Pediatric Hip Conditions

Question 1

What is Developmental Dysplasia of the Hip? How is Developmental Dysplasia of the Hip diagnosed in the neonate and why is it critical to detect this, if present, as soon as possible?

Answer 1

It may be better to think of this condition in terms of its old name “congenital dislocation of the hip” (CDH): the baby is born with the hip out of the socket or unstable.

Being out of socket is not good, of course, yet not so much for present function -the baby is not walking on it–but because for the hip joint to grow properly, the (mostly cartilage) head has to be in the socket. If the head is not in the socket, it will be grow to be mal-formed (“dysplastic”). Prompt detection and expeditious treatment allows the hip to remodel and form properly.

DDH can be detected on exam – there are a variety of physical exam maneuvers that can be used for diagnosis, including the Ortolani reduction maneuver (abduction and elevation to feel for reduction) and the Barlow provocation test (adduction/posterior pressure to feel for dislocation)—but in high risk patients (Breech position, female gender, first born children, and a positive family history are risk factors) ultrasound is used.

The goal of early treatment is to maintain reduction of the hip to provide the proper environment for the development of the femoral head and acetabulum, which requires that the cartilaginous surface of the femoral head be in contact with the cartilaginous floor of the acetabulum
Abduction splinting in a Pavlik harness (or even with double diapers for low tech areas) before 6 months of age can usually achieve and maintain hip reduction.
If found late, the hip needs to be reduced, perhaps surgically. Note: even though this put the hip in a “normal” position, it is not “normal” for this baby, and therefore the REDUCTION can damage the blood supply and cause AVN. Untreated DDH should not have AVN
The greater the delay in treatment, the harder it is to treat.

Question 2

What is a Slipped Capital Femoral Epiphysis?

Answer 2

First, you have to know that the femoral head (capitus) has a physis (a growth plate). Then you have to know that the bone towards the end, across the physis, is called the epiphysis.
Then you have to know that the physis is cartilage-like, and therefore weak. And then you can know/imagine that the epiphysis can slip off, a form of a growth plate fracture, really.

So what else do you need to know?

who gets this? 1 in 10,000 kids, 4x more common in blacks, usually during early puberty, when the physis active. Obesity and endocrinopathies are risk factors
How do you diagnose? Get an xray---but note that the complaint may be KNEE pain!
How do you treat? Pin it in situ
Why do you treat? Prevent progression, symptom relief. Most doctors do not attempt to relocate the epiphysis, fearing further damage to the blood supply.

Question 3

What is Perthes Disease?

Answer 3

Perthes is AVN of the femoral epiphysis (without a slip) in kids.
The typical patient is a 10 year old boy with a limp.

The cause is not known. The treatment is supportive—non weight bearing to prevent further collapse, maybe, and hope that the epiphysis revascularizes (which can happen).

It is often unilateral.

The older the patient, the worse the prognosis (consider: AVN with collapse in an adult has no cure; the closer one gets to being “adult” the more the disease behaves like the adult form of AVN.)

Question 4

Developmental Dysplasia of the Hip, a Slipped Capital Femoral Epiphysis and Perthes Disease might cause arthritis of the adult hip (ie, later in life). Why might successfully treated Developmental Dysplasia of the Hip have the best prognosis whereas untreated Developmental Dysplasia of the Hip might present the biggest treatment (surgical reconstruction) challenges?

Answer 4

DDH is truly treatable: relocate the hip before it deforms (or rather, “fails to form correctly”), and that maneuver is tantamount to a cure.

SCFE pinning is basically halting progression: make it better by not allowing it to get worse.

The “Treatment” of Perthes is lots of prayer: that is, the patient may get well even without treatment (or fail despite it).

At the other extreme, untreated DDH is the worst, because not only do you have bad arthritis (as you might with the other two, too-) but you don’t even have normal anatomy with which to reconstruct the hip! There is no socket either: the pelvis, as well needs normal anatomy on the other side of the joint, ie femoral head, to form correctly. If either is missing, then the other side of the joint can be marred.