Childhood Hip and Knee Conditions

Question 1

What is DDH?

Answer 1

Involves dislocation/subluxation of the femoral head during the perinatal period which affects the subsequent development of the hip

Question 2

What can DDH cause in the long term?

Answer 2

Severe arthritis at a young age, gait/mobility may be severely affected

Question 3

What are some risk factors for DDH?

Answer 3

Breech position, family history, other MSK or congenital conditions, Down’s syndrome, female, first born

Question 4

Most cases of DDH are in which hip?

Answer 4

Left, though 20% are bilateral

Question 5

Do all cases of DDH have apparent risk factors?

Answer 5

No (60% do not)

Question 6

What are some features to look for to suggest DDH?

Answer 6

Extra skin fold, asymmetry, decreased leg length

Question 7

What is the most important movement to check when assessing for DDH?

Answer 7

Abduction, one will be stiffer than the other

Question 8

Describe the Barlow test?

Answer 8

Abduct the hip and apply pressure on the knees, you will dislocate the hip

Question 9

Describe the Ortolani test?

Answer 9

Flex and adduct the hip, put pressure on the greater trochanter and you will reduce the dislocated hip

Question 10

If Ortolani and Barlow tests are positive for DDH, what test should be done next?

Answer 10

Ultrasound

Question 11

What is the main investigation for assessing DDH in children < 6 months of age?

Answer 11

Ultrasound

Question 12

What is the main investigation for assessing DDH in children > 6 months of age?

Answer 12

X-ray

Question 13

Which babies should have a routine ultrasound to image the hip at birth?

Answer 13

Breech position or positive family history

Question 14

How should you manage mild cases of DDH, with a shallow acetabulum and a mildly dislocatable but reduced hip?

Answer 14

Close examination and regular US scans

Question 15

If there is an early diagnosis of severe DDH, how should this be managed? What are the outcomes like?

Answer 15

Pavlik harness to keep the hip in flexion/abduction and hence reduced, really good outcomes

Question 16

Overflexion/abduction of the hip can lead to what?

Answer 16

AVN

Question 17

If there is a late diagnosis of DDH, how is it managed? What are the outcomes?

Answer 17

Surgical open reduction, the joint will probably never be normal

Question 18

If a child is diagnosed with DDH over 2 years old, how is this managed?

Answer 18

Combined femoral and acetabular surgery (breaking and reattaching)

Question 19

How long is a Pavlik harness used for? What ages can it be used for?

Answer 19

6 weeks continuous, 6 weeks part-time. Used up to 4-6 months of age.

Question 20

Those with late diagnosed DDH will go on to have what problems?

Answer 20

Early onset arthritis and hip replacement

Question 21

If the hip joint is infected, when will there be pain?

Answer 21

At rest and on movement, the child will be resistant to movement

Question 22

What is transient synovitis?

Answer 22

Self-limiting inflammation of the synovial (commonly hip)

Question 23

When is transient synovitis more common?

Answer 23

Following a viral URTI

Question 24

Which age and sex are more likely to have transient synovitis?

Answer 24

Boys, aged between 2 and 10

Question 25

What are some pathologies that need to be excluded in a child with possible transient synovitis?

Answer 25

Septic arthritis, rheumatoid arthritis, juvenile idiopathic arthritis

Question 26

How does a child with transient synovitis usually present?

Answer 26

A limp, or reluctance to bear weight on the affected side. Range of motion may be restricted slightly.

Question 27

Will the child be systemically unwell in transient synovitis?

Answer 27

No, except a possible low grade fever

Question 28

What test is used to exclude Perthes in a child with transient synovitis?

Answer 28

X-ray

Question 29

What test can be used to exclude septic arthritis in a child with transient synovitis? What should be done if there is any doubt of this?

Answer 29

CRP (if there is any doubt the hip can be aspirated and drained)

Question 30

What is the treatment for transient synovitis?

Answer 30

Exclude a more serious cause, short course of NSAIDs

Question 31

What is the onset of transient synovitis?

Answer 31

Insidious

Question 32

When should patients with transient synovitis be seen again if the pain has not gone?

