Approach to limping child

Case Scenario

• A 14 month old boy is brought to the office because the parents noticed a limp this morning when the child got out of bed…

Pathophysiology

• Three major factors cause a child to limp: pain, weakness, and structural or mechanical abnormalities of the spine, pelvis, and lower extremities (Clark, 1997; deBoeck & Vorlat, 2003; Lawrence, 1998).

• A normal gait is composed of symmetrical, alternating, rhythmical motions involving two phases: stance and swing. The stance phase normally encompasses 60% of the gait cycle. The type of gait may be helpful in identifying the etiology of the limp.

Some Abnormal Gaits• An antalgic gait results from pain in one extremity that causes the patient to

shorten the stance phase on that side with a resultant increase in the swing phase. The most common causes of an antalgic gait are trauma or infection.

• A Trendelenburg gait is a downward pelvic tilt away from the affected hip during the swing phase as a result of weakness of the contralateral gluteus medius muscle .The gait disturbance is commonly observed in children with developmental dysplasia of the hip, Legg-Calves-Perthes disease, or slipped capital femoral epiphysis. If the involvement is bilateral, a waddling gait results

• A steppage (equinus) gait is a result of the inability to actively dorsiflex the foot, with exaggerated hip and knee flexion during the swing phase. A steppage gait is seen in children with neuromuscular diseases (eg, cerebral palsy) that cause impairment of dorsiflexion of the ankle.

• A vaulting gait occurs when the knee is hyperextended and locked at the end of the stance phase and the child vaults over the extremity .A vaulting gait is seen in children with limb length discrepancy or abnormal knee mobility.

• A stooped gait is characterized by walking with bilaterally increased hip flexion A stooped gait is common in children with pelvic or lower abdominal pain.

Differential Diagnosis

Painless limp Painful limp Age

1- Developmental dyplasia of the hip2- Neuromuscular disease

-Cerebral palsy-Muscular dystrophy

3- lower limb length discrepancy

1- Infection Septic arthritis / osteomyelitis/ cellulitis / transient synovitis 2- Trauma3- Primary or metastatic neoplasm

1-3yr

Differential Diagnosis

Painless limp Painful limp Age

1-Developmental dyplasia of the hip

2- Neuromuscular disease:Cerebral palsyMuscular dystrophy

3- Lower limb length discrepancy

1-Infection 2- inflammatory JRA, SLE3- Trauma 4- Primary or metastatic tumor5- hematological disease Hemophilia, leukemia 6-Legg-Calve-Perthes Disease (AVN of femoral head)

4 - 10yr

Differential Diagnosis

Painless limp Painful limp Age

1- Developmental dyplasia of the hip2- Neuromuscular diseaseCerebral palsyMuscular dystrophy3- lower limb length discrepancy 4- chronic slipped upper femoral epiphysis

1-Infection 2- inflammatory :JRA, SLE3- Trauma 4-Primary or metastatic tumor5-hematological disease Hemophilia, leukemia6-Legg-Calve-Perthes Disease (AVN of femoral head)7-acute slipped upper femoral epiphysis*

11- 18yr

*very tall and/or obese. Limp and pain in the hip. Leg is held in an extemal rotation position. Often painful on internal rotation of the hip. Association with hypothyroidism

Approach

• History• Examination• Investigation• Management

History

• Age • Sex• Onset• Painful or painless? ( analysis…)• Acute or chronic • History of trauma• Association : Night pain (ALL), arthralgia,

swelling, morning stiffness(JRA), backache (malignancy or rheumatologic disease)

History

• Systemic review– Recent illness : URTI – Weight loss, anorexia– Fever, chills– Unexplained rash (SLE) or bruising (haematology

ds)– Voiding problem (neuromuscular ds)

