Paediatric Hip Conditions Flashcards
what hip conditions can cause the ‘limping child’ presentations
DDH (developmental dysplasia of the hip) reactive synovitis septic arthritis perthes SUFE
when do you get DDH
birth- 2 years (and plus)
when do you get perthes
4-8 ( 6 years peak)
when do you get SUFE
10-16 years
why does children acetabulum look like it has a hole in it
as just cartilage, ossifies over time
why are x rays not as good for hip joints in kids
as a lot of femoral head will be cartilage- ultrasound better
at what age does the greater trochanter show on an x ray
age 6
what is developmental dysplasia of the hip
disorder of abnormal development resulting in dysplasia and possible subluxation of the hip secondary to capsular laxity and mechanical factors
describe the dysplasia in DDH
shallow or underdeveloped acetabulum
what is capsular laxity more common in females
as they have more ligamentous laxity
what is the most common orthopaedic disorder in newborns
DDH
in who and which hip is DDH most common
in females in left hip (due to position in utero)
can you get bilateral DDH
yes 20% of cases
why is DDH seen in native american and laplanders but not africans
as papoose buts babys legs straight but baby sling puts hips in safety position- flexed and abducted
what is the pathphysiology of DDH
maternal and fetal laxity, genetic laxity, intrauterine and postnatal malpositioning= initial instability
initial instability=dysplasia
dysplasia= gradual dislocation
what happens in newborns when the femoral head isn’t properly positioned in the acetabulum
normal growth of femoral head and acetabulum not stimulated
what are the risk factors for DDH
first borns breech postition family history 6 x more common in females oligohydramnios (not enough amniotic fluid)
what is the presentation of DDH
abnormality on screening (early)
limping child (late): - trendellenberg gait
pain in later life, secondary arthritic changes
what should be done in clinical examination of DDH in new borns
inspection: leg lengths, restricted abduction, skin crease asymmetry
ortolani test- abducting the hips to try and relocate hip, fingers push femur forwards into acetabulum (already Out)
barlow test- pushing backwards to try to dislocate hip
what is the treatment for early presentation DDH
pavlik harness- keeps hips abducted and flexed- 23 hours a day for up to 12 weeks
what is the treatment for late presenting DDH
surgery
- closed reduction +/- tenotomies + spica
- open reduction +/- osteotomies + spica
what criteria distinguishes between reactive are septic arthritis
kochers criteria; fever, refusal to bear weight, ESR, serum WBC, CRP
what is the presentation of reactive arthritis
Hx of viral illness limp and hip/groin pain may present with referred pain to knee hip lying flexed/ externally rotated pain at end range of hip movements systemically well. apyrexial
how do you diagnose reactive synovitis
kochers, ultrasound (fluid in hip) +/- aspiration
what is the treatment for reactive synovitis
self limiting
analgesia/ NSAIDs
repeat review/ admission if any concern
why is septic arthritis a surgical emergency
high bacterial load that causes sepsis
destruction of the joint due to proteolytic enzymes
potential for osteonecrosis of the hip due to increased pressures
what is the presentation of hip septic arthritis
short duration of symptoms unable to weight bear and hip/groin pain hip lying flexed/externally rotated severe hip pain on passive movement usually pyrexial
how can septic arthritis get into the joint
direct inoculation (trauma/ surgery)
haematogenous seeding
extension from adjacent bone (osteomyelitis)
can develop from contiguous spread from osteomyelitis
septic arthritis can psread from highly vasular metaphysis to joints (common in neonates who have transphyseal vessels). what joints have intra articular metaphysis
hip, shoulder, elbow, ankle
what is the most common causative organisms of septic arthritis of the hip
staph aureus
how do you diagnose septic arthritis
blood test, blood cultures, kochers criteria, radiographs, ultrasound +/- aspiration
what is the treatment for septic arthritis
open surgical washout
antibiotics
what is perthes disease
avascular necrosis of the hip (idiopathic)
who gets perthes
4-8 year olds, more common in boys, higher in lower socioeconomic class
what are the risk factors for perthes
positive family history,
low birth weight,
second hand smoke,
asian, inuit and central american decent
(abnormal clotting factors, repeated trauma. mechanical overload)
what is the pathophysiology of perthes disease
osteonecrosis occurs secondary to disruption of blood supply to femoral head
followed by revascularisation with subsequent resorption and later collapse
creeping substitution pathway for remodelling after collapse
what are the stages of perthes disease
initial
fragmentation
reossification
remodelling
what factors can improve prognosis of perthes
younger age at presentation
preservation of a round femoral head
how does perthes present
gradual onset of painless limp sometimes intermittent groin pain hip stiffness (internal rotation and abduction) limp- trendellenberg, antalgic
how do you diagnose perthes
radiographs, MRI
what is the treatment for perthes
keep femoral head round whilst the process self terminates
restrict weight bearing
physio to maintain ROM
surgery in severe disease/ deformity
what is SUFE
slipped upper femoral epiphysis
affects proximal femoral physis- leads to slippage of the metaphysis relative to the epiphysis
what are the risk factors for SUFE
males obesity endocrine disorders -growth hormone deficiency -panhypopituritarism -hypothyroidism growth spurts
how does SUFE present
groin pain (or knee/ thigh) limp -externally rotated foot -antalgic obligatory external rotation on hip rotation
how do you diagnose SUFE
radiographs, MRI
what is the treatment of SUFE
surgery- percutaneous pinning of the hip
