Hip problems

Question 1

What is Developmental Dysplasia of the Hip (DDH)?

Answer 1

DDH involves dislocation or subluxation of the femoral head during the perinatal period, affecting normal hip joint development

Question 2

Which hip is more commonly affected in DDH?

Answer 2

The left hip

Question 2

When is DDH typically picked up?

Answer 2

1. During neonatal baby checks or the 6–8-week GP check
2. Late presentation often occurs at 12–18 months when the child begins to walk
   (1) Legs may be unequal length
   (2) Painless limping

Question 3

What imaging is used before and after 3 months for DDH?

Answer 3

Before 3 months – Ultrasound
After 3 months – X-ray

Question 4

What are Barlow and Ortolani tests used for?

Answer 4

1. Barlow’s
   = To check for posterior dislocation - flex and adduct the hip, keep the knee straight, sign is (+) if the hip dislocates posteriorly
2. Ortolani’s
   = to confirm dislocation - flexion and abduction reduce femoral head into acetabulum

Question 5

Why can’t X-rays be used for early DDH diagnosis?

Answer 5

The femoral head epiphysis is unossified until ~4–6 months

Question 6

What is the first-line treatment for DDH under 6 months?

Answer 6

Pavlik harness
= holds the hip flexed and abducted, worn 23–24 hrs/day

Question 7

What happens if DDH is diagnosed after 6 months?

Answer 7

Requires surgical management – closed or open reduction with spica casting

Question 8

What’s the prognosis of late-diagnosed DDH?

Answer 8

poorer

Question 9

What are the key signs on physical examination of a baby with suspected DDH?

Answer 9

1. Asymmetrical leg position or leg length
2. Loss of knee height when hips and knees are flexed (Galeazzi sign)
3. Asymmetrical skin creases (gluteal/thigh)
4. Reduced abduction of the hip in flexion

Question 9

What are the ideal conditions for examining a baby’s hips for DDH?

Answer 9

warm, relaxed, and fed

Question 10

A 6-week-old infant is reviewed in the GP surgery. He was delivered vaginally in a breech position at 38+4 weeks gestation. There were no intrapartum complications. Two days after birth, he was noticed to be jaundiced and had phototherapy which appeared to resolve the symptoms.

The newborn physical examination (NIPE) was otherwise unremarkable. His mother has a history of anaemia, asthma, and coeliac disease. Today, the infant appears happy and is progressing well in the 45th centile

What investigation should the GP refer the infant for due to his history? and why

Answer 10

All breech babies at or after 36 weeks gestation require USS for DDH screening at 6 weeks regardless of mode of delivery

Question 11

Name the risk factors for developmental dysplasia of the hip

Answer 11

1. Family history
2. Firstborn
3. Breach presentation (baby lying feet first in uterus instead of head first normally)
4. Multiple pregnancies
5. Females
6. moulded baby (feet/neck/head/spine) e.g. twins
7. Oligohydramnios

Question 12

A woman is preparing to be discharged from the postnatal ward with her 24-hour-old son. She inquires whether her baby requires a hip check since her friend’s baby needed one.

The woman had an uncomplicated pregnancy and had a successful external cephalic version at 36.5 weeks due to breech presentation. Her son was delivered vaginally headfirst after onset of spontaneous labour at 41 weeks, weighing 3.5 kg. The newborn examination was unremarkable, including negative Barlow and Ortolani tests. There is no family history of hip problems.

What is the appropriate next step?

Answer 12

reassure the mother that, based on current guidelines, her baby does not need further investigation for hip dysplasia

Refer for a hip ultrasound at 6 weeks

Question 13

A 3-month-old baby girl is diagnosed as having developmental dysplasia of the left hip following an ultrasound examination. Clinical examination of the hip was abnormal at birth. What treatment was she most likely to be given?

Answer 13

Pavlik harness

Question 14

You are doing the six-week check on a baby girl. What best describes the Barlow test for developmental dysplasia of the hip?

