis

Answer 5

X ray: early shows widening of joint space, late shows decreased femoral head size/flattening

Question 6

Perthes’ Disease treatment

Answer 6

Less severe (<1/2 fem head affected on lateral, joint space depth preserved) bed rest and NSAIDs until pain-free then XR monitoring
Severe (>1/2 fem head affected, narrowing of total joint space) then surgery

Question 7

Perthes’ Disease complications

Answer 7

OA earlier than normal and hip replacement needed, better prognosis in younger <6 yrs

Question 8

Slipped upper femoral epiphysis presentation

Answer 8

10-16 yrs, 20% bilateral, 50% obese
Epiphysis slips down and back
90% can weight-bear but limping and pain in groin/anterior thigh/knee
Flexion, abduction, medial rotation limited

Question 9

Slipped upper femoral epiphysis diagnosis

Answer 9

AP + lateral xray shows displaced growth plate

Question 10

Slipped upper femoral epiphysis complications

Answer 10

Delayed diagnosis can result in progression of slip
Avascular necrosis of femoral head
Early OA

Question 11

Slipped upper femoral epiphysis treatment

Answer 11

Surgery - early internal fixation to stabilise slippage - encourage physeal closure

Question 12

Developmental dysplasia of the hip risk factors

Answer 12

Breech birth (caesarean or vaginal)
Inc birth weight
Postmaturity
Oligohydramnios
Older mother
Sibling with DDH

Question 13

Developmental dysplasia of the hip diagnosis

Answer 13

US up to 4.5mths, pelvic xray after

Clinical hip tests

Question 14

DDH clinical tests - Reducible dislocation

Answer 14

Ortolani manoeuvre - Child’s hip flexed + abducted, push greater trochanter to relocate hip into acetabulum, clunk if positive

Question 15

DDH clinical tests - Sublux/dislocate unstable hip

Answer 15

Barlow manoeuvre - Hip flexed + adducted, axial load on femur dislocates femoral head if positive

Question 16

DDH clinical tests - shortening of femur due to DDH

Answer 16

Galeazzi test - Child supine with flexed hips + feet flat on table touching buttocks, different height knees is positive test, negative if both dislocated

Question 17

Developmental dysplasia of the hip signs

Answer 17

Widened perineum
Buttock flattened on affected side
Unequal leg length/groin creases
Limited abduction if >3 mths

Question 18

Developmental dysplasia of the hip treatment

Answer 18

Delay treatment for 6 wks from diagnosis to see if spontaneously resolves
<6mths flexion-abduction splint (Pavlik Harness, beware avascular necrosis)
6-18mths closed reduction
>18 mths open reduction with corrective osteotomy for femur/pelvis as needed

Question 19

Club foot (talipes equinovarus) conditions

Answer 19

Foot is:
Inverted
Adducted relative to hindfoot (which is in varus)
Plantarflexion deformity

Question 20

Club foot treatment

Answer 20

Ponseti method - foot manipulated + repeatedly placed in long leg plaster cast to correct forefoot adduction + hindfoot varus, gradual correction
If needed, soft tissue release 6-12mths with further surgery on bones later in childhood

Question 21

Posterior hip dislocation presentation

Answer 21

RTC, knee strikes dashboard
Femoral head felt in buttock
Leg is flexed, internally rotated, adducted and shortened
Often associated with # of femoral head/neck/shaft

Question 22

Posterior hip dislocation complications

Answer 22

Sciatic nerve laceration/stretch/compression

Equinus foot deformity if untreated

Question 23

Posterior hip dislocation treatment

Answer 23

Reduction under GA <4 hrs to prevent AVN

Traction for 3 weeks promotes joint capsule healing