Paediatric Ortho - The big three Flashcards
Causes of hip problems in 0-5 yrs?
> ‘Normal variant’ > Trauma > Transient synovitis > Osteomyelitis > Septic arthritis > DDH > JIA
Causes of hip problems in 5-10 yrs?
> Trauma > Transient synovitis > Osteomyelitis > Septic arthritis > Legg-Calve (Perthes disease)
Causes of hip problems in 10-15 yrs?
> Trauma > Osteomyelitis > Septic arthritis > SUFE > Chrondromalacia > Neoplasm
Countries (Aetiology) of developmental dysplasia of the hip?
> Northern Europe 0.7 to 2.2 per 1000
> Eastern Europe = 28.7/1000
> African Neonates = 0
> Apaches and Navajos = 5%
Are girls or boys more likely to have developmental dysplasia of the hip?
Girls 6:1
Which hip is more commonly have developmental dysplasia of the hip?
The left hip, 3:1
Aetiology of developmental hip dysplasia?
> Girls > First born > Oligohydramnios > Breech delivery > Family history > Other limb deformities > Baby >10lbs > Apaches and Navajos = 5% > Eastern Europe = 28.7/100
Clinical features of developmental hip dysplasia?
> Ortolani’s Sign
Barlow’s Sign
Piston Motion Sign
The Hamstring Sign
However only 40% DDH are picked up by examination
Management of developmental hip dysplasia - <3 months?
Simple splint = 90% response
How does someone usually present with Legg-Calve-Perthes Disease?
> Male 5:1 > Primary school age > Short stature > Limp > Knee pain on exercise > Stiff hip joint > Family tendency > Low social status
Phases of Legg-Calve Perthes Disease?
> Avascular necrosis
> Fragmentation - Revascularisation (Painful)
> Reossification - Bony healing
> Residual deformity
Takes around 3 years and can be left with a deformed hip
Treatment of Legg-Calve-Perthes Disease?
> Analgesia
> Restrict painful activities
> ‘Supervised neglect’ in most cases
> ‘Containment’ - Consider osteotomy in selected groups of older children (>7)
> Prognosis good onset <9y
Treatment of Legg-Calve-Perthes Disease?
> Analgesia
> Restrict painful activities
> ‘Supervised neglect’ in most cases
> ‘Containment’ - Consider osteotomy in selected groups of older children (>7)
> Prognosis good onset <9y
Aetiology of slipped upper (capital) femoral epiphysis (SCFE)?
US call is Slipper capital femoral epiphysis (SCFE)
> 1-10 per 100,000 > Teenage boys > Girls (9-14 yrs) > 20% become bilateral > Many overweight > Small proportion endocrine abnormalities (If they are short thick about it)
Classification of SUFE?
> Acute Vs Chronic (3 weeks)
> Stable yrs unstable (Lober)
What time scale to indicate chronic SUFE?
> 3 weeks
How is unstable SUFE managed?
> Fix - serendipitous reduction
> Unable to weight-bear, poor prognosis (Higher risk of developing avascular necrosis)
How is stable SUFE managed?
> Fix in situ
> Able to weight-bear, good prognosis
Detection of SUFE?
> Pain in hip or knee
Externally rotated posture and gait
Reduced internal rotation, especially in flexion
Plain X-rays (Best seen on lateral view)
Detection of SUFE - Radiographic features?
> Mild <1/3
Moderate 1/3-1/2
Severe >1/2
Pathology of SUFE?
> Displacement through hypertrophic zone (Growth plate)
> Metaphysis moves anterior and proximal
SUFE - Treatment?
Surgical:
> Stable slips are pinned in situ (Through the femoral head)
> Severe unstable slops consider open reduction but avascular necrosis is high risk
Outcome of SUFE treatment (Surgery)?
> AVN (Avascular necrosis):
- Stable slips (Able to bear weight) have a low risk of AVN
- Unstable slips (Unable to bear weight) have a high risk of AVN.
> Chondrolysis
> Deformity (Short, externally rotated, limited flexion)
> Early osteoarthritis
> Possiblility of loop on the other side (If there is an endocrine issue sometime the other leg is pinned prophylactically)
> Limb length discrepancy - Pinning through the growth plate can reduce growth (The younger at the time the larger the discrepancy)
> Impingement
Why can’t you use Xray to monitor Developmental hip dysplasia, what other imaging modality is used instead?
The hip hasn’t ossified prior to 3 months of age. Ultrasound is used instead
Management of developmental hip dysplasia - 3 months to 1 year?
Closed reduction and spica cast
Management of developmental hip dysplasia - >1 year?
Over a year open reduction and capsule reefing
Management of developmental hip dysplasia - >18 months?
Open reduction with femoral shortening +/- Per-acetabular osteotomy
Management of developmental hip dysplasia - > 6yrs?
Bilateral leave alone
Management of developmental hip dysplasia - >10 yrs?
Unilateral leave alone
If development hip dysplasia isn’t recognised and treated earlier what is likely to occur?
Poorer results with an increased risk of AVN (Avascular necrosis)
Screening for developmental dysplasia of hip?
Clinical examination:
- Baby relaxed and examined early
- Examiner experience and has time
- Does not identify all dysplastic hips
Universal ultrasound screening:
- Time consuming/massive workload
- Difficulty in compliance and follow-up
- Eliminates number of late presenters
- May not be cost effective
Selective ultrasound screening:
- Work load manageable
- Reduces late presentations
- But late presenters will always occur
If a child presents with a pain in the knee how should you manage?
Check the hip for developmental hip dysplasia as there is a high risk of Legg-Calve-Perthes Disease
(Same nerve supply)
Prognosis of Legg-Calve-Perthes Disease?
> Age at presentation, younger od better
Proportion of head involved = More is bad
Herring grade (lateral Pillar classification)
Radiography “head at risk signs” Caterall
The nearer the head is to round the better the outlook (Stulberg)
What is used on radiograph to help identify SCFE?
Trethowan’s sign - Klein line should have part of the epiphysis above this in SCFE there isn’t.
Outcome of SUFE treatment (Surgery) - Avascular necrosis?
AVN (Avascular necrosis):
- Stable slips (Able to bear weight) have a low risk of AVN
- Unstable slips (Unable to bear weight) have a high risk of AVN.