Answer 14

Attempts to dislocate an articulated femoral head

Question 15

What is transient synovitis?

Answer 15

It is a self-limiting inflammation of the synovium, most commonly affecting the hip in children, often following a viral illness

Also known as irritated hip

Question 16

What age group is typically affected by transient synovitis?

Answer 16

Children aged 2–10 years, with a peak incidence between 3–8 years

Question 17

What infection often precedes transient synovitis?

Answer 17

A recent viral upper respiratory tract infection.

Question 18

Which sex is more commonly affected by transient synovitis?

Answer 18

boys

Question 19

What are the clinical features of transient synovitis?

Answer 19

(1) Limp or refusal to weight bear
(2) hip/groin pain
(3) hip held in flexion
(3) usually well and afebrile
(4) possible low-grade fever
(5) pain at end range of hip movement

Question 20

How does transient synovitis differ from septic arthritis?

Answer 20

1. In transient synovitis, the child is well, often afebrile, and CRP is usually normal
2. Septic arthritis is associated with fever, raised inflammatory markers, and systemic illness

Question 21

What is the role of Kocher’s criteria?

Answer 21

To help distinguish septic arthritis from transient synovitis.
Criteria include:

(1) WCC >12
(2) Inability to weight bear
(3) Temp >38.5°C
(4) ESR >40 or raised CRP

Question 22

What is the definitive way to exclude septic arthritis?

Answer 22

Joint aspiration – will show normal fluid in transient synovitis

Question 23

How is transient synovitis managed?

Answer 23

1. Supportive: Rest and NSAIDs 2. Usually resolves in 1–2 weeks 3. If symptoms persist, reassess for other causes = eg, perthes

Question 24

According to NICE, which children with a limp can be monitored in primary care with a presumptive diagnosis of transient synovitis?

Answer 24

1. Children aged 3–9 years 2. well 3. afebrile 4. mobile but limping 5. symptoms for <72 hour

Question 25

What is the commonest cause of hip pain in children?

Answer 25

Transient Synovitis

Question 26

A 6-year-old boy is brought to the GP by his mother. Over the last several days, her son appears to be in pain when he walks. She states that this has never happened before and cannot think of what could be causing it. On examination, he refuses to walk. Vitals are stable, except for a temperature of 38ºC You examine the legs = There is no obvious inflammation, but the right hip is tender. You attempt to move the right leg, but the child screams in pain. The left leg appears to be normal. Otherwise, he has no past medical history and he takes no medications. Given the most likely diagnosis, what is the most appropriate management?

Answer 26

If a child with a limp/hip pain has a fever they should be referred for same-day assessment

Question 27

An 8-year-old boy presents to the emergency department with acute onset of joint pain. After taking a focused history and performing a musculoskeletal examination on the affected joint, as well as the joints above and below, the doctor makes a diagnosis of transient synovitis. What triad is most commonly associated with this diagnosis?

Answer 27

Hip pain, limp and recent infective illness

Question 28

What is Perthes disease?

Answer 28

It is idiopathic avascular necrosis of the femoral head in children, leading to bone collapse and potential long-term joint deformity

Question 29

What is the typical age and gender affected by Perthes disease?

Answer 29

boys aged 4–8 years, with a 5:1 male predominance

Question 30

What are the key risk factors for Perthes disease?

Answer 30

(1) Low birth weight (2) Passive smoking (3) Positive family history (4) Certain ethnic backgrounds (Asian, Inuit, Central European) (5) Short stature (6) small hands/feet

Question 30

What are the clinical signs of Perthes disease?

Answer 30

1. Loss of internal rotation (first sign) 2. Followed by loss of abduction 3. Positive Trendelenburg test = gluteal weakness 4. Leg muscle atrophy 5. Delayed bone age

Question 30

What are the main symptoms of Perthes disease?

