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MSK > Pain in the hip - Transient synovitis, DDH, Perthes and SUFE > Flashcards

Pain in the hip - Transient synovitis, DDH, Perthes and SUFE Flashcards

1
Q

What is developmental dysplasia of the hip?

A

Spectrum of conditions affecting the proximal femur and acetabular

Acetabular immaturity ⇒ hip subluxation ⇒ frank hip dislocation

In severe cases, a misplaced femoral head leads to the development of a false acetabulum in the pelvis

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2
Q

What is hip dysplasia?

A

Radiographic finding

An imperfect degree of coverage of the femoral head by the acetabulum.

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3
Q

What is hip subluxation?

A

Semi-dislocated but partial articulation of the joint surfaces is still maintained.

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4
Q

Which sex does DDH more commonly affect?

A

Females > Males - 6:1

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5
Q

What are the risk factors for the development of DDH?

A

“All the F’s”

  • Female
  • Firstborn
  • Foot first - breech
  • Family history
  • Further bony abnormalities - talipes equinovarus
  • Fat - Increased birth weight
  • Fluid - Oligohydramnios
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6
Q

What is the presentation of DDH in > 1 year olds?

A
  • Abnormal gait - Tendelenberg gait, waddling gait
  • Pain
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7
Q

How does DDH present in babies < 1 year old?

A
  • Restricted abduction - while knee is flexed
  • Delayed crawling/walking
  • Positive Barlow’s Sign - dislocate hips
  • Positive Ortolani’s Sign - relocate hips
  • Positive Galeazzi Test
  • Asymmetrical groin creases
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8
Q

How would you investigate a child you suspected had DDH?

A

Less than 6 months

  • Ultrasound

More than 6 months

  • Radiograph
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9
Q

How would you approach managing a child <3 months with DDH?

A

Simple splint (hip orthosis)

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10
Q

What can be a complication of DDH that is left untreated?

A

OA of the hip

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11
Q

What is Perthes disease?

A

Self-limiting disease of the femoral head comprising of necrosis, collapse, repair, and re-modelling

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12
Q

How does Perthes Disease occur?

A
  • Stage 1 - ischaemia - Variable area of femoral head involved
  • Stage 2 - resorption, fragmentation, re-vascularisation, and repair
  • Stage 3 - re-ossification and resolution
  • Stage 4 - re-modelling - flattening and distortion of femoral head
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13
Q

Which sex does Perthes disease more commonly affect?

A

Males - 4-5x more common

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14
Q

What percentage of those with Perthes disease are affected bilaterally?

A

10-15%

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15
Q

What is the aetiology of Perthes disease?

A

Unknown

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16
Q

What are the symptoms of Perthes Disease?

A
  • Pain - hip or knee
  • Limp
  • Decreased ROM
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17
Q

What age does Perthes disease most commonly affect?

A

Typically 4-8yrs old - overall range of 3-11yrs

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18
Q

What are the clinical signs of Perthes Disease?

A
  • Decreased ROM - esp. Internal rotation and abduction
  • Stiffness
  • Positive Trendelenberg test
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19
Q

How would you investigate Perthes Disease?

A
  • Bilateral Hip X-ray - Waldenstrom Staging - subchondral fracture and Femoral head collapse and fragmentation
  • Bone Scintigraphy - perfusion during ischaemic phase
20
Q

What stage of Waldenstrom’s staging is the following radiograph?

A

Stage 1 - Necrosis

Femoral head is radiodense and smaller

21
Q

What stage of Waldenstrom’s staging is the following radiograph?

A

Stage 2 - Fragmentation

Subchondral fracture, bone resorption and cyst formation

22
Q

What stage of Waldenstrom’s staging is the following radiograph?

A

Stage 3 - Reossification

23
Q

What stage of the Waldenstrom Staging is represented in the following Radiograph?

A

Stage 4 - Remodelling

Flattened femoral head/Shape maintained

24
Q

How would you manage someone with Perthes Disease?

