Paediatric Orthopaedics - the big three Flashcards
What are the big three?
DDH
Perthes disease
SUFE
How common is DDH?
0.24%
6X more common in girls
More common in L hip
In which groups of people is DDH more common?
First born Oligohydramnios (decreased uterine space) Breech presentation FH Other lower limb deformities
What is DDH?
Congenital malformation affecting the femoral head/acetabulum –> hip instability, subluxation of femoral head, hip dislocation etc.
How do you notice DDH?
Newborn screening
<6m: asymptomatic, barlow sign, ortolani sign
6-18m: inability to abduct hip, assymetrical gluteal folds
> 18m: hip pain and pain referred from hip to knee/ant thigh, hip deformity, waddling/trendlenburg gait, leg length discrepancy
What is barlow sign?
Hip clunks as it is dislocated during flexion & adduction with downwards pressure
What is ortolani sign?
Palpable clunk caused by hip reduction when hip flexed and abducted while applying upward pressure
What is piston motion sign?
Hip moves up and down like a piston cause it is not in the acetabulum properly
How do you diagnose DDH?
Screening
Hip USS if less than 4 months
Hip Xray if older than 4 months
What X-Ray findings might you see in DDH?
Disrupted Shenton’s line (medial border of femoral neck to lower border of superior pubic ramus)
Ossified nucleus of femoral head lies at Hilgereiner’s line (line through triradiate cartilage of acetabulum)
Ossified nucleus of femoral head lies lateral to perkins line (vertical line drawn perpendicular through lateral point of acetabulum)
How do you Mx DDH?
<3m - simple splint 3-12m - closed reduction and spica cast >1y open reduction and capsule reefing >18 months open reduction and femoral shortening >6y and bilateral leave alone >10y and unilateral leave alone
Older the children the poorer the results
What is typical presentation of Legg-Calve-Perthes Disease?
Boy Primary school age Short stature Limp Knee pain on exercise Stiff hip joint Systemically well
How do you screen for DDH?
Clinical exam only picks up 40%
What is the aetiology of Perthes disease?
Avascular necrosis of femoral head due to mismatch between rapid growth of femoral epiphyses and slower BS to area
Genetic factors, bleeding disorders, repetitive microtrauma
4 stages of Perthes disease seen on a radiograph
4 Waldenstorm stages
- Initial stage
- Fragmentation stage
- Reossification stage
- Healed stage
How do you Rx Perthes?
Maintain hip motion Analgesia Restrict painful activities ‘Supervised neglect’ in most cases ‘Containment’ - Consider osteotomy in selected groups of older children (>7) Prognosis good onset <9y
What is SCFE?
Slipped capital femoral epiphysis aka SUFE
Who does SUFE tend to affect?
Teenage boys (9-14)
How is SUFE classified?
Acute vs chronic (3wks)
Stable vs unstable (stable = wt bear, unstable cant weight bear)
What occurs in SUFE?
Usually presents after minor trauma
Displacement through the GP, with the epiphysis always sliding down and back
Typical presentation of SUFE
- Boy
- 10-16yrs
- Overweight
- Limp
- Pain groin, knee or ant. thigh
Externally rotated posture + gait
Reduced IR, especially in flexion
What are risk factors for SUFE?
Increasing load as well as weak physis
Adolescence, delayed bone age, increasing weight (obesity)
What are the secondary causes of SUFE?
Hypothyroidism
Hypogonadism
Trauma
GH therapy
How do you Ix SUFE?
Plain Xray
Best seen on lat view/frog leg
