Common Pediatric Hip Problem

Prepared by

Pediatric Orthopedic gruop SurgeonsKKUH

Common Pediatric Hip problems

DDHSCFEPerthe’s

DDH

Nomenclature

• CDH : Congenital Dislocation of the Hip• DDH : Developmental Dysplasia of the Hip

Pediatric Hips Dislocation

• Types:– Idiopathic isolated pathology– Teratologic:

• Neurologic as: patient with C.P or MMC• Muscular as: Arthrogryposis• Syndromatic as: Larsen syndrome

– Miscellaneous:• Complication to hip septic arthritis• Traumatic

Pediatric Hips Dislocation

• Note delivery in its self (OBGY Dr.) does not dislocate a hip

• DDH occurs in the 3ed trimester • Teratologic usually in the 1st trimester

Normal pelvis

adult child

CHILDADULT

DDH

Normal hip Dislocated hip

Patterns of disease

1) Dislocated 2) Dislocatable3) Sublaxated 4) Acetabular dysplasia

Causes (multi factorial)

• Hormonal – Relaxin, oxytocin

• Familial – Lig.laxity diseases

• Genetics– F 4-6x > M– Twins 40%

• Mechanical – Pre natal– Post natal

Mechanical Causes

• Pre natal– Breach , oligohydrominus , primigravida , twins (torticollis , metatarsus adductus )

• Post natal– Swaddling , strapping

Infants at Risk• Positive family history: 10X• A baby girl: 4-6 X• Breach presentation: 5-10 X• Torticollis: CDH in 10-20% of cases• Foot deformities:

– Calcaneo-valgus and metatarsus adductus• Knee deformities:

– hyperextension and dislocation – Parents who are relatives (consanguinity)

DDH

• When risk factors are present the infant should be reviewed:– Clinically– Radiologically

Examination

• The infant should be– Quiet– Comfortable

DDH

• Look:– External rotation– Lateralized contour– Shortening– Asymmetrical skin

folds• Anterior – posterior

DDH

• Move– Limited abduction

DDH

• Special test (depending on the age):– Galiazzi sign– Ortolani, Barlow test only till 4-6 m of age– Hamstring Stretch test – Trendelenburg sign older comprehending child– Limping:

• Unilateral one sided limping• Bilateral waddling gait (Trendelenburg gait)

DDH- Giliazi test

DDH- Ortolani test

DDH- Barlow test

DDH- Hamstring Stretch Test

DDH- Trendelenburg Test

DDH- Investigations

• 3w -3m U/S

• > 3months X-ray pelvis (AP + abduction)

DDH

• The pathology is of 2 componants:– Femoral head position.– Acetabular development.

Femoral Head Position

Normal hip Dislocated hip

Acetabular Development

Normal hip Dislocated hip

DDH- Radiology> 6m: reliable & ossification center normally appears (5-6m) of age, if

delayed or did not appear it’s one of the signs of DDH

Treatment - Aims

A concentrically, reduced, stable, painless, mobile hip joint.

•Obtain concentric reduction•Maintain concentric reduction•In a non-traumatic fashion•Without disrupting the blood supply to femoral headThat is why:

Refer to pediatric orthopedic surgeon

DDH- Treatment

• Method depends on age• The earlier started:

– Its easier– Better the results (higher remodeling potential)– Treatment is mainly non-operative

• Should be detected EARLY• Either surgical or non-surgical

Treatment• Birth – 6m

– In OPD: reduce + maintain with Pavlik harness or hip spica (H.S)• 6-12 m:

– GA + closed (? Open) reduction + maintain with H.S• 12 - 18 m:

– GA + open reduction + maintain with H.S 6w, then B.S cast for months • 18 – 24 m:

– GA + open reduction + acetabuloplasty + H.S 6w, then B.S cast 6w • 2-8 years:

– GA + open reduction + acetabuloplasty + femoral shortening + H.S 6w, B.S 4-6w

• Above 8 years:– GA +open reduction + acetabuloplasty (advanced) + femoral shortening +

H.S

Pavlik Harness

• Maximum to start it is 6m of age, if older use other method

• Is kept on for 6w continuous, then use a rigid abduction splint

• This is to achieve stable reduction• It’s a dynamic splint

Abduction splint

• It’s a rigid splint• This is to maintain the reduction & wait for

improvement of the acetabular cover to be < 30° & with concavity

Normal Hip Arthrogram

Hip Arthrogram Guided Reduction

Dislocate view Reduced view

Hip Spica

Broom-Stick Cast

Example: Open reduction & Acetabuloplasty

Example: Open reduction & Acetabuloplasty & Femoral Shortening

DDH

• Late complications if not treated:– Severe pain (hip area, back)– Early hip arthritis – LLD (leg length discrepancy) – Pelvic inequality (tilt)– Early Lumbar spine degeneration

SCFE

SCFE

• Slipped Capital Femoral Epiphysis• At the level of physis • Its considered as Salter-Harris fracture, type-1• So it is an emergency

SCFE- Top View

Anterior slippage

SCFE

• Types:– Radiological:

• Acute < 3w • Chronic > 3w, can see start of callus formation• Acute on chronic

– Clinical:• Unstable can not weight bear on that limb• Stable can put weight (walk)