Examination

• General inspection + Gait • Vital signs & anthropometric measurements • Musculoskeletal examination +Back exam • Neurological examination• Evaluate leg lengths- anterior iliac spine to

medial mallelous

Investigations

• FBC • ESR, CRP TRO Infection• Blood culture • Coagulation profile TRO Haematological• Peripheral Blood Film disorder• Immunological : RF, ANA TRO Rheumatological

disorder

Investigations

• Imaging studies– Plain x ray – U/S– CT– MRI – Radionuclide studies– Bone scan

Investigations

• Synovial fluid aspiration

Septic Arthriti

s

JRA traumatic

normal

Purulent Cloudy yellow

Bloody to straw

colored

Clear to yellow

appearance

50,000- 200,000

5,000- 80,000

<5,000 <200 WBC

75-100% 50-75% <25% <25% Polymorphs

Bacterial culture positive

Low glucose

High protien

High RBC count

other

CASE SCENARIO 21 months old Malay Boy - NKMI - p/w refuse to bear weight using right LL x 2/7 - previously can walk since 1 y.o. and can run and suddenly refuse standing on right LL - right knee joint not warm or swollen - no h/o fall / trauma before - Afebrile , No URTI sx

PMH/PSHx: nil

FHx: no chronic illness running in family

Developmental : able to walk at 1 y.o. speak 2-3 words with meaning

O/E: Alert , playing with toysRight hip joint: - well flexed, abducted, externally rotated- No skin changes, no bruises seen- not warm , not swollenRight knee joint :- Able to flex , not warm or swollen, non-tenderRight ankle joint: - Able to move , not warm or swollen . Non-tenderIMP : transient synovitis of right hip joint

Ix

• ESR not elevated• CRP not elevated• USG hip Joint: - no psoas abscess seen bilaterally- no hip effusion seen bilaterally

Transient synovitis (irritable hip)

-Transient synovitis is the most common cause of acute hip pain in children aged 3-10 years. -The disease causes arthralgia and arthritis secondary to a transient inflammation of the synovium of the hip.-affects boys twice as often as girls.- Usually it is a diagnosis of exclusion, once trauma and infection are excluded

Symptoms

- Unilateral hip or groin pain is the most common symptom.

- Limp.- Recent history of an upper respiratory tract

infection in 50% of patients.- Usually afebrile or have a mildly elevated

temperature.- Very young children with transient synovitis may

have no symptoms other than crying at night.

Signs

- Hip kept in flexion with slight abduction and external rotation.- some may have mild restriction of motion, especially to abduction and internal rotation- The hip may be painful with passive movement and tender to palpation.- The most sensitive test for transient synovitis is the log roll, in which the patient lies supine and the examiner gently rolls the involved limb from side to side. This may detect involuntary muscle guarding of one side when compared to the other side.

Causes

• No definitive cause of transient synovitis is known, although the following have been suggested:

• Patients with transient synovitis often have histories of trauma, which may be a cause or predisposing factor.

• One study found an increase in viral antibody titers in 67 of 80 patients with transient synovitis.

• Postvaccine or drug-mediated reactions and an allergic disposition have been cited as possible causes.

Differential diagnoses

Common • Septic arthritis.• Juvenile idiopathic arthritis.• Juvenile rheumatoid

arthritis.• Osteomyelitis.

Less common• Avascular necrosis (Perthe’s

disease).• Fracture.• Gonococcal arthritis.• Lyme’s arthritis.• Soft tissue injuries.• Tumor or malignancy.

Investigations

• Usually to rule out other diagnoses.• WBC, ESR and CRP are usually elevated in

septic arthritis.• XRAYS: can exclude bony lesions.• Ultrasound guided aspiration of the effusion.

Sign of effusion : Widening of the joint space. Note that the space is wider on the left side. Discrepancies greater than 1 mm indicate the presence of fluid.

Management

• Apply heat and massage .• Advise bedrest for 7-10 days, allowing the patient

to rest in a position of comfort.• Advise the patient with transient synovitis not to

bear weight on the affected limb.• Advise the patient with transient synovitis to

avoid full unrestricted activity until the limp and pain have resolved.

• Non-steroidal anti-inflammatory drugs (NSAIDs).

