Paediatric Hip Disorder Flashcards
Legg-Calve-Perthes disease
Perthes disease
idiopathic avascular necrosis of the proximal femoral epiphysis in children (4-10)
the blood supply to the head of femur gets disrupted which leads to death or necrosis of the tissue. arteries of the hip: lateral and medial femoral circumlex aftery, artery of ligamentum teres
overtime there is new blood vessel formation and the dead tissue is removed by macaphages. head of emur becomes weak and changes shape so there is a reduced range of movement
clinical features of Perthes disease
limp (can be painless)
Hip stiffness with loss of internal rotation and abduction (limited movement of hip joint)
Pain
Antalgic gait
Muscle spasms
Leg length discrepancy (late finding)
Restricted ROM (abduction and internal rotation) (soft tissue swelling)
particularly affects abduction and internal rotation
muscle atrophy (leg looks smaller)
investigations for Perthes
bilateral AP pelvic xray
frog leg lateral xray reveals flattened and misshapen femoral head.
MRI
radiographic findings:
sclerosis of femoral head
collapse/fragmentation of ossification centre resulting in flattening of femoral head
Asymmetrical femoral epiphyseal size
Increased density of femoral head epiphysis
Radiolucency
Coxa plana: femoral head widening and flatting (shown in Figure 4)
Coxa magna: proximal femoral neck deformity
‘Sagging rope sign’: thin sclerotic line running across the femoral neck
*Crescent’s sign is a specific finding on a radiograph in late stages of the disease and represents a subchondral fracture.
management of Perthe’s disease
conservative:
observe, activity limitation, physic, NSAID, casting, bracing
bone re-modelling
surgical- osteotomy
(complications) Osteoarthritis General joint stiffness and immobility Premature physeal arrest, degenerative arthritis Acetabular dysplasia Unequal, shortened limb length
slipped capital femoral epiphysis (SCFE)
*adolecents
*growth plate fractures
slippage between neck and overlying head of the femur (capital / physics)
the metaphysics of the femur displaces anteriorly and superiorly which leads to displacement of the capital femoral epiphysis
diaphysis - long and hard (shaft)
metaphysics (at the level of femoral neck)
cartilaginous growth plate (physis)
perichondria ring- dense connective tissue that helps resist forces to that the femoral head and neck don’t slip away from each other.
it becomes too weak to resist forces between head and neck so the two slip away from each other (the neck displaces anterior lateral and superiorly which makes it look like the physics has slipped backwards)
SCFE clinical signs
classically presents in overweight teenage boys with hip pain and limp. affectsd limb is shortened and externally rotated.
Pain
Abnormal leg alignment: external rotation
Abnormal gait/limp: may have Trendelenburg gait
Decreased range of movement
Weakness and muscle atrophy
XRAY- in frog leg lateral view- displacement of the femoral epiphysis*
management of SCFE
In situ fixation of the epiphysis with a screw
Bone graft epiphysiodesis
Spica cast
In situ fixation with multiple pins
transient synovitis
intermittent inflammatory disorder of the synovial of the hip, common in paeds
(aka irritable hip syndrome)
transient synovitis clinical features
Hip presents in flexion, abduction and external rotation
there is no (or mild) restriction of hip movements- especially abduction and internal rotation
well and febrile.
hx of viral illness
Limp
Pain
Muscle spasms
investigations for transient synovitis
bloods: FBC (raised WCC)
CRP (Raised)
imaging:
AP lateral / frog leg
USS to rule out septic arthritis
*ultrasound can show fluid collection
management of transient synovitis
a self-limiting disorder that typically lasts 7-10 days, therefore management is focused on relieving the patient’s symptoms:
Bed rest (short period) Activity restriction Analgesia: paracetamol and NSAIDs.
summary of conditions DDH Perthes Transient synovitis SCFE
DDH (development dysplasia of hip0 <4-6 months. Mx with Palvik harness
Perthes male and Caucasian. non surgical
SCFE male, obese, endocrine disorder. surgical
transient synovitis- usually follows URTI, bloods, self limiting, analgesia
Juvenile rheumatoid arthritis
rheumatoid olio or polyarthritis of the hip joint. protective limp and limited range of movement
labs- bloods
mx- NSAIDs, DMARDs, pysio
Osgood-Schlatter disease
overuse injury caused by multiple small avulsion fractures within the ossification centre of the tibial tuberosity
traction apophysitis at the insertion of the patella tendon in the tibia tubercule
common in sporty adolescents and more common in boys
self limiting
osteomyelitis
severe pain
limbs
xray and USS normal
bloods: raised WCC, ESR and CRP
can be difficult to differentiate clinically from septic arthritis but usually presents more chronic and less severe. usually can still walk.
TB of the hip
loss of bone density adjacent with narrowing of the joint space
bone destruction and abscess formation
usually 2’ to lung / bowel and has constitutional symptoms
‘toddler’s fracture’
fracture of soft tissue injury younger than 3 y/o
can be child maltreatment
point tenderness over one redness, bruising, swelling
DDH
developmental dysplasia of the hip
ball and socket hip joint fails to develop normally.
hip condition and ages
<3 fracture / NAI / DDH
3-10 transient synovitis, perthe’s
10-19 SUFE, Perthes, Osgood-Schlatter disease, Sever disease, Ostochondritis dissecans, Chondromalacia patellae
any age:
septic arthritis
osteomyeltitis
other infections
Sever’s disease
overuse injury caused by repetitive micro trauma from the pull of Achilles tendon on the unossified aphohysis
active children / sporty
resolves in 2 weeks- 2months
septic arthritis
infection of synovial and joint space
any joint and commonly affects lower limbs
lead to joint desturction
osteomyelitis
infection of the bone
single bone
inflammation and joint destruction
pain on palpation
decreased limb use
malignancy
primar bone tumors
sarcoma, leukaemia and lymphoma
osteosarcoma >10 years
night pain
hepatosplenomegaly
lymphadenopathy
pathological fractures
JIA
juvenile idiopathic arthritis
inflammatory joint disease joint pain, swelling without a large effusion morning stiffness >6 weeks systemic symptoms eye involvement
CKS diff diagnosis
https://cks.nice.org.uk/topics/acute-childhood-limp/diagnosis/differential-diagnosis/
in summary
- hip dysplasia
- irritabile hip
- perthes disease
- slipped upper femoral epiphysis
- juvenille idiopathic arthritis
- septic arthritis
- hip dysplasia
+ Barlow and ortolini
unequal skin folds / leg length
picked up on newborn exam - transient synovitis (irritable hip) 2-10 years old, hip pain associated with viral infection
- Perthes. hip pain and limp due to vascular necrosis of the femoral head. degernative. 4-8 years old.
progressive hip pain over a few weeks, lip, stiffness and reduced movement, X-ray shows widening of joints space and decreased femoral head size
4. slipped upper femoral epiphysis 10-15 y/o obese boys the neck and head displaces (looks like its the epiphysis)t trauma, knee or distal thighs pain
5. juvenile idiopathic chronic arthritis <16 y/o more than three monhs <4 joints affected joint pain and swelling ANA +ve, limp
- septic hip- acute hip pain, systemic upset.
