Paediatric orthopaedics - the big three Flashcards
What are the big three
DDH - Developmental Dysplasia of the Hip
Perthes disease
SUFE - Slipped Upper Femoral E piphysis
What can DDH lead to
Developmental dysplasia of the hip can lead to arthritis
What age does DDH usually affect
newborns
What age does Perthes disease normally affect
primary school age
what age does SUFE usually affect
Slipped upper femoral epiphyses - End of primary, beginning of secondary school
Where in the world is DDH - developmental dysplasia of the hip - most common
inuits - people who live in the arctic regions
Which gender is DDH more common in
Females 6:1 Males
Which hip is more commonly effected by DDH
Left hip - babies more commonly lie on their left side
What are the risk factors for DDH
first born
oligohydramnious - less fluid in the fluid filled sac the baby is in so the child is more likely to have renal problems and therefore they cannot kick around as much and have more chance of dislocated hip
Breech presentation - born feet first
Family history
other lower limb deformities
Overweight babies
What are the clinical features of DDH
Ortolani’s sign - as you abduct the hip, the hip pops into the socket
Barlows sign - apply a downward pressure over the knee with your thumb. If the hip is unstable, the femoral head will slip out of the acetabulum, producing the palpable sensation of the hip dislocating.
Piston motion sign - push on hip and you can feel it moving
Hamstring sign - flex thigh onto stomach and you should not be able to extend the knee unless the hip is dislocated
Why is Xray not done in new borns to look for DDH
Head of femur does not ossify until 3 months old at least so ultrasound has to be used
What is the treatment of DDH
If the DDH is caught early <3 months old - simple splint will be effective - pavlick harness
Closed reduction and spica cast if between 3 months and a year old
Over 18 months - open reduction with femoral shortening with or without peri-acetabular osteotomy
Over 6 years and bilateral - no treatment
Over 10 years old and unilateral - leave alone
What is the correlation between age of diagnosis of DDH and effectiveness of treatment
The younger DDH is diagnosed, the easier and more effective the treatment will be
Who is perthes disease more commonly seen in
Male - 10:1
Primary school age - 3,4,5
Short stature
Limp
knee pain on exercise
stiff hip joint
systemically well
How does DDH occur
Avascular necrosis of the hip
What happens in perthes disease
the blood supply to the head of the femur is interrupted. The femoral head then “necroses,” or loses blood supply, which weakens the bone and can lead to multiple fractures. Next, the bone is taken up by the body, or resorbed, which can lead to a complete collapse of the femoral head - Bone becomes soft and then the head of the femur collapses down and the space between the acetabulum and the femur increase
What is the correlation with the shape of the femoral head and prognosis in perthes disease
The rounder the head the better - perthes can cause flattening of the femoral head
What is the correlation between age and prognosis in perthes disease
Younger diagnosis - better outcome
What is the Herring grade
The more collapsed down, the lateral pillar (lateral part) of the head was, the more severe, the perthes disease was
How is perthes disease treated
Very young do not need treatment
Mantain hip motion
analgesia
restrict painful activities
Osteotomy in selected older children over 7
What happens in an osteotomy
The head of the femur is broken and then contained into the acetabulum - points into the socket
What is used for diagnosis of perthes disease
X-ray
Who is SUFE - slipped upper femoral epiphysis more common in
Teenage boys - 9-14 years old slightly more than females
Mainly overweight
What is acute SUFE
symptoms for less than 3 weeks
What is chronic SUFE
symptoms more than 3 weeks
What is an unstable SUFE
Unable to weight bear - bad prognosis
What is stable SUFE
able to weight bear - good prognosis
What is the presentation of SUFE
pain in hip or knee
externally rotated posture and gait
reduced internal rotation especially if the hip is flexed up
How is SUFE investigated
X-ray
What is the treatment for SUFE
Surgical - screw through the centre of bone and through the neck of the femur - bone grows across the growth plate and stops the slip getting worse
In severe unstable slips can do open reduction but avascular necrosis risk is high
What are the risk factors of SUFE
avascular necrosis
chondrolysis - damage to the cartilage
deformity
osteoarthritis
slip possibility on the other side
limb length discrepancy
impingement
What is the correlation between stability of slip and risk of avascular necrosis in SUFE
The more stable the slip is, the less risk of A vascular necrosis