Prognosis

• Usually marked improvement within 24-48 hours.

• Two thirds to three fourths of patients have complete resolution within 2 weeks.

• The remainder may have less severe symptoms for several weeks.

• The recurrence rate is 4-17%; most recurrences develop within 6 months.

Complications

• 32.1% of patients develop coxa magna : an overgrowth of the femoral head and broadening of the femoral neck. It leads to dysplasia of the acetabular roof and subluxation.

• 1-3 % develop perthe’s disease.

SEPTIC ARTHRITISIN CHILDREN

• Septic arthritis in children is monoarticular more than 90% of the time.

• Knee and hip joints account for about two thirds of all cases.

• Children less than 2 years old are more susceptible to septic arthritis than older children.

• After S. aureus, group B streptococcus and Gram-negative microorganisms are important pathogens in the neonate and young infant.

• Candida and Gram-negative bacilli are usually acquired in the hospital or in another health care setting.

• Septic arthritis and osteomyelitis can coexist or complicate each other in the very young child because the metaphyseal and epiphyseal blood vessels communicate and the metaphyses of some long bones are within the joint capsule. (eg hip joint)

• Avascular necrosis of the femoral head is unique to septic arthritis of the hip in children.

• Early surgical decompression to reduce the high intra-articular pressure will restore blood flow to the femoral head.

• Leg length discrepancy, limitation of joint mobility, and secondary degenerative joint disease are late sequelae in 25% of cases.

Septic arthritis - Definition

• Hematogenous bacterial infection of the hip, usually

• in infants or toddlers, with or without involvement of

• the proximal femoral metaphysis.• Synonym: Septic coxitis

• Hip - commonest septic joint

• condition during growth, reaching a distinct peak in frequency during infancy.

• via hematogenous transmission, resulting in colonization of the joint with bacteria

• in infants - occur from propagation of adjacent proximal femoral osteomyelitis

Any OM changes, widening of joint space

• Kocher criteria: (for child with painful hip) - includes:

1) non-weight-bearing on affected side 2) ESR greater than 40 mm/hr3)Fever4)WBC count of >12,000 mm3

• when 4/4 criteria are met, there is a 99% chance that the child has septic arthritis

• when 3/4 criteria are met, there is a 93% chance of septic arthritis

• when 2/4 criteria are met, there is a 40% chance of septic arthritis

• when 1/4 criteria are met, there is a 3% chance of septic arthritis

Organisms

• epiphyseal plate prevents infection from entering joint space in older children

• but apparently does not act as a barrier in infants

• synovial membrane inserting distally to epiphysis,

• allowing bacteria to spread directly from the metaphysis to joint space;

• metaphysis of shoulder, hip, radial head, and ankle remain intracapsular during early childhood

• the hip joint seems especially prone to sepsis from adjacent osteomyelitis

• synovial reflections over the metaphyseal bone decrease with age;

Examination

• Limp• pain in groin area that occasionally radiates

down the medial side of thigh;

     - progressive accompanied by spasm of the hip muscles

    - hip in flexion and external rotation & decreased internal rotation compared to the normal hip

    - patient resists all attempts to move hip;     - palpate the SI joint for local tenderness;

Differential diagnosis

• Acute osteomyelitis - tenderness and swelling over the metaphysis

• Transient synovitis • Tuberculosis• Acute rheumatic fever• Haemarthrosis

Investigations

• Joint fluid aspiration analysis: AFB, Gram stain, C&S, protein, glucose, wcc and crystal.

• FBC : leukocytosis• Blood C&S• C-reactive protein• ESR • X-ray• Ultrasound        

Investigations

Blood investigations Imaging

Synovial fluid analysis

Investigations Explaination

Full blood count Elevated white blood cell count

ESR > 40 mm/hr

CRP > 20 mg/dL

Blood culture May be positive

Synovial fluid analysis

Aseptic technique is used during aspiration of synovial fluid.Avoid taken from infected site of skin.The fluid is then analyzed by gross and microscopic examination and culture.