• When its acute or unstable urgent surgery

SCFE

• Causes:– Hormonal hypothyroid, abnormal G.H,

hypogonadisum – Metabolic Chronic renal failure – Mechanical (obesity)– Trauma– Unknown

SCFE

• Typically:– 8 – 12y old – Male– Obese– Black

• 20 - 25 % to affect the other hip, within 18m post affection

SCFE

• History:– Pain hip, anterior thigh, knee– Duration of C/O (more or less than 3w)– Gait painful or painless – Trauma minor or none– Any known hormonal or metabolic issues

SCFE

• Examination:– The limb is in ext. rotation– With hip flexion the limb goes in spontaneous ext.

rotation– Limited int. rotation & abduction– Painful hip R.O.M– Gait can or can not (antalgic) weight bear on

affected limb

SCFE

SCFE

• Investigation:– XR pelvis:

• AP standing & frog lateral• See the actual slip • Positive “Klein Line”• Or just wide physis pre slip phase

– XR knee is normal– MRI in unusual or unclear presentations

SCFE- XR AP

SCFE- XR Frog Lateral

SCFE- Chronic

SCFE- Kline’s Line

SCFE- Kline’s Line

SCFE

SCFE- Example 1

SCFE- Example 2

SCFE

• Severity:– Depends on degree of slip– The metaphysis is divided to 3 (1/3)– The more the slip the worsted the severity

SCFE- Severity

SCFE

• Treatment:– Acute or chronic its an emergency refer to

Orthopedic urgently– Aim prevent further slippage & fuse the physis

SCFE

• Treatment:– Acute:

• Emergency in-situ fixation (no reduction done)• Using 1 or 2 (6mm) screws• Pin threads pass the physis, & stops 5mm before the

articular surface to prevent “Chondrolysis”• Do hormonal essay if any abnormality refer to

endocrine

– Chronic salvage corrective osteotomies

SCFE

SCFE

SCFE

SCFE

• Complications:– Chondrolysis that causes early hip OA– Femoral AVN– FAI ( Femoral Acetabular Impingement) – If not treated coxa vara or valga– Stiff hip joint– LLI (leg length inequality) – Pelvic obliquity – Early Lumbar spine degeneration

SCFE- Chondrolysis

SCFE- Chondrolysis

SCFE- AVN

Legg-Calve-Perth’s Disease(LCP)

Perth’s Disease

• It is vascularity of head of femur (AVN) of an unknown cause.

• So a patient with SCA & femoral AVN does not have Perth’s disease.

Perth’s Disease

Legg-Calve-Perth’s Disease

Perth’s Disease

• Typically: – 4-8 years old– males– obese – Bil in 10 – 12% of patients

Perth’s Disease

• Theories of its cause:– Minor trauma (hyperactive child)– A.V malformation– Virus infection

• Most agree its multifactorial

Perth’s Disease

• Severity depends on how much of the head is involved

Perth’s Disease

• Stages (weeks-years per stage):– Vasculitis– Fragmentation– Reossification / Healing– Reossified / Healed

Perth’s Disease

• Prognosis:– < 6y of age:

• Good prognosis (heals well)• Usually conservative treatment

– > 9y of age:• Usually bad prognosis• Needs surgical treatment (may be >1 operation)

– 6-9 y of age:• Various outcomes• Majority of patients present in this age gp

Perth’s DiseaseAt 3y of age 5y 7y 9y

Perth’s Disease

• History:– Pain hip, anterior thigh, knee– Antalgic gait– Trauma minor or none– URTI few weeks earlier– C/O since weeks to months

• The usual a minor trauma few months ago with initial antalgic gait & now pain is better but still limping

Perth’s Disease

• Examination:– Antalgic gait– Restricted hip ROM in all directions, esp. with more

sever head involvement– Worse restriction for internal rotation & abduction– Knee normal – Thigh muscle wasting (disuse)

Perth’s Disease

• Investigation:– XR pelvis AP standing & frog lateral– XR knee is normal– MRI:

• In unusual presentations• Vary early in the disease even before classical XR changes

Perth’s Disease XR changes

AP standing Frog lateral

Perth’s Disease XR changesSubchondral fracture,

one of the 1st signs of LCP,best seen on frog lat XR

Metaphyseal cysts

Perth’s Disease XR changes

Perth’s Disease

Perth’s Disease

• Treatment:– Refer to Orthopedic Dr. as an urgent case.– Vary controversial, depending on age, stage &

classification. – Aim have a painless, contained, mobile hip joint

Perth’s Disease

• Treatment:– But basic guidelines:

• Pain relief (may) admit, skin traction few days, analgesia• Increase hip ROM P.T, mobilize PWB or NWB• Keep hips abducted:

– So head will mold better in the acetabulum, and less body weight on the femoral heads.

– By abduction splint or casting (Broom-Stick cast or Spica cast)

• While keeping the head contained:– Do containment osteotomy in the fragmentation stage. – If came in late reossification stage wait till heals then do salvage

surgery

Perth’s Disease

Perth’s Disease

Perth’s Disease

Perth’s Disease

• Complications:– Abduction hinge may need Chelectomy– Heals in coxa magna (big), brevia (short), plana

(wide)– Stiff hip joint– LLI (leg length inequality) – Pelvic obliquity – Early hip OA – Early Lumbar spine degeneration

Perth’s Disease Abduction Hinge

Remember

Common Pediatric Hip problems:

DDHSCFE

Perthe’s