Answer 30

1. Limp and atraumatic hip or knee pain 2. Pain worsens with activity 3. Unilateral in most cases 4. Slow progression over weeks

Question 31

What is the first-line investigation for Perthes disease?

Answer 31

Pelvic X-ray, although early stages may appear normal

Question 32

What investigations are used if the X-ray is inconclusive?

Answer 32

MRI or technetium bone scan

Question 33

What is the first-line management for Perthes disease?

Answer 33

Conservative = Activity restriction, physiotherapy, regular X-rays

Question 34

When is surgery considered in Perthes disease?

Answer 34

1. Persistent deformity or subluxation 2. Older children (>6 years) 3. Severe disease 4. Surgical options include osteotomy of the femur or acetabulum

Question 35

What is the prognosis of Perthes disease?

Answer 35

Good if diagnosed early, especially in children <6 years

Question 36

What are the later radiographic signs of Perthes disease on X-ray?

Answer 36

1. Flattening and collapse of the 2. Femoral head 3. Decreased femoral head size 4. Widening of joint space 5. Osteonecrosis

Question 37

A 4-year-old boy is reviewed by the orthopaedic doctor following 3 weeks of a progressively worsening limp. Blood tests were unremarkable and x-rays demonstrated a hip joint effusion but no significant structural deficits to the femoral head noted; a diagnosis of Perthes' disease is made. What would be the most appropriate initial management strategy for this child?

Answer 37

Perthes' disease presenting under the age of 6 years has a good prognosis requiring only observation

Question 38

A 10-year-old boy presents with symptoms of right knee pain. The pain has been present on most occasions for the past three months and the pain typically lasts for several hours at a time. On examination; he walks with an antalgic gait and has apparent right leg shortening. What is the most likely diagnosis?

Answer 38

SCFE

Question 39

What is Slipped Upper Femoral Epiphysis (SUFE)?

Answer 39

A condition where the femoral head slips inferiorly and posteriorly relative to the femoral neck at the growth plate (physis) = usually during adolescence Also known as slipped capital femoral epiphysis

Question 40

Who typically gets SUFE?

Answer 40

1. Overweight boys 2. Aged 8–18 3. During pubertal growth spurts 4. More common in African-American children 5. Can be associated with hypothyroidism or renal disease

Question 41

What causes the slippage in SUFE?

Answer 41

Weakness of the physis (growth plate) during rapid growth means it cannot withstand mechanical stress, leading to epiphyseal slip

Question 42

What are the symptoms of SUFE?

Answer 42

(1) Hip, groin, thigh, or knee pain Limp (2) Reduced weight bearing (3) Pain may be referred to the knee due to obturator nerve involvement (4) Can be bilateral in 1/3 of cases

Question 43

What are the types of SUFE?

Answer 43

Acute (<3 weeks) Chronic (>3 weeks) Acute-on-chronic

Question 44

What are the key signs of SUFE on examination?

Answer 44

(1) Antalgic gait (2) Limited internal rotation of the hip (3) Shortened and externally rotated leg in severe cases

Question 45

What is the first-line treatment for SUFE?

Answer 45

Urgent surgical fixation to stabilise the femoral head and prevent further slippage = internal fixation

Question 46

Why is SUFE a potential diagnostic pitfall in knee pain?

Answer 46

Because the obturator nerve supplies both hip and knee joints, SUFE can present as isolated knee pain = always examine the hip in limping children!!!

Question 47

A 14-year-old male patient presents to the outpatient clinic with a 2-month history of left hip pain that has progressively worsened. The pain started after he began a new baseball training regimen. The patient reports that the pain radiates to the left thigh and knee and is exacerbated by physical activity. On physical exam, the patient has a notable limp, and the left hip shows limited medial rotation and abduction. When the hip is passively flexed, it tends to laterally rotate. The patient has a body mass index (BMI) in the 95th percentile for his age. Based on the patient’s history and the physical exam findings, what is the most likely diagnosis?