Gross examinations include appearance, volume, viscosity, mucin clotting (amount of proteoglycans).

Microscopic examinations include leucocyte count, staining of smears, serum glucose ratio, protein.

Finally, culture and sensitivity for definitive diagnosis and treatment.

Suspected condition

Appearance Viscosity White cells

Crystals Biochemistry Bacteriology

Normal Clear yellow

High Few - As for plasma -

Septic arthritis

Purulent Low + - Glucose low +

Tuberculous arthritis

Turbid Low + - Glucose low +

Rheumatoid arthritis

Cloudy Low + + - - -

Gout Cloudy Normal ++ Urate - -

Pseudogout Cloudy Normal + Pyrophosphate

- -

Osteoarthritis

Clear yellow

High few Often + - -

ImagingX ray

Early Stage – Normal

Look for soft tissue swelling, loss of tissue planes, widening of joint space

Late stage – Narrowing and irregularity of joint space

Plain film findings of superimposed osteomyelitis may develop (periosteal reaction, bone destruction, sequestrum formation).

Narrowing of joint space and irregularity of subchondral bone.

Joint space losssubchondral erosions and

sclerosis of the femoral head

osteonecrosis and complete collapse of

the femoral head

Ultrasonography

• More reliable in revealing a joint effusion in early cases.• Widening of space between capsule and bone of > 2mm

indicates effusion.• Echo-free transient synovitis• Positively echogenic septic arthritis

TreatmentGeneral supportive care-Analgesics-IV fluids

Splintage- The joint must be rested either on a splint or in a widely split plaster-In neonates and infants, with hip infection the joint is held abducted and 30 degree flexed, on traction to prevent dislocation.

AntibioticsTreatment is started once the blood and samples are obtained without waiting for the detail results.Choice of antibiotic depends on the most likely pathogen

Surgical Management

Surgical Drainage (serial needle aspiration + antibiotics)

Arthroscopic debridement and copious irrigation with normal saline (Arthrotomy washout)

Indications for Arthrotomy washout• Joint does not respond to serial aspirations • No improvement in 48hrs of tx • Frank pus is aspirated • Loculations noted on MRI or U/S

Complications• Bone destruction and dislocation of the joint (esp Hip)

•Cartilage destruction -may lead to either fibrosis or bony ankylosis- secondary osteoarthritis

•Growth disturbance - presenting as either localised deformity or shortening of the bone

Legg-Calvé-Perthes disease (LCPD)-coxa plana

• Legg-Calvé-Perthes disease (LCPD) is the name given to idiopathic osteonecrosis of the capital femoral epiphysis in a child.

• Usually ages 4-8yo• As early as 2yo, as late as teens• Boys:Girls= 4-5:1• Bilateral 10-12%• No evidence of inheritance

Pathogenesis

• Up to 4 yearsMetaphyseal vessels,lateral epiphyseal

vessels,scanty vessels from ligamentum teres

• 7 years oldVessels of ligamentum teres has developed

Between 4-7 years,femoral head depends entirely on the lateral

epiphysael vessels.

*Lateral epiphyseal vessels situated in the retinacula makes them susceptible to streching and pressure from an effusion.The precipitating cause is an effusion into the hip joint following:

Etiology1)idiopathic2) slipped capital femoral epiphysis3) Trauma4)steroid use5)sickle-cell crisis6)Synovitis7) congenital dislocation of the hip.

PathologyTakes 2-4 years to complete.Involve 3 stages.

Stage 1:bone deathEpisodes of ischemia leads to part of bony femoral head dies,x-ray looks normal bt it stops

enlarging.

Stage 2:revascularization and repairNew blood vessels enter the necrotic area and new bone is laid down on the dead trabeculae,x-

ray-increased in density.If only part of the epiphysis is involved & the repair is rapid bony architecture is completely restored.

