Paediatrics Hips Flashcards
Brief description of DDH
DDH involves dislocation or subluxation of the femoral head during the perinatal period which affects the subsequent development of the hip joint.
DDH is more common in?
Girls and the left hip but 20% cases are bilateral
Risk factors for DDH
Positive family history of DDH Breech position First born babies Down's syndrome Presence of other congenital disorders (e.g. talipes)
If DDH is left untreated what can happen?
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.
Clinical Signs of DDH
shortening
asymmetric groin/ thigh skin crease
Clink/ clunk on Ortolani or Barlow manoeuvres
Positive Ortolani test
Reducing a dislocated hip with abduction and anterior displacement
Positive Barlow test
Dislocatable hip with flexion and posterior displacement
If Barlow or Ortolani test is positive what further invetsigation is required? What may it show?
Ultrasound
Dislocated hip, unstable hip or a shallow acetabulum
Why are x-rays not used in the diagnosis of DDH?
The femoral head epiphysis is unossified until around 4‐6 months but xrays are the investigation of choice after this age.
How are mild cases of DDH treated? Slightly shallow acetabulum and mildly dislocatable but reduced (in joint hip)
Closely observed with serial examination and USS to ensure the hip remains reduced.
How are dislocated or persistently unstable hips caused by DDH treated?
Reduced and held with a special harness known as a Pavlik harness which keeps the hips in comfortable flexion and abduction thus maintaining reduction.
SE of over-flexing and abducting the hip.
AVN
How long should a Pavlik harness be used for?
Full time for around 6 weeks and part time for a further 6 weeks once the hip is confirmed to be stable.
Up to what age can a Pavlik harness be used?
Up to around 4-6 months
Success rate of Pavlik harness
85-90%
If a child has persistent dislocation of the hip over 18 months old, what treatment is required?
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.
What is the most common cause of hip pain in childhood?
Transient synovitis
Clinical presentation of Transient synovitis
Limp or reluctance to weight bear on the affected side
ROM may be restricted
May have low grade fever but not systemically unwell
Treatment for transient synovitis of the hip.
Short course of NSAIDs and rest.
Who does transient synovitis of the hip most commonly affect?
2-10 years
Boys > Girls
Describe Perthes Disease
Idiopathic osteochondritis of the femoral head. Femoral head transiently loses if blood supply resulting in necrosis with subsequent abnormal growth.
Who does Perthes disease most commonly affect?
4-9 years
Boys > Girls (5:1)
esp. very active boys of short stature
Clinical presentation of Perthes disease
Pain
Limp
Unilateral
If bilateral, considerunderlying skeletal dysplasia or thrombophilia
Clinical signs of Perthes disease
Loss of internal rotation
Loss of abduction
Later - positive Trendellenburg test from gluteal weakness
Treatment of Perthes disease
Regular x-ray observation
Avoidance of physical activity
In Perthes disease, if the femoral head subluxes what treatment is required?
Osteotomy of the femur or acetabulum
Describe SUFE
Femoral head epiphysis slips inferiorly in relation to the femoral neck.
Who does SUFE most commonly affect?
Overweight pre-pubertal adolescent boys
Predisposing factors to SUFE
Hypothyroidism or renal disease
Clinical presentation of SUFE
Pain - may be in groin but can be just knee pain
Limp
Clinical signs of SUFE
Loss of internal rotation is predominant sign
Treatment of SUFE
Surgery to pin the femoral head
Severe acute slips - gentle manipulation may be attempted but risks ANV
Chronic severe slips - osteotomy