Answer 47

Slipped capital femoral epiphysis

Question 48

To confirm the suspected diagnosis, radiographic imaging is taken of the patient’s left hip. Which direction would the displacement of the femoral epiphysis most likely be observed in on the imaging?

Answer 48

Posterior and Inferior displacement of the femoral epiphysis relative to the femoral neck

Question 49

A 13-year-old boy is brought to the emergency department with his parents with acute-onset right-sided groin pain and an inability to weight bear after a fall. His heart rate is 95 bpm, his blood pressure is 120/74 mmHg, his BMI is 32 kg/m² and he is afebrile. On examination, he has an antalgic gait and decreased range of motion. The neurovascular status of both legs is intact. Given the likely diagnosis, what is also most likely to be seen on examination?

Answer 49

Reduced internal rotation of the leg in flexion

Question 50

A 13-year-old boy presents to the GP with gradual onset right groin pain and a limp. He is otherwise well, with no past medical or family history. On examination, there is a restricted range of motion of the right leg, which appears shortened and externally rotated. There is no swelling or warmth felt over the joints. His notes document normal vital signs, height in the 50th percentile and weight in the 90th percentile. Which of the following is the most appropriate first-line investigation?

Answer 50

Plain X-ray of both hips (AP and frog-leg views)

Question 51

A 12-year-old boy is seen in the paediatric clinic with his mother. She tells you that her son has been limping over the last week with complaints of pain in his left hip and groin. There is no history of trauma to note. His past medical history includes eczema and he completed a course of antibiotics for tonsillitis 3 weeks ago. On examination, there is palpable tenderness in the left groin, hip and knee. There is a loss of internal rotation of left hip flexion due to extreme pain. He is in the 95th percentile of weight for his age. What is the most likely diagnosis?

Answer 51

Slipped upper femoral epiphysis

Question 52

A 7-year-old boy presents to his GP with his mum. He has had a limp in his left leg over the last two days and is experiencing hip pain. He is still managing to mobilise. On examination, hip motion is difficult in all directions from the pain, and his temperature is 37.5ºC. His mum explains that he recently had a runny nose and cough, but these symptoms have now resolved. He is on the 90th centile for weight and 50th centile for height. What is the most likely diagnosis?

Answer 52

A child with hip pain, limp and recent infective illness → ? transient synovitis

Question 53

A 6-year-old boy presents with pain in the hip it is present on activity and has been worsening over the past few weeks. There is no history of trauma. He was born by normal vaginal delivery at 38 weeks gestation On examination he has an antalgic gait and limitation of active and passive movement of the hip joint in all directions. C-reactive protein is mildly elevated at 10 but the white cell count is normal What is this?

Answer 53

Perthes Disease = Gradual onset of hip pain, worsens with activity. No trauma history

Question 54

'A 6-year-old boy presents with a groin pain. He is known to be disruptive in class. He reports that he is bullied for being short. On examination, he has an antalgic gait and pain on internal rotation of the right hip' What does this suggest?

Answer 54

Petrthes

Question 55

'A 40-year-old man with a history of alcohol excess and long-term prednisolone use for brittle asthma presents with a two-month history of left hip pain. On examination, there is limited movement of the hip in all directions. An x-ray shows a subchondral fracture, segmental flattening of the femoral head and osteopenia What does this woman have?

Answer 55

Avascular necrosis

Question 56

'A 29-year-old man who is a keen jogger complains of pain on the lateral aspect of his left hip. On examination there is a full range of movement but tenderness is noted on the anterolateral aspect of the joint' What does this suggest?

Answer 56

Trochanteric bursitis

Question 57

What investigations should be performed in transient synovitis is suspected?

Answer 57

XRAY + ultrasound

Question 58

What specific movements are limited in transient synovitis?

Answer 58

Extension and internal rotation of the hip can be found

Question 59

What is the treatment for transient synovitis?

Answer 59

NSAID's + 6 week rest