Stage 3:distortion and remodelling

If large part of the bony epiphysis is damaged & the repair process is slow,epiphysis may collapse and growth of the head and neck will be distorted

Epiphysis ends up flattened(coxa plana),flat and enlarged(coxa magna) and the femoral head will be incompletely covered by the acetabulum.

Clinical features• Male• 4-8 years old• Hip pain, may be referred to the medial aspect of the ipsilateral

knee or to the lateral thigh.• All ROM are limited• The quadriceps muscles and thigh soft tissues may undergo atrophy• the hip may develop adduction flexion contracture• The patient may have an antalgic gait with limited hip motion.• passive range of motion are limited, especially internal rotation and

abduction. • Children can have a Trendelenburg gait resulting from pain in the

gluteus medius muscle.

Investigation

1)Plain radiograph• hip radiographs, anteroposterior and frog-leg lateral

views of the pelvis to establish the diagnosis.• Initial radiographs can be normal, • Early changes-increased density of the bony

epiphysis and widening of the joint space.• Late changes-flattening,fragmentation and lateral

displacement of the epiphysis with rarefraction at the metaphysis.

Herring classification

The Herring classification addresses the integrity of the lateral pillar of the femoral head.

• A: there is no loss of height in the lateral one third of the head and there is little density change.

• B: there is a lucency and less than 50% loss of lateral height.

• C: there is a more than 50% loss of lateral height.

Herring classification Coxa magna

Coxa plana

Lateral Pillar Classification

• 3 groups:– A) no lateral pillar

involvment– B) >50% lat height

intact– C) <50% lat height

intact

• CT scan: allow early diagnosis of bone collapse and also demonstrate subtle changes in the bone trabecular pattern.

• Ultrasonography :preliminary diagnosis of transient synovitis of the hip and the onset of CP.Hip effusion with capsular distension is well depicted on sonographic images.

• MRI: allows more precise localization of the femoral head.

Treatment• Skin traction as long as the hip is

painful(usually takes 3 weeks)• Further treatment is taken by assessment of

the prognostic value:Good prognosis

1)Onset under age 62)Partial involvement of

femoral head3)Absence of metaphyseal

involvement4)Normal femoral head shape

No active Tx needed

Poor prognosis1)Age over 6 years old

2)Involve the whole femoral head

3)Severe metaphyseal rarefraction

4)Lateral displacement of femoral head

containment

• Containment means keeping the femoral head well seated within the acetabulum

• Can be achieved by:1) holding the hips widely abducted in plaster

or removable splint.(at least will take a year).2) Varus osteotomy of the femur or innominate

osteotomy of the pelvis.

Osteotomies

Slipped capital femoral epiphysis (SCFE)

INTRODUCTION

The capital femoral epiphysis is somewhat unique. It is one of the few epiphyses in the body that is inside the joint capsule. (The joint capsule is the tissue that surrounds the joint.)

Slipped upper femoral epiphysis" term refer to slippage of the overlying epiphysis of proximal femur posteriorly and inferiorly due to weakness of the growth plate in relation to metaphysis.

Most often, it develops during periods of accelerated growth, shortly after the onset of puberty.

The femoral epiphyses maintains its relation with acetabulum ,it’s the femoral neck and shaft upward and anterior movement on epiphyses thus epiphyses displaces relatively posterior

SLIPPED CAPITAL FEMORAL EPIPHYSES

EPIDEMIOLOGY AND RISK FACTORS

Most common in adolescent period with rapid growth plate (boys aged 10-16 y, girls aged 12-14 y).

Obesity is a risk factor because it places more shear forces around the proximal growth plate in the hip at risk.

Bilateral slippage is common of which 2nd slip is about 12-18mths later to 1st (left hip is more common than right).

Etiology:1. Local trauma 2. obesity3. Endocrine disorders (e.g primary or secondary hypothyroidism, adiposogenital dystrophy(hypogonadal male), 4. Deficiency or increase of androgens.5. Growth hormone deficiency

Slipping of the upper femoral epiphysis occurs predominantly in obese children with underdeveloped sexual characteristics and less commonly, in tall, thin children.

