Pain in the hip - Transient synovitis, DDH, Perthes and SUFE Flashcards
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
What is hip dysplasia?
Radiographic finding
An imperfect degree of coverage of the femoral head by the acetabulum.
What is hip subluxation?
Semi-dislocated but partial articulation of the joint surfaces is still maintained.
Which sex does DDH more commonly affect?
Females > Males - 6:1
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
What is the presentation of DDH in > 1 year olds?
- Abnormal gait - Tendelenberg gait, waddling gait
- Pain
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
How would you investigate a child you suspected had DDH?
Less than 6 months
- Ultrasound
More than 6 months
- Radiograph
How would you approach managing a child <3 months with DDH?
Simple splint (hip orthosis)
What can be a complication of DDH that is left untreated?
OA of the hip
What is Perthes disease?
Self-limiting disease of the femoral head comprising of necrosis, collapse, repair, and re-modelling
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
Which sex does Perthes disease more commonly affect?
Males - 4-5x more common
What percentage of those with Perthes disease are affected bilaterally?
10-15%
What is the aetiology of Perthes disease?
Unknown
What are the symptoms of Perthes Disease?
- Pain - hip or knee
- Limp
- Decreased ROM
What age does Perthes disease most commonly affect?
Typically 4-8yrs old - overall range of 3-11yrs
What are the clinical signs of Perthes Disease?
- Decreased ROM - esp. Internal rotation and abduction
- Stiffness
- Positive Trendelenberg test
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 > 38.5oC
- 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
