The big 3: DDH, Perthes Disease and SUFE Flashcards
What are the 3 hip conditions otherwise known as the ‘big 3’?
- Developmental Dysplasia of the Hip (DDH)
- Perthes Disease
- Slipped Upper Femoral Epiphysis (SUFE)
What is DDH?
A condition where the “ball and socket” joint of the hip does not properly form in babies and young children.
It’s sometimes called congenital hip dislocation or hip dysplasia.
Incidence of DDH
- More common in Eastern Europe
- Girls 6:1 Boys
- More commonly affects the left hip
Risk factors of DDH
- First born - uterus isn’t stretched in the mother (from previous births) so there is less space for the foetus
- Oligohydramnios - reduced fluid in the uterus - baby doesn’t move as much
- Breech presentation - foetus presents buttocks or feet first
- FH
- If the child has another lower limb deformity
- Increased weight (high birth weight)
Which clinical signs are most useful to test for DDH in Neonates(2)
Ortalani’s and Barlow’s signs
After a few weeks these become harder to get useful information from
What is Ortolani’s sign?
- The Ortolani method is 1/2 special tests for DDH
- Baby is on their back with knees and hips flexed. Palms are placed on the baby’s knees with thumbs on the inner thigh and 4 fingers on the outer thigh. Gentle pressure is used to abduct the hips.
- +ve Ortolani’s sign = the examiner feels a clunking sensation which is the femoral head slipping into the acetabulum and this means that the hip was dislocated
What is Barlow’s test?
- Neonates hips are flexed and downward pressure is exerted along the femur
- The hips are then pushed posteriorly and if there is movement this means the hip wasn’t joined and was subluxatable/dislocated (it can be pushed partially out of the joint with little force)
- Most subluxatable hips at birth return to normal in a few weeks from birth
- A small % continue to be unstable and can gradually become dislocated
Why are babies not x-rayed at birth for DDH?
- The head of the femur doesn’t ossify until the child is at least 3 months old
- X-ray exposure - radiation
Which imaging technique is the ‘gold standard’ for the diagnosis of DDH?
Ultrasound
How is DDH treated?
The older the child, the poorer the result and the more complications that occur…
- Treatment typically involves a Pavlik harness if the baby presents at <6 months.
- The harness is fitted and kept on permanently, adjusting for the growth of the baby.This harness keeps the baby’s hips flexed and abducted to allow the acetabulum to develop a normal shape.
- The child is regularly reviewed and the harness is removed when their hips are more stable, usually after 6 – 8 weeks.
- Surgery is required when the harness fails or the diagnosis is made >6 months.
- After surgery is performed, a hip spica cast (like trousers) is used to immobilise the hip for a prolonged period.
Look
- All babies in the UK are examined at birth before discharge.
- If the baby is relaxed then an experienced examiner will be able to find dislocated hips more easily, however, they are not always identified.
What is Perthes Disease?
- A rare condition affecting the hip joint in children.
- Part or all of the femoral head loses its blood supply and may become misshapen (avascular necrosis)
- Poorly understood why it occurs but it’s thought that there’s a possible relationship between repeated minor trauma or coagulation tendencies. It could also be familial or related to low social status
Describe a typical presentation of Perthes Disease
- M>F
- Typically primary school age
- Short stature (almost always)
- Limp
- Pain - felt in the thigh or knee - comes on during or after exercise
- Stiff hip joint
- Always systemically well
Problems are variable - changes day to day
What might you see in an x-ray of the hip of someone with Perthes Disease?
Widening of the joint space between the femur head and the acetabulum which is related to the fact that the nutrition of the articular cartilage comes from the synovial fluid, so even if the epiphysis becomes avascular the cartilage continues to develop.
As the epiphysis collapses the space will also widen and it becomes sclerotic.
What are the 4 stages classified by Waldenstrom that show the typical changes seen over time on an x-ray in Perthes Disease?
- Initial/collapse stage - avascular necrosis - increased joint space, sclerosis
- Fragmentation stage - epiphyses appears to be breaking up
- Reossification stage
- Residual deformity - Healing stage - bone reforms and remodells
Which sign on an x-ray helps to identify a slip?
Trethowan’s sign
See image
- Klein’s line is drawn parallel to the neck of the femur (and the growth plate) - this line cuts more of the epiphysis
- On the abnormal hip - the line only just cuts the epiphysis - the fact that on the affected side the hip is not cut to the same extent is known as Trethowan’s sign