CLASSIFICATION• Based on onset of symptoms-acute -chronic -acute on chronic FUNCTIONAL CLASSIFICATION-stable -Unstable

MORPHOLOGICAL CLASSIFICATION-mild -moderate -severe

BASED ON SYMPTOMS -

SYMPTOMS <2WKS >2WKS grdual X-RAY displaced epiphyses remodelling and no remodelling healing notedACUTE ON CHRONIC SLIPS-Symptoms lasting longer than 1mth and

recent sudden exacerbation pain after trivial trauma

FUNCTIONAL CLASSIFICATION-It is important to determine ability of the patient to bear weight.

According to LODER-

1. "Stable" SCFEs allow the patient to (walk) with or without crutches (walking aids).

2. "Unstable" SCFEs do not allow the patient to ambulate at all regardles of duration of symptoms; these cases carry a higher rate of complication, particularly of AVN.

MORPHOLOGICAL CLASSIFICATION-Grading Severity of SCFE according to AP and Lateral X-ray viewsPRESLIP-irregularity,widening,and indistinctness of physes

Grade-1 Grade-II Grade-III

ANTERIOR AND VALGUS SLIP• the displacement is either superior and posterior (so-called

valgus slip)or, even more rarely, anterior.• In valgus slips there is a restriction of adduction as well as of

flexion.• In anterior slips there is a limitation of extension and external

rotation—exactly the opposite of what is found in typical slips.• X-RAY of valgus slip show -superior or lateral displacement of the capital epiphysis on the

femoral neck on the AP projection -posterior displacement on the lateral projection.

Anterior slips may appear little different from typical slips on the AP projection, but the anterior displacement of the capital epiphysis is identified on the lateral projection.

SYMPTOMS

1. Pain : in the groin and around the knee(d/t referred pain from the hip)

2. Limb looked shortened, held in external rotation

3. Flexion, abduction, medial rotation are limited

4. External rotation, adduction are increased.

5.Axis deviation – pathognomonic – when hip is flexed, the limb goes into external rotation

• X-RAYS-AP VIEW-thretowan’s sign[kleins line]• -steel metaphysel blanch sign• -sham’s sign• -capner’s sign• -widening of growth plate• -decrease of epiphyseal height• X-RAY -frog-leg [lowenstein]lateral view• CT-SCAN• MRI SCAN

INVESTIGATIONS

A.P. VIEW-inferior,And medial translation of epiphyses

LATERAL VIIEW-to measure lateral epiphyseal shaft angle, anterior or posterior translation

TRETHOWAN’S SIGN-• In normal hip a line drawn tangential to superior

femoral neck[klein’s line] intersects small portion of lateral capital epiphyseal.

• In posterior displacement of epiphyses the line doesn’t intersect.

METAPHYSEAL BLANCH SIGN-• In AP VIEW-crescent-shaped area of increased

density overlying the metaphysis adjacent to the physis • This increased density is due to the overlapping of the femoral neck and the posteriorly displaced capital epiphysis

SHAM’S SIGN- In the normal hip the inferiomedial femoral neck

overlaps the posterior wall of the acetabulum producing triangular radiographic density

• With displacement of capital epiphysis this dense triangle is lost because this portion of the femoral neck is located lateral to the acetabulum.

CAPENERS SIGN-

In pelvic AP view in the normal hip, the posterior acetabular margincuts across the medial corner of the upper femoral metaphysisWith slipping, the entire metaphysis is lateral to the posterioracetabular margin

LATERAL VIEW• Very early slips may appear to be normal in AP

VIEW but may be clearly noted in lateral view• CHRONIC CASE OF SCFE X-RAY-• Reactive bone formation along superolateral

aspect of neck• Bone remodelling and broadening of neck

resulting in PISTOL GRIP like appearance[hordons hump]

USG-It has been useful in the detection of early slips -joint

effusion and a “step” between the femoral neck and the epiphysis created by slipping.

• Absolute displacement of 6 mm, >2 mm is diagnostic of a slipped epiphysis.

