Pediatric Hip conditions - 22/10/18 Flashcards
When does Developmental dysplasia of the hip present?
Birth to 2 years
When does Perthes present?
4-8 years
When does SUFE present?
10-16 years
What 3 things contribute to the formation of the acetabulum?
Ilium
Ischium
Pubis
When does the greater trochanter form?
6+?
What is the normal angle of the head of the femur?
135
Hilgenreiners line?
Horizontal line through tricartilagenous
Perkens lines?
Perpendicular lines through ilium and ischiuum
What are the three layers of the femoral head?
Hyaline cartilage
Subchondral bone
Cancellous bone
What does DDH stand for?
Developmental dysplasia of the hip
What is DDH?
Disorder of abnormal development resulting in dysplasia and possible subluxation or dislocation of the hip secondary to capsular laxity and mechanical factors
What does DDH incluse?
Dysplasia
Subluxation
Dislocation
Who is DDH most common in?
Females
Why is DDH more common in females?
Ligamentum laxity
Which hip is DDH most common?
Left hip
Why is DDH rarely seen in african patients?
Baby wrap
-the way babies are carried
What is the pathophysiology of DDH?
Initial instability thought to be caused by maternal and fetal laxity, genetic laxity and intrauterine and postnatal malpositioning
What is the pathoanatomy of DDH?
Initial instability leads to dysplasia
Leads to gradual dislocation
What are risk factors for DDH?
Firstborns 6x commoner in females Breech presentations family history Oligohydramnios
What are patient presentations of DDH?
Abnormality on screening
Limping child
Pain in later life
How is DDH diagnosed?
Clinical examination
Ultrasound
Radiographs
Why do DDH patients have a trendelenburg gait?
shorter lever arm distance
Increased workload on abductors
What may be seen on clinical examination of DDH?
leg lengths Restricted abduction Skin crease asymmetry Ortolani Barlows
What is the barlow test?
Pushing backwards to try and dislocate hip
What is the ortolani test?
Abducting the hips to try relocate hip
Fingers push femur forwards into acetabulum
What is the treatment of early presenting DDH?
Pavlik harness
How long should the pavlik harness be worn?
23hrs a day
Up to 12 weeks
Night time splinting for a few more weeks
How should DDH be monitored?
Serial USS
What is the position of the legs in the pavlik harness?
Abducted
Flexed
What is the treatment of late DDH?
Surgery
Closed reduction +/- tenotomies + spica
Open reduction + osteotomies + spica
What is reactive synovitis and what causes it?
Inflammation of the synovium
Often due to viral illness
What is the presentation of reactive synovitis?
History of viral illness Limp and hip/groin pain Referred pain to knee Hip lying flexed/externally rotated Pain at end range of hip movements Systemically well Apyrexal
How is reactive synovitis diagnosed?
Kochers critea
Ultrasounds +/- Aspiration
What is the Kochers criteria?
Fever over 385
Refusal to bear weight
CRP>20
Serum WBC>12000/mm3
What are the chances of septic arthritis with kochers?
0 - 0.2% 1 - 3% 2 - 40% 3 - 93% 4 - 99.6%
What is the treatment of reactive synovitis/
Self limiting
Analgesia
NSAIDS
Repeat review
What is septic arthritis of the hip?
Intra-articular infection of the hip joint
Why is septic arthritis an emergency?
High bacterial load
Destruction of joint
Potential for osteonecrosis
How does septic arthritis present?
Short duration of symptoms Unable to bear weight Hip lying felxed Severe hip pain Usually pyrexial
What is the pathophysiology of septic arthritis of the hip?
Direct inoculation
Haematogenous seeding
Extension from adjacent bone
Contigous spread of osteomyelitis
What is the most common organism causing septic arthritis in 1-5year olds?
Staph aureus
How is septic arthritis of the hip diagnosed?
Blood tests Blood cultures Kochers criteria Radiographs Ultrasounds
What is the treatment of septic arthritis?
Open surgical washout
Antibiotics for 6 weeks
What is Perthes disease?
Avascular necrosis of the hip
What causes perthes?
Idiopathic
What are risk factors for perthes?
Family history
Low birth weight
Second hand smoke
Asian, inuit and central european decent
What is the pathophysiology of perthes?
Osteonecrosis
Disruption of blood supply
Revasularization
Collapse
What are the stages of perthes?
Initial
Fragmentation
Reossification
Remodelling
What factors affect prognosis?
Age
-Younger = better prognosis
Preserving round femoral head
How does perthes present?
Gradual onset of painless limp Intermittent groin pain Hip stiffness Limp -Trendelenburg -Antalgic
How is perthes diagnosed?
Radiographs
MRI
How is perthes treatment?
KEEP FEMORAL HEaD ROUND
Restrict weight bearing
Maintain ROM
How is surgery used for perthes?
Osteotomy in severe
What is SUFE?
Slipped upper femoral epiphysis
A condition affecting the proximal femoral physis that leads to slippage of the metaphysis relative to the epiphysis
What are the risk factors for SUFE?
Males Obesity Endocrine disorders: -GH deficiency -Panhypopituitrism -Hypothyroidism
What is SUFE associated with/
Period of rapid growth
How does SUFE present?
Variable
Groin pain
Limp
How is SUFE diagnosed?
Radiographs
MRI
What is seen on X-ray of SUFE?
Ice-cream cone appearance?
How is SUFE treated?
Percutaneous pinning of the hip
+/- pinning of the other side
+/- open reduction if a very sever slip
