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Orthopedics > The Limping Child > Flashcards

The Limping Child Flashcards

1
Q

What age group does congenital dislocation tend to affect? What is the incidence?

A

Birth; 2 in 1000

5-20 per 1000 hips are lax at birth

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2
Q

What age group does osteomyelitis tend to affect? What is the incidence?

A

0-5 years; 1 in 1000

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3
Q

What age group does Perthe’s disease tend to affect? What is the incidence?

A

5-10 years; 1 in 10,000

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4
Q

What age group do slipped femoral epiphyses tend to affect? What is the incidence?

A

10-15 years; 1 in 100,000

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5
Q

What age group does avascular necrosis tend to affect? What is the incidence?

A

Adults; 1 in 100,000

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6
Q

What is the commonest cause of the painful hip in a young child?

A

‘Irritable hip’ - a transient synovitis secondary to a viral illness

This is a diagnosis of exclusion

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7
Q

What is ‘irritable hip’?

A

A transient synovitis secondary to a viral illness that presents as a painful hip in young children. It is a Dx of exclusion

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8
Q

True or false: most dislocated or dislocatable hips become stable within the first few weeks of life

A

True - considered to be due to physiological laxity of the joint capsule

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9
Q

Why is congenital dislocation the hip considered a misnomer?

A
  1. Not always a dislocation
  2. Not always present at birth

Perhaps better classified as developmental dysplasia of the hip (DDH)

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10
Q

What is CDH/DDH?

A

‘Congenital dislocation’ or ‘developmental dysplasia’ of the hip
- A congenitally determined deformation of the hip in which the head of the femur is or may be completely or partially displaced from the acetabulum

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11
Q

True or false: in DDH, females are affected more than males

A

True

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12
Q

What proportion of DDH cases are bilateral?

A

1/3

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13
Q

What is the aetiology of DDH?

A

Unknown

  1. Familial tendency
  2. Position of foetus in uterus, i.e. decreased intrauterine space

Higher incidence if

a. Joint laxity/shallow acetabulum in 1st order relatives
b. Breech presentation
c. First born
d. Oligohydramnios
e. North American Indian - wrap babies tightly with hips extended and legs together

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14
Q

List 4 risk factors for DDH

A
  1. Joint laxity/shallow acetabulum in 1st order relatives
  2. Breech presentation
  3. First born
  4. Oligohydramnios
  5. North American Indian
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15
Q

When is the best time to screen for DDH?

A

At birth, during routine postnatal examination

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16
Q

What warning signs may be noted on examination for DDH?

A
  1. Syndromic facies
  2. Scoliosis
  3. Asymmetry of gluteal skin folds (in newborn) or inguinal skin folds (3-4 month old)
  4. Ortolani’s test +ve
  5. Barlow test +ve
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17
Q

What does Ortolani’s test detect? Describe it

A

Detects a dislocated hip

  • Hip and knees flexed to 90 degrees
  • Thighs grasped in each hand
  • Thumb over inner thigh and fingers rested over greater trochanters
  • Hips abducted gently

Normal: 90 degrees easily
Resistance if dislocated

+ve test: gentle pressure applied to greater trochanters by fingers; click felt as hip relocates

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18
Q

What does Barlow’s test detect? Describe it

A

Detects a dislocatable hip

Modified Ortolani’s test:
- During abduction phase, firm pressure applied in line of femur so that a lax hip dislocates posteriorly

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19
Q

Following examination of a newborn infant you suspect developmental displasia of the hip. Barlow’s test is positive. How do you proceed?

A 
Ultrasound scan
- Shape of cartilaginous socket
- Position of head of femur
X-rays - not helpful
- Femoral head does not calcify until 10 weeks
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20
Q

True or false: X-rays are needed to confirm the diagnosis of a suspected developmental dysplasia of the hip

A

False - femoral head does not calcify until 10 weeks. US indicated

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21
Q

What are the principles of treatment for DDH?

A

Reduction - closed or open methods - to hold head of femur in place until ace tabular rim is sufficiently developed

22
Q

How is closed reduction achieved in the newborn?

A
  1. Double nappies to abduct hips
    - Reassessment with US after 2-3 weeks
  2. Pavlik harness
    - Few months, regular US
  3. Hip spica cast
  4. Arthrogram under GA
    +/- Tenotomy of abductors
    - Look for concentricity of hip
23
Q

When should an open reduction be carried out for DDH?

A

If hip cannot be easily concentrically reduced using closed methods. Usually carried out at a later stage (nearer 1 year old) - hip left untreated in interim

24
Q

True or false: examination of DDH under anaesthesia is usually an elective procedure

A

True - higher risks in babies; experienced paediatric anaesthetist needed

25
Q

What is the commonest open reduction procedure used to treat DDH?