• CT-useful in documenting presence of decreased upper femoral neck anteversion or true retroversion.

• it’s more accurate measure head–neck angle.• CT is useful in the management of slips. • First, CT of the hip can be very helpful in demonstrating

whether penetration of the hip joint by fixation devices has occurred (Fig. 18-9).

• CT is also used to confirm closure of the proximal femoral physis and also when reconstructive osteotomy is being considered.

• MRI-useful to assess AVN

COMPLICATIONS

1. Avascular necrosis.

2. Chondrolysis.

3. Secondary Osteoarthritis.

4. Coxa vara (is a deformity of the hip, whereby the angle between the ball and the shaft of the femur is reduced to less than 120 degrees).

5. Slipping of the opposite hip ≈ 20% to 80% of cases

IDEAL TREATMENT

•Prevent further slippage•Stimulate early physeal closure•Reduction of epiphyseal displacement•Avoid complications like osteonecrosis , chondrolysis and osteoarthritis

•Any child with SCFE and open epiphyses needs treatment ,without stabilisation it progresses.

•In a patient with closed physes, the only surgical treatment in the absence of severe degenerative changes is proximal femoral osteotomy. Indications are functional limitations, unacceptable gait, or cosmetic deformity

MANAGEMENT-• Conservative management-rest and traction- Rest for at least 12wks and traction can be an alternative to surgical treatment- Indicated in – temporary measure before operative mx or slip due to

hypothyroidism

• Closed manipulative reduction- High risk of ischemic necrosis of head.- So, manipulate only acute severe slips that may be technically difficult or

impossible to pin in situ.• Only for acute and acute on chronic severe slips• Within 24 hours of slip

• Operative management

- In situ pinning • 1 cannulated screw for both stable and unstable hip

Operative management - ORIF: open reduction, limited osteotomy, and internal fixation,

if necessary, have been recommended if a severe acute or chronic slip which cannot be reduced by closed methods

- Osteotomy: moderately or severely displaced chronic slips produce permanent irregularities in the femoral head and acetabulum, some form of realignment procedure often is indicated to restore the normal relationship of the femoral head and neck and possibly delay the onset of degenerative joint disease

Developmental Dysplasia of Hip

A spectrum of disorder including :Acetabular dysplasia without displacementSubluxationDislocation

Epidermiology

Reported incidence is 5 – 20 per 1000 live births. Re – examination 3 weeks after birth is only 1 or 2 per 1000 infants. ( i.e spontaneous correction) Girls are more common with ratio 7:1 Left hip is more often affected, 1 in 5 cases is bilateral.

Aetiology1- Genetic factors( families, even in entire population-

generalized join laxity, shallow acetabulum)2- Hormonal changes in late pregnancy→ lig. laxity3- Intrauterine malposition( breech + extended legs)4- Postnatal factors( swaddling- simultaneous hip and

knee extension may lead to hip dislocation during early development)

PathologyFemoral head dislocate posteriorly and later lies superolateral to acetabulumCartilagenous socket is shallow and antervertedCapsule is stretchedLigamentum teres is elongated and hypertrophied

Clinical FeaturesEvery newborn child should be examined for signs of

hip instability esp. in children with positive family history or with breech presentation

Methods in testing instability:Ortolani’s test (reducible)Barlow’s test (dislocatable)

Ortolani’s Test1. Baby’s thighs are held with the thumbs medially and

fingers resting on the greater trochanters2. Hip are flexed to 90°and gently abducted3. Normally, there is smooth abduction to almost 90°but

in congenital dislocation the movement usually impede4. If pressure is applied to greater trochanter there is soft

‘clunk’ as the dislocation reduce (the jerk of entry) 5. If abduction stops halfway and there is

no jerk of entry, they may be anirreducible dislocation

When test is positive, the dislocated femoral head will fall back into acetabulum with palpable ‘clunk’ as the hip abducted. When hip is adducted, the examiner will feel the head dislocate posteriorly.