Answer 32

A few weeks

Question 33

What is Perthes disease?

Answer 33

Idiopathic osteochondritis of the femoral head

Question 34

Who does Perthes disease typically occur in?

Answer 34

Between ages 4-9, more common in small boys who are hyperactive

Question 35

How does Perthes disease usually present?

Answer 35

Pain and a limp (though can be painless)

Question 36

Can Perthes be bilateral?

Answer 36

Yes, but usually not at the same time

Question 37

If Perthes occurs in both hips at the same time, what can this suggest?

Answer 37

Underlying skeletal dysplasia

Question 38

What happens to the femoral head in Perthes?

Answer 38

It gradually loses its blood supply, resulting in necrosis with subsequent abnormal growth

Question 39

What are indicators of a worse prognosis in Perthes?

Answer 39

Older age, AVN

Question 40

What will an incongruent joint as a result of Perthes lead to?

Answer 40

Early onset arthritis and possible hip replacement at a young age

Question 41

What is the general treatment for Perthes disease?

Answer 41

X-ray monitoring and avoidance of activity

Question 42

What position is it best for the hip to be in in Perthes?

Answer 42

Abduction

Question 43

Onset below what age implies a better prognosis in Perthes?

Answer 43

< 7

Question 44

Who does SUFE tend to affect?

Answer 44

Pre-pubertal adolescent boys (10-16) who are overweight

Question 45

What happens in SUFE?

Answer 45

The femoral head epiphysis slips inferiorly in relation to the femoral neck

Question 46

Pain is the main feature of SUFE, where can this pain be?

Answer 46

In the groin, or sometimes only in the knee

Question 47

SUFE causing pain in the hip and knee is due to nerve supply from where?

Answer 47

Obturator nerve

Question 48

What movement is the first to be lost in SUFE?

Answer 48

Internal rotation

Question 49

What may precede the onset of SUFE? What may not have occurred?

Answer 49

May be precede by a growth spurt, often puberty is delayed

Question 50

Can SUFE be bilateral?

Answer 50

Yes, about a third of cases. Treat for both even if not present.

Question 51

What ethnic group is SUFE more common in?

Answer 51

Black children

Question 52

What other conditions may predispose to SUFE?

Answer 52

Hypothyroidism and renal disease

Question 53

What imaging is essential in SUFE?

Answer 53

Lateral x-ray

Question 54

SUFE can tear vessels can cause a risk of what?

Answer 54

AVN

Question 55

Is AVN in SUFE reversible?

Answer 55

No, if not caught then the hip can die

Question 56

What is the management for SUFE?

Answer 56

Pinning of the physis in situ (bilateral)

Question 57

Can stable slips become unstable in SUFE?

Answer 57

Yes

Question 58

An adolescent who cannot weight bear has what until proven otherwise?

Answer 58

SUFE

Question 59

If you suspect emergency SUFE, what should be done?

Answer 59

Immediate x-ray (including lateral) and do not weight bear

Question 60

What implies a worse prognosis in SUFE?

Answer 60

The greater the degree of the slip

Question 61

What can SUFE result in in the long term?

Answer 61

Early hip replacement

Question 62

What should always be checked in a young person presenting with knee pain?

Answer 62

Hips for SUFE

Question 63

What makes knee extensor mechanism problems common in adolescence?

Answer 63

Increased weight and more sporting activities

Question 64

What is a specific type of knee extensor mechanism problem which may occur in adolescence and is self limiting but ay require physio?

Answer 64

Patellar tendonitis

Question 65

Anterior knee pain is more common in which sex?

Answer 65

Females

Question 66

What are some reasons the anterior knee pain is more common in girls?

Answer 66

Muscle imbalance, ligamentous laxity, skeletal predisposition

Question 67

What is the treatment of anterior knee pain?

Answer 67

Self-Limiting, physio may help

Question 68

What may very rare, resistant cases of anterior knee pain require?

Answer 68

Surgery (tibial tubercle transfer)

Question 69

What types of meniscal tears are children and young people more likely to get?

Answer 69

Peripheral or bucket handle tears

Question 70

Do young people with meniscal tears have a good recovery rate?

Answer 70

Yes