26: Paediatric Orthopaedics - The BIG THREE Flashcards
what are the big three childhood hip problems?
- developmental dysplasia of the hip (DDH)
- Perthes Disease
- Slipped upper femoral epiphysis (SUFE)
Developmental dysplasia of the hip (DDH) definition
- a congenital abnormality of the hip joint in which the ball of the femur (femoral head) and the socket of the pelvis (acetabulum) do not articulate properly.
- This malalignment can result in the joint dislocating easily and continuing to develop abnormally.
DDH aetiology
5 Fs
- female (more common)
- firstborn
- family history
- frank breech presentation: babies presenting buttocks or feet first in the womb have a higher risk.
- fluid: low amniotic fluid levels (oligohydramnios) can increase risk
DDH clinical presentation in infants
- limited hip abduction, especially when hip is flexed
- asymmetry of gluteal and thigh skinfolds
- apparent limb length discrepancy
DDH clinical presentation in older children
- walking difficulties or a limp
- delayed walking
- waddling gait in bilateral cases
DDH investigations
- Barlow (tests for posterior dislocation) and Ortolani (tests for relocation on hip abduction) tests are primary screening tools.
- If DDH suspected, hip US should be ordered for confirmation, especially in infants < 6 months
- for older infants and children, pelvic radiography may be more suitable
DDH management
- In mild cases or those detected early: may be self-limiting within the first few months of life
- A Pavlik harness may be used to maintain the hip in a flexed and abducted position.
- More severe cases, or those not responding to non-operative management > surgical intervention for reduction and stabilisation
what is Perthes disease?
- refers to avascular necrosis of the femoral head in children aged 4-8 (usually boys).
- This condition arises due to disruption in blood flow to the femoral head, which subsequently leads to ischaemia.
Perthes disease aetiology
- pathologically avascular necrosis of hip
- possible relationship to coagulation tendency
- possible relationship to repeated minor trauma
- familial tendency
- classicaly low social status
Perthes disease signs and symptoms
- gradual onset of limp
- hip pain, which may also be referred to the knee
- pain persisting for more than 4 weeks
Perthes disease investigations
- hip x-ray is primary diagnostic tool
- can show sclerosis and fragmentation of the epiphysis
what are the 4 Waldenstrom stages in Perthes disease?
- initial stage
- fragmentation stage
- reossification stage
- healed stage
Perthes disease management
Depends on extent of necrosis:
- if less than 50% of femoral head involved: conservative measures e.g. bed rest, non-weight bearing, and traction can lead to resolution. Prognosis favourable in these circumstances.
- if more than 50%: plaster cast to keep hip abducted or even an oseotomy. Associated with poorer outcomes and a higher risk of degenerative arthritis in later life.
definition of slipped upper femoral epiphysis (SUFE)
- a prevalent hip disorder in adolescents
- this condition results from the proximal femoral growth plate’s weakness allowing displacement of capital femoral epiphysis
SUFE aetiology
- predominantly male 80% cases
- typically adolescents
- obesity
- endocrine disorders such as hypothyroidism and hypogonadism
- ethnicity: particularly afro-caribbean and hispanic populations
SUFE is typically diagnosed using
- anterolateral and frog-leg x-rays