Barlow’s Test• Thumb is placed in groin • Grasping the upper thigh, an attempt is made to lever

the femoral head out of the acetabulum by fully adduct hips and push posteriorly

• Indicate unstable hipWhen the test is positive, the examiner will feel the femoral head make a small jump out of acetabulum. When the pressure is release, the head is felt to slip back into place.

The infantLimitation of abduction - < 50-60°

Shortening of the femur by Galeazzi sign

placing both hip in 90° of flexion and comparing the height of knee and look for asymmetry

Clinical Features

Increase thigh folds on the affected side than the normal side

because of the foreshortened the thigh.

Clinical Features

Walking childrenAbnormal gait – due to shortened of the affected leg

Trendelenburg gaitWaddling gait - if bilateral hip affected

(walk with short steps and a clumsy swaying motion)

Excessive lordosis – secondary to hip flexion contracture

Clinical Features

Investigation1. Ultrasonography

Neonate’s hip is composed primarily of cartilage – difficult by using radiographic techniquesShows the shape of cartilaginous socketPosition of femoral head

2. Plain X-rayIn newborn the unstable hip may appear radiographically normal, as the child reach 3 to 6 month of age the dislocated hip will be evident radiographically.

Investigation

X- Ray (A) Acetabulum : Shallow and sloping(Acetabular roof angle < 30)

(B)Femoral head : Underdeveloped and out Perkin’s lines = Vertical line at the outer edge of

acetabulum Hilgenreiner’ line = Horizontal line through the

triradiate cartilages. Normally the head is medial to vertical and below the horizontal

(C) Shenton’line is broken

(Inferior border of superior ramus

and inferior border of the neck)

(D) Von Rozen line = Hips abducted 45

Femoral shaft should point into the acetabulum

A

B

C

Von Rosen’s Line

Management0-6 months+ve Ortolani+ve Barlow+ve US Double napkins OR Abduction pillow for 6 weeksStable hip = follow-up for 6 monthsPersistent instability = Splint for 3-6 months (Pavlic harness)Splintage

Hold the hips flexed and abducted

3 Golden Rules for splintage:Hip must be properly reduced before splintageAvoid extreme positionHips should be able to move

Types:Von Rosen’s Splint (easy to apply)Pavlik Harness (difficult to apply but more freedom to move)

Management

Von Rosen’s Splint

Persistent dislocation: 6-18monthsFailed early treatment or missed dislocationHip must be reduced by closed method or operation

Closed reductionPerformed under GA with arthrogramGradual traction to minimize avascular necrosisPlastic spica for 6 weeks (60° flexion, 40° abduct, 20° int rotate)

Reassess and spica for another 6 weekschecking by x-ray – to ensure femoral head concentrically reduced and acetabular roof develop normally

Management

Operation Indicated when concentric reduction failedPsoas tendon is dividedRedundant tissue is removedHip is reduced (60° flexion, 40° abduct, 20° int rotate)

Spica is applied (6wks) andhip is splinted

Management

Management18months-4 yearsClosed reduction is less likely to succeed.

Traction: help to loosen the tissue and bring the femoral head down opposite the acetabulum

Arthrography: clarify anatomy of hip shows whether there is an inturned limbus or any marked degree of acetabular dysplasia.

Operation remove redundant capsuleUsually require derotation femoral osteotomy held by a plate and screw1cm segment removed from proximal femur to reduce pressure on hipIf there is marked acetabular dysplasia, may require acetabuloplasty

After operation, hip is held in a plaster spica for 3 monthsKeep under clinical and radiological surveillance

Children >4 yearsUp to 8 y/o; reduction and stabilization as above, risk of AVN and hip stiffness (>25%)

Over 8 y/o;– unilateral [mobile hip, little pain, abnormal gait.]

• no intervention @ open reduction + acetabular reconstruction.

– bilateral [deformity + waddling gait not so noticeable]• non-intervention unless painful/severe deformity. (fail leads to asymmetrical deformity.)

Management

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