Orthopaedics Flashcards
What does the term DDH stand for?
What is an alternative name for DDH?
DDH = developmental dysplasia of the hip
Another term you may hear to refer to it is congenital dislocation of the hip but this is no longer used as there are different degrees of abnormality (not just dislocated hips) and also isn’t always there from birth but can develop later.
What are some risk factors for DDH?
Why is this clinically important?
- Oligohydramnios - little amount of amniotic fluid in the womb. It can increase the risk of developing DDH because the baby isn’t able to move about within the uterus as much
- Breech presentation
- First degree family history of DDH
- Club foot (talipes)
If the baby has the risk factors of family history, breech presentation, foot (talipes) and spine abnormalities or neuromuscular disorder it is recommended they undergo an ULTRASOUND at 6 weeks
What is DDH?
DDH is an abnormality of the hip joint.
There can either be a problem with the acetabulum, a problem with the femur or a problem with the surrounding structures. This results in the acetabulum and femur not being in as close contact. If it is severe there is no contact between them are this is called dislocation.
What does clinical examination for DDH in a newborn involve?
What tests on physical examination can be done to screen for DDH? What do they tell you
- Asymmetrical gluteal or thigh skin folds.
- Limb length discrepancy (Galeazzi sign).
- Limitation and asymmetry of hip abduction when the hip is flexed to 90°.
Barlow and Ortolani tests can be used on newborn babies. They can tell you is the hip is unstable but are difficult to do after the age of 2-3 months.
Limited hip abduction (less than 60°) when the hip is flexed to 90° is the most important sign of a dislocated or dysplastic hip
How may DDH present later in life?
- Femur length discrepancy (galeazzi sign)
- Walking with one bent knee (longer leg) or walking with on foot on tiptoes - may present with a PAINLESS LIMP
- Limited abduction when fully flexed#
- Positive Trendelenburg’s test
- Difficulty putting nappies on
What is galeazzi’s sign?
The child is examined lying supine with the hips and knees flexed to 90° and the height of each knee is compared and unilateral femoral shortening is seen
What movement is often limited with children with DDH?
Limited abduction of a flexed hip
How may DDH present in a child 2-6 months of age?
Unilateral limitation and asymmetry of hip abduction is the most reliable sign of DDH after eight weeks
Galeazzi’s sign
What is the investigation of choice for DDH?
US in children <4.5 months
X-ray for older
What is the first line treatment for DDH? Who is it used for?
Pavlik harness
Used for children who’s hip remain unstable at 6 weeks
Treatment should ideally occur within 3 months of life. Pavlik’s harness can only be used up to the age of 6 months
If DDH presents later in life how can it be treated?
Open reduction and osteotomy is used for children who are > 6 months
When is the Pavlik harness contraindicated?
If the child is >4.5 months old
What are some differentials of _____in a child aged 1-3 years?
a) Acute painful limp
b) Chronic and intermittent limp
ACUTE + PAINFUL 1. Infection - septic arthritis, osteomyelitis 2. Transient synovitis 3. Malignant disease e.g leukaemia or neuroblastoma 4. Trauma - accidental/non-accidental, CHRONIC AND INTERMITTENT 1. DDH, talipes 2. Cerebral palsy 3. JIA
What are some differentials of _____in a child aged 3-10 years?
a) Acute painful limp
b) Chronic and intermittent limp
ACUTE + PAINFUL 1. Infection - septic arthritis, osteomyelitis 2. Transient synovitis 3. Perthes disease (acute) 4. Malignant e.g leukaemia 5. Trauma and overuse injuries 6. JIA 7. Complex regional pain syndrome CHRONIC AND INTERMITTENT 1. Perthes disease (chronic) 2. JIA 3. Neuromusclar - e.g duchennesmuscular dystrophy 4. Tarsal coalition
What are some differentials of _____in a child aged 11-16 years?
a) Acute painful limp
b) Chronic and intermittent limp
ACUTE + PAINFUL
- Mechanical - trauma, overuse injuries, sport injuries
- SUFE (acute)
- Infeciton - septic arthritis/osteomyelitis
- JIA
- AVN of the femoral head
- Bone tumours and malignancy
- Reactive arthritis
- Complex regional pain syndrome
- Osteochondritis dissecans of the knee
CHRONIC AND INTERMITTENT
- SUFE (chronic)
- JIA
- Tarsal coalition
In what age group does Perthes’ disease usually present in?
How does it typically present?
Age 4-8 (3-10)
Affects boys more than girls with the ratio 5:1
Hip or knee pain, reduced range of motion and stiffness
What is Perthes’ disease?
What is the pathophysiology?
Perthes disease is avascular necrosis of the femoral head and is a self limiting disease. (There is specifically AVN of the nucleus of the proximal femoral epiphysis)
The subsequent bone remodelling that occurs distorts the epiphysis and generates abnormal ossification
What investigations are usually carried out to assess Perthes’ disease?
What is seen on these investigations?
X-rays
Initially x-rays may be normal
Early signs on x-ray include joint space widening
Later there can be a decrease in the size of the femoral head with patchy density
Even later on there may be collapse and deformity of the femoral head with new bone formation
A bone scan or MRI may also be useful
What is the aim of treatment with Perthes’ disease? (E.g to avoid what complication)
What types of treatment can be given to children with Perthes?
Main aim is to avoid OA
This is done by trying to maximise the contact between the femoral head and the acetabulum and also try to maintain the sphericity of the femoral head
TREATMENT: Physio Bed rest and NSAIDS for pain relief Traction Plaster casts If the child is >6 surgery may be required
What are the findings on examination of a patient with Perthes’ disease?
Reduced abduction
Limited internal rotation with flexed and extended hip
Antalgic gait
In what age group of children does transient synovitis commonly present in?
How does it commonly present?
Age 2-10 or 2-12
Sudden onset hip pain/limp
Commonly following a viral infection
Not systemically unwell
What are the main features in a history which help to differentiate transient synovitis from septic arthritis?
FEVER: TS fever is mild/absent, in septic arthritis fever is moderate/high
APPEARANCE: TS child often looks well, SA child looks ill
HIP MOVEMENT: TS comfortable at rest, limited internal rotation and pain on movement, SA - hip held flexed, severe pain at rest and worse on any attempt to move the joint
What movements are commonly affected in a child with transient synovitis?
Internal rotation
What is the difference in terms of the finding on bloods of a child with transient arthritis vs septic arthritis?
US findings?
Radiography findings?
CRP: SA raised TS: normal/slight increase
WCC: TS - normal, AS: normal/high
US: Fluid in joint for both TS and SA
Radiograph: Normal for TS, for SA can be normal or increased joint space