A
  • Less severe disease
    • Maintain hip motion
    • Analgesia - NSAIDs, paracetamol
    • Restrict painful activities
  • More severe
    • Pin the hips
    • Surgical - osteotomy in selected groups of older children >7
25
Q

What is the general rule for determining prognosis in Perthes Disease?

A

The nearer the head is to round, the better the prognosis

26
Q

What is Slipped Upper Femoral Epiphysis (SUFE)?

A

Occurs when weakness in the proximal femoral growth plate allows displacement of the capital femoral epiphysis

27
Q

What age range does SUFE more commonly affect?

A

9-14 years

28
Q

What sex does SUFE more commonly affect?

A

Males

29
Q

What groups of individuals does SUFE more commonly occur in?

A

Obese Children

30
Q

What percentage of those with SUFE have bilateral disease?

A

20%

31
Q

What can SUFE be caused by?

A
  • Obesity
  • Rapid growth during adolescence
  • Endocrine Disorder
32
Q

What are the clinical features of SUFE?

A
  • Pain - groin, hip, knee +/- thigh pain
  • Previous trauma
  • Externally rotated - when hip flexed
  • Reduced internal rotation and ROM
  • Positive Trendelenberg test
33
Q

What imaging would you do to investigate someone who you suspected had SUFE?

A

Bilateral AP x-rays - Klein line doesn’t intersect with femoral head

  • Mild - <1/3
  • Moderate - 1/3-1/2
  • Severe - >1/2

Frog leg lateral X-rays

  • Klein’s line does not intersect femoral head
  • Bloomberg sign positive - Physis blurred/widened
34
Q

What bloods would you do to investigate someone you suspected had SUFE?

A
  • Metabolic panel - renal osteodystrophy
  • Serum TFTs - hypothyroidism
  • Serum GH - GH deficiency
35
Q

How would you treat someone with SUFE?

A

Fixation of epiphysis with single screw - 1st LINE TREATMENT

36
Q

What complications can occur if a SUFE is left untreated?

A
  • Avascular Necrosis
  • Chondrolysis - short term, low likelihood
  • Deformity - short, externally rotated, limited flexion
  • Osteonecrosis - variable time frame, medium likelihood
  • Early osteoarthritis
  • Impingement
37
Q

With regard to radiographic features in SUFE, what are klein lines?

A
  • Line along the superior edge of the neck of the femur ⇒ normally intersect the lateral part of the superior femoral epiphysis
  • If line fails to intersect the epiphysis during the acute phase, it is called Trethowan’s sign
38
Q

When a child presents with a limp or knee/hip pain, what must you first rule out?

A

Septic arthritis

39
Q

If a child presents with a limp and/or hip/knee pain, what should you consider as part of the differential diagnosis once you have ruled out Septic arthritis?

A
  • Osteomyelitis
  • Trauma
  • Perthes Disease
  • Haemarthrosis
  • SUFE
  • Inflammatory arthritis
  • Tubercular arthritis
  • Reactive Arthritis
40
Q

If a child present with a limp and/or hip/knee pain, what condition can be diagnosed by exclusion of all other causes?

A

Transient synovitis (irritable hip)

41
Q

What is transient synovitis?

A

A condition where children present with a limp. By definition, the irritability should be transient: discomfort, muscle spasm around the hip joint and limp disappear within 7–10 days

42
Q

What prognostic clinical signs could you use to determine between septic arthritis (an emergency) and transient synovitis (benign) in a child?

A
  • Temp > 38.5oC
  • WCC>12
  • CRP>20
  • Non-weight bearing
43
Q

Why is first born a risk factor for DDH?

A

First-born babies are at higher risk since the uterus is small and there is limited room for the baby to move; therefore affecting the development of the hip

44
Q

What is the most sensitive test on clinical examination for DDH in a child <1 year old?

A

Hip abduction

45
Q

How would you manage a child with DDH between the age of 3 months - 1 year?

A

Closed reduction and SPICA cast

46
Q

How would you manage a child with DDH over the age of 1 year?

A

Open reduction and capsule reefing/femoral shortening

MSK (27 decks)

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