Paediatric Hip Disorder

Question 1

Legg-Calve-Perthes disease

Perthes disease

Answer 1

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

Question 2

clinical features of Perthes disease

Answer 2

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)

Question 3

investigations for Perthes

Answer 3

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.

Question 4

management of Perthe’s disease

Answer 4

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

Question 5

slipped capital femoral epiphysis (SCFE)

Answer 5

*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)

Question 6

SCFE clinical signs

Answer 6

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*

Question 7

management of SCFE

Answer 7

In situ fixation of the epiphysis with a screw
Bone graft epiphysiodesis
Spica cast
In situ fixation with multiple pins

Question 8

transient synovitis

Answer 8

intermittent inflammatory disorder of the synovial of the hip, common in paeds

(aka irritable hip syndrome)

Question 9

transient synovitis clinical features

Answer 9

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

Question 10

investigations for transient synovitis

Answer 10

bloods: FBC (raised WCC)
CRP (Raised)

imaging:
AP lateral / frog leg
USS to rule out septic arthritis
*ultrasound can show fluid collection

Question 11

management of transient synovitis

Answer 11

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.

Question 12

summary of conditions
DDH
Perthes
Transient synovitis
SCFE

Answer 12

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

Question 13

Juvenile rheumatoid arthritis

Answer 13

rheumatoid olio or polyarthritis of the hip joint. protective limp and limited range of movement

labs- bloods

mx- NSAIDs, DMARDs, pysio

Question 14

Osgood-Schlatter disease

Answer 14

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

Question 15

osteomyelitis

Answer 15

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.

Question 16

TB of the hip

Answer 16

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

Question 17

‘toddler’s fracture’

Answer 17

fracture of soft tissue injury younger than 3 y/o

can be child maltreatment

point tenderness over one redness, bruising, swelling

Question 18

DDH

Answer 18

developmental dysplasia of the hip

ball and socket hip joint fails to develop normally.

Question 19

hip condition and ages

Answer 19

<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

Question 20

Sever’s disease

Answer 20

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

Question 21

septic arthritis

Answer 21

infection of synovial and joint space
any joint and commonly affects lower limbs
lead to joint desturction

Question 22

osteomyelitis

Answer 22

infection of the bone
single bone
inflammation and joint destruction

pain on palpation
decreased limb use

Question 23

malignancy

Answer 23

primar bone tumors
sarcoma, leukaemia and lymphoma

osteosarcoma >10 years

night pain
hepatosplenomegaly
lymphadenopathy
pathological fractures

Question 24

JIA

Answer 24

juvenile idiopathic arthritis

inflammatory joint disease
joint pain, swelling
without a large effusion
morning stiffness >6 weeks
systemic symptoms
eye involvement

Question 25

CKS diff diagnosis

Answer 25

https://cks.nice.org.uk/topics/acute-childhood-limp/diagnosis/differential-diagnosis/

Question 26

in summary

• hip dysplasia
• irritabile hip
• perthes disease
• slipped upper femoral epiphysis
• juvenille idiopathic arthritis
• septic arthritis

Answer 26

1. hip dysplasia
   + Barlow and ortolini
   unequal skin folds / leg length
   picked up on newborn exam
2. transient synovitis (irritable hip) 2-10 years old, hip pain associated with viral infection
3. 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

6. septic hip- acute hip pain, systemic upset.