Children’s Orthopaedics – ‘The Big 3’ - DDH, Perthes’ Disease, SUFE

Question 1

What are the 3 most common childhood hip problems?

Answer 1

• DDH: developmental dysplasia of the hip
• Perthes disease
• SUFE: slipped upper femoral epiphysis

Question 2

Who tends to get DDH? Which hip is most commonly affected? When is the condition usually identified?

Answer 2

• More common in girls & first borns
• Usually left hip
• Usually identified during the newborn, 6 week or 8 month baby checks

Question 3

Risk factors for DDH?

Answer 3

• First born / high birth weight
• Oligohydramnios (reduced fluid w/in uterus)
• Breech presentation (feet / buttocks of baby closest to cervix)
• Family history
• Other lower limb deformities (not TEV)

Question 4

Clinical signs of DDH?

Answer 4

• Ortolani’s Test (neonates): abduction of hip causes joint reduction with a clunk
• Barlow’s Test (neonates): gentle posterior pressure with legs adducted causes dislocation / subluxation
• Hamstring sign: thigh flexed up onto abdomen and knee extended, knee shouldn’t extend fully unless hip is dislocated

Question 5

Symptoms / signs of DDH?

Answer 5

• One leg appears longer than the other
• Abnormal gait / limp
• Pain if detected late on

Question 6

Investigations for suspected DDH?

Answer 6

• Ultrasound**
• X-Ray if late on, but not useful until after a year in some children as ossification of the head of the femur has yet to occur

Question 7

Treatment of DDH?

Answer 7

• If child < 3 months old: 90% resolve with splintage. Most common splint is Pavlik Harness
• 3 months - 1 yr old: reduction under anaesthetic and spika plaster cast
• Over 1 yr: surgical reduction + capsule reefing
• Over 18 months: open reduction with femoral shortening +/- periactetabular osteotomy

Question 8

When is DDH left untreated? Which condition can develop from DDH and often has poor prognosis?

Answer 8

• If diagnosis is make past age 6 and the DDH is bilateral
• If diagnosis is made past age 10 in unilateral cases
• Avascular necrosis of head of femur (Usually requires surgical intervention)

Question 9

How are babies screened for DDH in the UK?

Answer 9

Selective ultrasound screening

• Every baby examined at birth, if any question of hip deformity progress to ultrasound screening
• High birth weight babies and those with other lower limb deformities are often also given ultrasounds

Question 10

What is Perthes disease known as in the USA?

Answer 10

Legg - Calve - Perthes Disease

Question 11

Who tends to get Perthes Disease?

Answer 11

• Males
• Primary school age (3 - 12 years)
• Family history
• Classically occurs in low-socially economic status

Question 12

What is Perthes disease?

Answer 12

Avascular necrosis of the femoral head of unknown aetiology

Question 13

Signs / symptoms of Perthes disease?

Answer 13

• Short stature
• Limp
• Knee pain on exercise
• Stiff hip joint
• Systemically well

Question 14

Radiological signs of Perthes disease?

Answer 14

• Increased joint space
• Sclerosis
• Altered shape of femoral head
• Osteophytes

Question 15

What are the Waldenstrom stages of Perthes disease?

Answer 15

Classification of radiographic appearances

1. Initial stage
2. Fragmentation stage
3. Reossification stage
4. Healed stage

Question 16

What factors affect the prognosis of Perthes disease?

Answer 16

• Younger age at presentation leads to better prognosis
• Proportion of femoral head involved
• How round the femur re-ossifies
• Herring grade (grade given to hip based on height to which the collapse of the femur extends)

Question 17

Treatment of Perthes disease?

Answer 17

• Maintain hip motion, analgesia & restrict painful movements
• “supervised neglect” in most cases
• Consider osteotomy in selected groups of older children (> 7 yrs)

Question 18

Who tends to get SUFE (slipped upper femoral epiphysis)? Is the injury usually uni or bilateral?

Answer 18

• Boys aged 10-15
• Usually obese
• 20% bilateral

Question 19

Symptoms of slipped upper femoral epiphysis?

Answer 19

• Hip / groin pain (better with rest)
• Referred pain in KNEE
• Pain on weight bearing
• Affected leg appears shorter & externally rotated

Question 20

What’s another name for slipped upper femoral epiphysis?

Answer 20

• Slipped capital femoral epiphysis

Question 21

What are some different ways in which SUFE is classified?

Answer 21

• Acute vs Chronic (3 wks)
• Magnitude of slip (angle / proportion)
• Stable vs unstable (can the child weight bear?)

Question 22

Investigations for SUFE? Common radiological findings?

Answer 22

X-Ray (often better seen from lateral angle)

• Femoral epiphysis in abnormal (slipped) position in relation to femoral neck.
• Trethowan’s sign: line drawn parallel to neck of femur should evenly divide epiphysis. If line is superior to epiphysis on either side: slip

Question 23

Which part of the femur is actually displaced in a slipped upper femoral epiphysis?

Answer 23

The metaphysis

Metaphysis moves anterior and proximal, puts the epiphysis and the neck out of line

Question 24

Treatment of SUFE?

Answer 24

Screw fixation through metaphysis to fix joint alignment

Question 25

Possible late complications of SUFE?

Answer 25

• Limb length discrepancy

- Early osteoarthritis