T&O - The Limping Child Flashcards
What are the 5 main causes of hip pain (and age ranges) in children?
- Congenital hip dysplasia: birth 1/1000
- Septic hip/infections: 0-5 years old
- Transient synovitis (4-8 ya)
- Perthes’ disease: 5-10 years old 1/10 000
- Slipped femoral physis: 10-15 1/100 000
Congenital Dislocation of hip: what is it? Incidence and age range
- Congenitally determined developmental deformation of the hip joint, in which the head of the femur is or may be completely or partially displaced from the acetabulum
- 2:1000 live births, F>M, higher incidence in breech presentation
What test do you perform to check for CHD?
- Ortolani’s test: hips and knees flexed to 90 degrees, thighs grasped in each hand and hips are abducted to 90 degrees. Should be able to do so easily and without resistance.
- Barlow’s test: The maneuver is easily performed by adducting the hip (bringing the thigh towards the midline) while applying pressure on the knee, directing the force posteriorly.
If either test + then do an Ultrasound to shows shape of cartilaginous socket and position of head femur
CHD: Rx
Put child in Pavlik Harness , closed or open reduction: aim to reduce hip in position until acetabulum rim is sufficiently developed.
Septic hip: demographics, presentation and notable imaging results
- 0-4 ya
- Presentation: limping, minor or no trauma, limited ROM, pyrexia
- X-ray findings: no abnormalities
What criteria do you use to diagnose septic hips in children?
Kocher criteria:
- Fever >38.2
- Non weight bearing
- ESR >40
- WBCs >12000
*If 2 criteria met (60%), if 3 criteria met (93%)
What is the pathophysiology of septic hip in children?
- Inflammation causes compression of head of femur, which obstructs blood supply to head of femur
- Leads to rapid onset of pain in swollen joint
Transient synovitis: demographics and presentation
- Typical age group = 2-10 years
- Presentation: limping, minor or no trauma. Might have a Hx of recent infection of vaccination (but aetiology unknown) and have limited ROM. Self limiting condition where there is inflammation of synovium, most common cause of sudden hip pain in children
Transient synovitis: imaging findings
- X ray findings: no abnormalities
- Ultrasound scan: may show some collection
How do you differentiate between septic knee and transient synovitis?
- Will be Kocher negative
- Only exception: may have mild WBC elevation
- Can fully weight bear with transient synovitis
Perthes Disease: demographics, pathophysiology and presentation
- Type of osteochondritis usually in male patients, 4-10ya
- There is AVN of femoral head which occurs when the blood supply to the rounded head of the femur is temporarily disrupted leading to inadequate blood suppy.
- Bone cells die and results in avascular necrosis
- Features
- hip pain: develops progressively over a few weeks (can become painless or be in groin/radiate to the knee)
- limp
- stiffness and reduced range of hip movement
*
Perthes Disease: important imaging findings
X-Ray initially normal. Changes as the disease progreses are:
- Small capital femoral epiphysis (early)
- Sclerosis of head
- Widening of the joint space from joint fluid ligamentous laxity
- Destruction of the articular cortex similar to septic arthritis
- Crescent sign-subarticular lucency from subchondral fracture (late sign)
- Fragmentation of femoral head
Perthes Disease: Rx
Rx:
- bed rest until pain subsides
- further surgical Rx is based on trying to contain head in acetabulum to enable it to retain best shape possible.
What is a SUFE? Age range, presentation and pathophysiology
Slipped capital/upper femoral epiphysis (10-15 ya)
- Children of pubertal age: affects either fat and sexually underdeveloped kids or tall and thin kids (M>F).
- Epiphysis slips posterio-inferioly in either acute (20%) or chronic slip (60%) or combination (20%)
-
Presentation: limping, knee pain, minor trauma, no fever, loss of internal rotation of leg in flexion
- Acute pt present with groin pain/referred to thigh or knee, can be shortened and externally rotated
SUFE: Rx
- Acute Slip Rx: usually involves surgery to reduce epiphysis (fix with pin)
-
Chronic slip:
- Don’t reduce b/c AVN may result - epiphysis usually pinned in situ to prevent further slippage
- *Always do a hip exam on a child 8-10 ya with painful knee as can get referred pain.
- These people may develop deformity/OA/disability risk
- Don’t reduce b/c AVN may result - epiphysis usually pinned in situ to prevent further slippage
SUFE: what is a klein line?
- Line of Klein describes a line along the superior edge of the neck of the femur. It is useful in detecting early slipped upper femoral epiphysis in adolescents. The line should normally intersect the lateral part of the superior femoral epiphysis.
- If the line of Klein fails to intersect the epiphysis during the acute phase, it is called Trethowan sign. In very subtle cases, asymmetry between the lines of Klein might be the only way of determining a slipped upper femoral epiphysis.
