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Musculoskeletal > Paediatric Hip Disorders > Flashcards

Paediatric Hip Disorders Flashcards

1
Q

What is Developmental Dysplasia of the Hip (DDH)?

A

abnormal development resulting in dysplasia and possible subluxation/dislocation of the hip

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2
Q

What type of dysplasia can occur in DDH?

A

shallow or underdeveloped acetabulum

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3
Q

Is DDH more common in males or females?

A

Most common in females

- especially in left hip

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4
Q

What ethnicities are more likely to develop DDH?

A

more commonly in Native Americans and Laplanders

(due to way of carrying children, does not promote normal growth)

Rarely seen in African patients - Baby wrap carrying method promotes correct growth

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5
Q

Why does DDH occur?

A

Initial instability thought to be caused by:

  • maternal and fetal laxity
  • genetic laxity
  • intra-uterine position
  • postnatal malpositioning
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6
Q

Why is normal growth and development hindered in DDH?

A

Correctly positioned femoral head stimulates normal head and acetabular growth

In DDH the femoral head was never in the right position, or it dislocated and hindered growth

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7
Q

What actions make up the “safety position” of the hip?

A

Hip flexion

Hip abduction

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8
Q

What are the risk factors for developmental dysplasia of the hip?

A
  • Firstborns
  • Females (6:1)
  • Breech presentations
  • Family history
  • Oligohydramnios (deficiency of amniotic fluid)
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9
Q

At what stage do patients with DDH usually present?

A

Abnormality on screening (early)

Limping child (late) “Trendelenberg Gait”

Pain later in life (secondary arthritic changes)

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10
Q

Why is Ultrasound more useful in investigating DDH than radiographs?

A

Not much will show up on radiograph

Young children = more cartilage which has not ossified and therefore wont show up

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11
Q

By using the “H Lines” on a normal pelvic radiograph, in which quadrant should the femoral head lie?

A

Inferior medial

at least 90% should be in here

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12
Q

What 3 bones come together and are joined by the tri-radiate cartilage ?

A

Ilium
Ischium
Pubis

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13
Q

At what age do patients with DDH usually present?

A

Between birth and 2 years

can (rarely) be diagnosed in utero

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14
Q

At what age does Perthes disease usually affect children?

A

Between 4 and 8 years old

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15
Q

What age are patients who get a slipped upper femoral epiphysis (SUFE)?

A

Usually adolescents 10-16 years old

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16
Q

Describe the Barlow’s Test for clinical examination of suspected DDH

A

Push Backwards to try to dislocate hip

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17
Q

Describe the Ortolani Test for examination of suspected DDH

A

the hip is already OUT

=> abduct it and push femoral head forward into acetabulum

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18
Q

How is an early presentation of DDH treated?

A

PAVLIK HARNESS

  • holds hips in “safety position”
  • 23hrs a day for 12 weeks until US = normal
  • Night time splinting for a few more weeks
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19
Q

How is a late DDH presentation treated?

A

SURGERY

Closed reduction
+/- tenotomies (cutting tendon)
+ spica (cast with plastic bar across bottom)

Open reduction
+ osteotomies (cutting bone for realignment)
+ spica

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20
Q

What tendons are usually cut during a closed reduction DDH procedure?

A

Psoas or Quad tendon

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21
Q

What bones are cut during an open reduction DDH surgery?

A

Pelvis, Proximal femur or BOTH

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22
Q

What is Reactive synovitis?

A

Inflammation of the synovium

often secondary to a viral illness

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23
Q

How do patients with reactive synovitis usually present?

A
  • Hx of viral illness
  • Limp
  • hip/groin pain (may refer to knee but uncommon)
  • Hip lying flexed/externally rotated
  • Pain at end range of hip movements
  • systemically well, apyrexial
24
Q

What is used to help diagnose reactive synovitis?

A

Kocher’s criteria

Ultrasound +/- aspiration

25
Q

What are Kocher’s Criteria?

A

Fever >38.5
Refusal to weight bear
CRP >20
Serum WBCs >1200/mm^3

26
Q

What is the purpose of Kocher’s criteria?

A

Distinguishes between Reactive synovitis and septic arthritis

27
Q

How is reactive synovitis treated?

A
  • Self-limiting condition
  • Analgesia / NSAIDs
  • Repeat review / admission if any concern
28
Q

What is septic arthritis?

