Paediatric Hip Problems Flashcards
what is developmental dysplasia of hip (DDH)
a disorder of abnormal development resulting in dysplasia and possible subluxation or dislocation of hip secondary to capsular laxity and mechanical factors
what is prevalence of DDH
5 in 1000 babies
girls account for 80% of cases
what hip is DDH more common in
left hip (due to intrauterine position) but 20% of cases is bilateral
what are risk factors for DDH
family history of DDH breech presentation first born babies downs syndrome other congenital disorders (talipes, arthrogryposis)
what are symptoms of DDH
shortening
asymmetric grin / thigh skin creases
clink or clunk of ortolani or barlow manoeuvres (early)
limping child (late)
what is ortolani manoeuvre
reducing a dislocated hip with abduction and anterior displacement
what is barlows manoevure
dislocatable hip with flexion and posterior displacement
how is DDH diagnosed
positive ortolani or barlow test requires further evaluation with US
Xray cannot be used until 4-6 months
what is treatment for mild DDH
closely observed with serial examination and US to ensure hip remains reduced
what is treatment for dislocated or persistently unstable hips DDH
reduced and held in pavlik harness which keeps hips in comfortable flexion an abduction
used full time for 6 weeks and PT for another 6 weeks
what is treatment for DDH with persistent dislocation over 18 months or presenting late
closed reduction +/- tenotomies + spica cast
open reduction + osteotomies + spica cast
what is complication of persistent or undiagnosed DDH
acetabulum very shallow
more severe = false acetabulum occurs proximal to original one with shortened lower limb
severe arthritis due to reduced contact area
what is transient synovitis of hip (reactive synovitis)
self limiting inflammation of the synovium of the hip
most common cause of hip pain in childhood
what causes transient synovitis of hip
commonly occurs shortly after URTI although sometimes no cause found
who is most commonly affected by transient synovitis of hip
age 2-10 years and boys more commonly affected than girl
what are symptoms of transient synovitis of hip
limp or reluctance to bear weight
maybe referred pain to knee
range of motion restricted (but not as much as septic arthritis)
hip lying flexed / externally rotated
may have low grade fever but not systemically unwell or septic
how is transient synovitis of hip diagnosed
radiographs can exclude perthes disease
normal CRP and clinical picture more suggestive of transient synovitis may exclude septic arthritis
what criteria is used to distinguish between transient synovitis of hip and septic arthritis of hip
kochers criteria
how is transient synovitis of hip treated
once more serious cause excluded:
self limiting - resolves in few weeks
NSAIDs and rest
what is perthes disease (aka legg-calve-perthes disease)
avascular necrosis / compression osteochondritis of hip
the femoral head transiently loses blood supply resulting in necrosis with subsequent abnormal growth
who is the incidence of perthes disease higher in
ages 4-9 and more common in boys (5:1) esp active boys of short stature
higher in lower socioeconomic classes
what are risk factors of perthes disease
family history
low birth weight
second hand smoke
Asian, inuit and central european descent
what are the symptoms of perthes disease
pain and a limp (sometimes groin or knee pain)
mostly unilateral
loss of internal rotation followed by loss of abduction
later, there will be + trendellenburg test from gluteal weakness
how is perthes disease diagnosed
radiographs and MRI
how is perthes disease treated
no specific tx other than regular xray observation and avoidance of physical activity
approx 50% of cases of perthes disease do well, what happens when they dont
some cases = femoral head becomes aspherical, flattened and widened causing alternation of abductor muscle resulting in weakness (trendelenburg +ve)
occasionally = femoral head may sublux requiring osteotomy of femur or acetabulum
by which classification determines risk of arthritis in perthes disease
stulberg spherical congruity (I&II) - no arthritis aspherical congruity (III&IV) - mild arthritis mid-late adult aspherical incongruity (V) - severe arthritis before 50
what is slipped upper femoral epiphysis (SUFE) and who does it effect
condition which mainly affects overweight pre-pubertal boys where femoral head epiphysis slips inferiorly in relation to femoral neck
why does the femoral head slip in SUFE
the growth plate (physis) not strong enough to support body weight and the epiphysis slips due to strain
what are symptoms of SUFE
pain and limp
externally rotated foot
pain may be felt in groin or KNEE (obturator nerve)
loss of internal rotation is predominant clinical sign
how is SUFE diagnosed
xray changes may be subtle and lateral view must be obtained to detect mild slip
MRI
what is the treatment of SUFE
urgent surgery to pin the femoral head to prevent further slippage = percutaneous pinning of hip +/- pinning of other side or +/- open reduction of very severe slip
what is the prognosis of SUFE depending on the degree of slip
mild slips = favourable
acute slips = gentile manipulation may be attempted but this risks AVN
chronic severe slips = may require osteotomy
some cases may require hip replacement in adolescence or early adulthood
