Paediatrics Hips

Question 1

Brief description of DDH

Answer 1

DDH involves dislocation or subluxation of the femoral head during the perinatal period which affects the subsequent development of the hip joint.

Question 2

DDH is more common in?

Answer 2

Girls and the left hip but 20% cases are bilateral

Question 3

Risk factors for DDH

Answer 3

Positive family history of DDH 
Breech position 
First born babies 
Down's syndrome 
Presence of other congenital disorders (e.g. talipes)

Question 4

If DDH is left untreated what can happen?

Answer 4

Acetabulum is very shallow and in more severe cases a false acetabulum occurs proximal to the original one with a shortened lower limb. Severe arthritis due to reduced contact area can occur at a young age and gait / mobility may be severely affected.

Question 5

Clinical Signs of DDH

Answer 5

shortening
asymmetric groin/ thigh skin crease
Clink/ clunk on Ortolani or Barlow manoeuvres

Question 6

Positive Ortolani test

Answer 6

Reducing a dislocated hip with abduction and anterior displacement

Question 7

Positive Barlow test

Answer 7

Dislocatable hip with flexion and posterior displacement

Question 8

If Barlow or Ortolani test is positive what further invetsigation is required? What may it show?

Answer 8

Ultrasound

Dislocated hip, unstable hip or a shallow acetabulum

Question 9

Why are x-rays not used in the diagnosis of DDH?

Answer 9

The femoral head epiphysis is unossified until around 4‐6 months but xrays are the investigation of choice after this age.

Question 10

How are mild cases of DDH treated? Slightly shallow acetabulum and mildly dislocatable but reduced (in joint hip)

Answer 10

Closely observed with serial examination and USS to ensure the hip remains reduced.

Question 11

How are dislocated or persistently unstable hips caused by DDH treated?

Answer 11

Reduced and held with a special harness known as a Pavlik harness which keeps the hips in comfortable flexion and abduction thus maintaining reduction.

Question 12

SE of over-flexing and abducting the hip.

Answer 12

AVN

Question 13

How long should a Pavlik harness be used for?

Answer 13

Full time for around 6 weeks and part time for a further 6 weeks once the hip is confirmed to be stable.

Question 14

Up to what age can a Pavlik harness be used?

Answer 14

Up to around 4-6 months

Question 15

Success rate of Pavlik harness

Answer 15

85-90%

Question 16

If a child has persistent dislocation of the hip over 18 months old, what treatment is required?

Answer 16

Open reduction to clear soft tissues and may also need an osteotomy to shorten and rotate the femur and/ or pelvic osteotomy to deepen and reorientate the acetabulum.

Question 17

What is the most common cause of hip pain in childhood?

Answer 17

Transient synovitis

Question 18

Clinical presentation of Transient synovitis

Answer 18

Limp or reluctance to weight bear on the affected side
ROM may be restricted
May have low grade fever but not systemically unwell

Question 19

Treatment for transient synovitis of the hip.

Answer 19

Short course of NSAIDs and rest.

Question 20

Who does transient synovitis of the hip most commonly affect?

Answer 20

2-10 years

Boys > Girls

Question 21

Describe Perthes Disease

Answer 21

Idiopathic osteochondritis of the femoral head. Femoral head transiently loses if blood supply resulting in necrosis with subsequent abnormal growth.

Question 22

Who does Perthes disease most commonly affect?

Answer 22

4-9 years
Boys > Girls (5:1)
esp. very active boys of short stature

Question 23

Clinical presentation of Perthes disease

Answer 23

Pain
Limp
Unilateral
If bilateral, considerunderlying skeletal dysplasia or thrombophilia

Question 24

Clinical signs of Perthes disease

Answer 24

Loss of internal rotation
Loss of abduction
Later - positive Trendellenburg test from gluteal weakness

Question 25

Treatment of Perthes disease

Answer 25

Regular x-ray observation

Avoidance of physical activity

Question 26

In Perthes disease, if the femoral head subluxes what treatment is required?

Answer 26

Osteotomy of the femur or acetabulum

Question 27

Describe SUFE

Answer 27

Femoral head epiphysis slips inferiorly in relation to the femoral neck.

Question 28

Who does SUFE most commonly affect?

Answer 28

Overweight pre-pubertal adolescent boys

Question 29

Predisposing factors to SUFE

Answer 29

Hypothyroidism or renal disease

Question 30

Clinical presentation of SUFE

Answer 30

Pain - may be in groin but can be just knee pain

Limp

Question 31

Clinical signs of SUFE

Answer 31

Loss of internal rotation is predominant sign

Question 32

Treatment of SUFE

Answer 32

Surgery to pin the femoral head
Severe acute slips - gentle manipulation may be attempted but risks ANV
Chronic severe slips - osteotomy