A

Intra-articular infection of the joint

SURGICAL EMERGENCY

29
Q

Why is septic arthritis a surgical emergency?

A
  • High bacterial load that causes sepsis
  • proteolytic enzymes destroy joint cartilage
  • osteonecrosis of the hip due to increased pressure
30
Q

How do patients with septic arthritis usually present?

A
  • 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 but children may be haemodynamically stable
31
Q

Why does hip lie flexed/externally rotated in conditions such as painful septic arthritis?

A

Maximises joint space

32
Q

What usually causes septic arthritis?

A
  • direct inoculation from trauma or surgery
  • haematogenous seeding
  • extension from adj. bone (osteomyelitis)
  • can develop from contiguous spread of osteomyelitis
33
Q

How does septic arthritis usually spread in babies/children ?

A
  • spread from highly vascular metaphysis

- common in neonates who have transphyseal vessels that allow spread into the joint

34
Q

What joints are usually affected in septic arthritis in children?

A

joints with intra-articular metaphysis include:

  • hip
  • shoulder
  • elbow
  • ankle
35
Q

What organism predominantly affects neonates in septic arthritis?

A

Streptococcus

36
Q

What organism most commonly affects infants/children/adolescents and adults in septic arthritis?

A

Staphylococcus aures

37
Q

What organism is usually responsible for septic arthritis in IVDUs?

A

Pseudomonas / atypical organisms

38
Q

What blood tests are important in septic arthritis?

A

Blood tests (FBC, CRP +/- ESR)

Blood cultures!!!

39
Q

What other investigations would you do in septic arthritis?

A

Kochers criteria
Radiographs to rule out other pathologies
Ultrasound +/- aspiration (usually in theatre)

40
Q

How is septic arthritis treated?

A
  • OPEN SURGICAL WASHOUT
  • Repeat washout if not improving
  • Antibiotics for 6 weeks
41
Q

What is Perthes disease?

A

Idiopathic avascular necrosis of the hip

42
Q

Are males or females more likely to develop Perthe’s disease?

A

Males

5:1

43
Q

Perthe’s disease occurs more in lower socioeconomic classes. TRUE/FALSE?

A

TRUE

44
Q

Is Perthe’s disease usually bilateral?

A

Can present in both hips but NOT usually at same time

45
Q

Describe the pathophysiology of Perthe’s disease

A
  • osteonecrosis secondary to disruption of blood supply to femoral head
  • revascularization
  • subsequent resorption and later collapse
46
Q

What are the 4 stages in Perthe’s disease?

A

Initial
Fragmentation
Reossification
Remodelling

47
Q

What factors affect prognosis in Perthe’s disease?

A

Age

younger at presentation = better prognosis

48
Q

How do patients with Perthe’s disease usually present?

A
  • Gradual onset of painless limp
  • Sometimes intermittent groin pain (or knee/thigh)
  • Hip stiffness
  • int rotation and abduction
  • Limp (Trendelenberg/Antalgic Gait)
49
Q

What imaging modalities are used in Perthe’s investigation?

A

Radiographs
MRI

due to patient being older => these modalities can be used

50
Q

How is Perthe’s disease treated non-surgically?

A

AIM = keep femoral head round whilst the process self-terminates

  • Restrict weight-bearing
  • Maintain range of movement with physio
  • No evidence for bracing
51
Q

How is Perthe’s disease treated surgically?

A

YOUNG patients with severe disease and deformity
=> Femoral and pelvic osteotomies

OLDER patients with secondary osteoarthritis
=> Total hip arthroplasty

52
Q

How is a slipped upper femoral epiphysis (SUFE) actually defined?

A

slippage of the metaphysis relative to the epiphysis

53
Q

What are the risk factors for a SUFE?

A
  • Male
  • Obesity

Endocrine disorders:

  • Growth hormone deficiency
  • Panhypopituitarism
  • Hypothyroidism
54
Q

How does a patient with a SUFE usually present?

A
  • Groin pain (or knee/thigh)
  • Limp
  • Externally rotated foot
  • Antalgic Gait
  • Obligatory external rotation on hip flexion
55
Q

How does a SUFE usually appear on an X-Ray?

A

Like ice-cream falling off the cone

56
Q

How is a SUFE treated surgically?

A

Percutaneous pinning of the hip

+/- pinning of the other side for prophylaxis
+/- open reduction if a very severe slip

Musculoskeletal (27 decks)

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