Paediatric Orthopaedics - The Big 3

Question 1

What does DDH stand for?

Answer 1

Developmental dysplasia of the hip

Question 2

Describe the epidemiology of DDH in terms of ethnicity, sex and which hip is more commonly affected?

Answer 2

• different in different parts of world
• most prevalent in Eskimo’s and least in northern Europe
• girls:boys 6:1
• left hip more commonly affected than right

Question 3

What are risk factors for DDH?

Answer 3

• firstborn
• oligohydramnios: reduced fluid within the uterus
• breech presentation
• family history
• other lower limb deformity
• high birth weight

Question 4

What is oligohydramnios?

Answer 4

Reduced fluid within the uterus

Question 5

What are the clinical features of DDH?

Answer 5

• Ortolani’s sign
• Barlow’s sign
• Piston motion sign
• Hamstring sign

Question 6

What investigations are done for DDH?

Answer 6

X-ray is not done due to reducing x-ray exposure, and it would show things too late anyway due to femur not ossifying until 3 months

Investigation:

• USS

Question 7

What does the treatment of DDH depend on?

Answer 7

Age of patient

Question 8

What is the treatment for DDH?

Answer 8

• <3 months: simple splint
• 3 months-1 year: closed reduction and spica cast
• >1 year: open reduction and capsule reefing
• >18 months: open reduction with femoral shortening with or without peri-acetabular osteomy
• >6 years and bilateral: leave alone

Question 9

How does the prognosis of DDH with treatment change with age?

Answer 9

The older the child the poorer the result

Question 10

Is any screening done for DDH in the UK?

Answer 10

Selective US screening is done in UK:

• Every baby examined at birth
• US may follow if indicated

Question 11

What is the aetiology of perthes disease?

Answer 11

• avascular necrosis of hip due to coagulation tendency/repeated minor trauma
• familial
• low social status

Question 12

Describe the epidemiology of perthes disease in terms of sex and age?

Answer 12

• M>F
• Primary school age

Question 13

What are the clinical features of perthes disease?

Answer 13

• Limp
• Knee pain on exercise
• Stiff hip joint
• Systemically well

Question 14

What investigation is done for perthes disease?

Answer 14

X-ray

Question 15

How is perthes disease staged on an x-ray?

Answer 15

Four Waldenstrom stages:

1) Initial stage
2) Fragmentation stage
3) Reossification stage
4) Healed stage

Question 16

What impacts the prognosis of perthes disease?

Answer 16

• Younger age at presentation do better
• Proportion of head involved
• Herring grade

Question 17

What is the treatment of perthes disease?

Answer 17

• maintain hip motion
• restrict painful activity
• analgesia
• osteotomy (>7 years)

Question 18

What does SUFE stand for?

Answer 18

Slipped upper femoral epithysis

Question 19

Describe the epidemiology of SUFE in terms of sex and age?

Answer 19

• M>F
• Many overweight
• Age 9-14 years

Question 20

How can SUFE be classed?

Answer 20

• acute v chronic
• magnitude of slip (angle or proportion)
• stable v unstable
• unstable: unable to weight bear (poor prognosis)
• stable: able to bear weight (good prognosis)

Question 21

What is the difference between stable and unstable SUFE?

Answer 21

• Stable v unstable
  
  • Unstable is unable to weight bear (poor prognosis)
  • Stable is able to bear weight (good prognosis)

Question 22

How is the magnitude of SUFE classified?

Answer 22

ratio of width of femur to amount of slip

• mild <1/3
• moderate 1/3-1/2
• severe >1/2

Question 23

Describe the pathology of SUFE?

Answer 23

• Displacement through hypertrophic zone
• Metaphysis moves anterior and proximal

Question 24

What are the clinical features of SUFE?

Answer 24

• pain in hip or knee
• externally rotated posture and gait
• reduced internal rotation, especially in flexion
• plain x-rays (best seen on lateral x-rays)

Question 25

What investigations are done for SUFE?

Answer 25

• X-ray
• Slip can be identified early using Trethowan;s sign on AP film

Question 26

What is the treatment for SUFE?

Answer 26

operative

• stable: pinned in situ
• unstable: open reduction

Question 27

What are possible complications of SUFE?

Answer 27

• AVN
  
  • Stable slips have low risk, unstable slips have high risk
• Chrondolysis
• Deformity
• Early OA
• Limb length discrepancy
• Impingement