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

What is developmental dysplasia of the hip?

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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What is hip dysplasia?

Radiographic finding

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

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What is hip subluxation?

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

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Which sex does DDH more commonly affect?

Females > Males - 6:1

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What are the risk factors for the development of DDH?

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

Abnormal gait - Tendelenberg gait, waddling gait
Pain

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How does DDH present in babies < 1 year old?

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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How would you investigate a child you suspected had DDH?

Less than 6 months

Ultrasound

More than 6 months

Radiograph

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

Simple splint (hip orthosis)

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

OA of the hip

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What is Perthes disease?

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

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How does Perthes Disease occur?

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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Which sex does Perthes disease more commonly affect?

Males - 4-5x more common

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What percentage of those with Perthes disease are affected bilaterally?

10-15%

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What is the aetiology of Perthes disease?

Unknown

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What are the symptoms of Perthes Disease?

Pain - hip or knee
Limp
Decreased ROM

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What age does Perthes disease most commonly affect?

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

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What are the clinical signs of Perthes Disease?

Decreased ROM - esp. Internal rotation and abduction
Stiffness
Positive Trendelenberg test

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How would you investigate Perthes Disease?

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

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

Stage 1 - Necrosis

Femoral head is radiodense and smaller

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

Stage 2 - Fragmentation

Subchondral fracture, bone resorption and cyst formation

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

Stage 3 - Reossification

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

Stage 4 - Remodelling

Flattened femoral head/Shape maintained

How would you manage someone with Perthes Disease?

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

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

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

What is Slipped Upper Femoral Epiphysis (SUFE)?

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

What age range does SUFE more commonly affect?

9-14 years

What sex does SUFE more commonly affect?

Males

What groups of individuals does SUFE more commonly occur in?

Obese Children

What percentage of those with SUFE have bilateral disease?

20%

What can SUFE be caused by?

* Obesity * Rapid growth during adolescence * Endocrine Disorder

What are the clinical features of SUFE?

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

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

**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

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

* **Metabolic panel** - renal osteodystrophy * **Serum TFTs** - hypothyroidism * **Serum GH** - GH deficiency

How would you treat someone with SUFE?

**Fixation of epiphysis with single screw** - 1st LINE TREATMENT

What complications can occur if a SUFE is left untreated?

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

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

* 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_***

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

Septic arthritis

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?

* **Osteomyelitis** * **Trauma** * **Perthes Disease** * **Haemarthrosis** * **SUFE** * **Inflammatory arthritis** * **Tubercular arthritis** * **Reactive Arthritis**

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

**Transient synovitis (irritable hip)**

What is transient synovitis?

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

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

* **Temp \> 38.5^oC** * **WCC\>12** * **CRP\>20** * **Non-weight bearing**

Why is first born a risk factor for DDH?

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

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

Hip abduction

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

Closed reduction and SPICA cast

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

Open reduction and capsule reefing/femoral shortening