A

Derotation varus osteotomy of the femur

  • Leg rotated to a position where head has maximum covering of acetabulum
  • Femur then sawed just below trochanters and shaft allowed to rotate back to neutral position
  • Two ends fixed using a Coventry screw plate
  • Plaster spica for a few weeks
  • Clinical and radiological f/u once toddler is walking to assess ace tabular development
26
Q

What is a Salter osteotomy and when is it indicated?

A

Pelvic osteotomy to reposition acetabulum, to better accomodate femoral head.

Performed in patients with DDH if outcome of a derotation varus osteotomy is not satisfactory. Delayed until child is 2 years of age.

27
Q

At what age can X-rays be used to assess the acetabulum?

A

After about 6 months

28
Q

If CDH is missed at the time of birth, when is the diagnosis usually made?

A

At 12-18 months when child begins to walk with abnormal gait

29
Q

What are the late signs of CDH in a 12-18 month year old?

A
  1. Abnormal gait
  2. Limb shortening
  3. External rotation of foot
  4. Asymmetrical skin creases
  5. +ve Trendelenburg test
30
Q

True or false: closed reduction is usually unsuccessful in children who are diagnosed with CDH late

A

True - lip of labrum or loose capsule impedes reduction

31
Q

True or false: with bilateral CDH, deformities and abnormalities of gait are less noticeable

A

True - because they are symmetrical

32
Q

True or false: most surgeons would not operate on patients with bilateral CDH above the age of 6 years

A

True - if one side fails, there is a risk of converting them to a unilateral asymmetrical deformity

33
Q

What is Perthe’s disease and in which patients is it usually seen?

A

A type of osteochondritis - AVN of the femoral head.

34
Q

How does Perthe’s disease typically present?

A 
Males
4-10 years
Limp
Pain 
- Initially, then painless
- Groin, radiating to knee
35
Q

What is the differential for hip pain in children under 10?

A
  1. Perthe’s disease
  2. Infection
  3. Transient synovitis
36
Q

What are the radiological features of Perthe’s disease?

A

X-rays:

  • Usually normal
  • Early: increased density at epiphysis
  • Later - epiphysis flattens and fragments

Bone scan:
- Useful in early stages

37
Q

What is the treatment for Perthe’s disease?

A
  1. Bed rest until pain subsides
    - Dead bone can revascularise and remodel
  2. Operative Rx to contain head in acetabulum (depends on X-rays)
38
Q

What is the main long-term complication of Perthe’s disease?

A

Osteoarthritis of the hip

39
Q

Why is it important to diagnose Perthe’s disease early?

A

Dx after age 10 associated with very high risk of developing OA

40
Q

What does SCFE stand for? What is it?

A

Slipped capital femoral epiphysis - an uncommon condition usually found in children of pubertal age. Epiphysis slips posteriorly either as an acute (20%) or chronic event (60%), or a combination of the two (20%)

41
Q

Which two groups does SCFE tend to affect?

A
  1. Fat and sexually underdeveloped
  2. Tall and thin

Boys more than girls

42
Q

What is the aetiology of SCFE?

A
  1. Endocrine factors
    - Fat children have higher incidence
    - Hormonal imbalance at time of growth spurt
  2. Mechanical factors
43
Q

How does an acute slip in SCFE usually present?

A
  1. Pain - groin or referred to knee
  2. Leg shortening
  3. External rotation
  4. All movements initially painful
44
Q

What is the treatment for SCFE?

A

Acute slip - usually surgical ORIF
Chronic
- Reduction not advised due to risk of AVN
- In situ pinning to prevent further slippage

45
Q

What are the main risks of surgery for SCFE?

A
  1. AVN in chronic SCFE

2. Chondrolysis - higher risk if guide-wire or pin penetrates articular cartilage

46
Q

What are the 3 main long term complications of hip disorders?

A
  1. Disability
  2. Deformity
  3. OA
47
Q

When is irritable hip typically diagnosed?

A

Dx of exclusion in children aged 1-10 years that present with a limp and pain in the hip

48
Q

What is thought to be the cause of irritable hip?

A

Viral synovitis - often preceding URTI

49
Q

What is the most important diagnosis to rule out in a child presenting with a limp and pain in the hip? How is this done?

A

Septic arthritis

  • FBC, CRP, ESR
  • US may be helpful
  • Urgent aspiration/analysis
50
Q

How is irritable hip treated and what is the prognosis?

A

Usually settles with rest and analgesia over 2-3 days

Orthopedics (18 decks)

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