Good Morning!
4-month-old Well Child visit
Illness Scripts
• Predisposing Conditions
– Age, gender, preceding events (trauma, viral illness,
etc), medication use, past medical history (diagnoses,
surgeries, etc)
• Pathophysiological Insult
– What is physically happening in the body, organisms
involved, etc.
• Clinical Manifestations
– Signs and symptoms
– Labs and imaging
Hip Disease in Pediatrics
• Spectrum of disease
– Acetabular dysplasia
– Hip subluxation
– Hip dislocation
• Typical vs tetralogic DDH
– Typical: occurs in otherwise normal patients
– Tetralogic: identifiable causes such as
arthrogryposis or genetic syndrome
• Some degree of hip instability in 1/100 to
1/250 births
• Actual dislocated or dislocatable hips are
much less common
– Found in 1-1.5/1000 live births
• Higher incidence in Native American and
Eastern European cultures
– vs Asian or African cultures
– Environmental factors
• Caused by increased laxity of the hip capsule,
doesn’t maintain a stable femoroacetabular
articulation
• Increased laxity due to:
– Physiologic: family history of joint laxity, maternal
estrogens/hormones, M:F ratio of 1:9**
– Mechanical: primigravida, breech presentation**,
oligohydraminos, postnatal positioning
• Clinical findings in the Neonate:
– asymptomatic
– requires screening with specific maneuvers
• Barlow – action is dislocating an unstable hip
• Ortolani – action is returning a dislocated femoral head
back into the acetabulum  “CLUNK”
• Clinical findings in the Infant:
– Limited hip abduction
– Apparent shortening of the thigh
• Galeazzi sign
– Proximal location of the greater trochanter
– Asymmetry of the gluteal or thigh folds
– Asymmetry of the hip
• Galeazzi sign
• Clinical findings in the Walking Child:
– Limp
– Waddling gait
– Leg-length discrepancy
• Affected side is shorter
– Excessive lordosis
• Diagnostic testing
– Ultrasound**
• Diagnostic test of choice prior to the appearance of the
femoral head ossific nucleus ~ 4-6 months
• High incidence of false positive from age 0-4 weeks
• Provides dynamic information about stability of hip
• Role of screening ultrasound
• Diagnostic testing
– X-rays
• Recommended once the proximal femoral epiphysis
ossifies ~ usually by 4-6 months
• Lots of lines and angles and things to determine how
asymmetric the hips are
Radiograph of a patient presenting at age 8 months with DDH. The left hip is dislocated.
Nemeth B A , and Narotam V Pediatrics in Review
2012;33:553-561
©2012 by American Academy of Pediatrics
• Treatment
– Newborn to <6 months:
• Pavlik
harness
• Treatment
– 6 months to 2 years:
• Closed reduction
• Spica cast x 12 weeks
– >2 years:
• Open reduction
• Post-surgery spica
cast x 6-12 weeks
• May require other surgical
repairs to pelvis
• Complications
– Avascular necrosis of the femoral epiphysis
• Most vulnerable to damage to epiphyseal vessels
before 4-6 months
• Revascularization will follow but if the physis is severely
damaged, can result in abnormal growth
• With appropriate treatment, incidence of avascular
necrosis for DDH is reduced to 5-15%
• Idiopathic avascular necrosis of the femoral
epiphysis
• Overall incidence in the US ~ 1/1,200
• Male:Female ratio
of 4-5:1**
• Peak incidence
between 4-8 yrs old**
• Bilateral involvement
in ~10%, but at
different stages
• Temporary interruption of blood supply to the
proximal femoral epiphysis
– Leads to osteonecrosis
and femoral head
deformity after repair
process
– Often damages the
proximal femoral physis
leading to a short neck
and trochantric
overgrowth
• Clinical presentation
– Most common presenting symptom is a LIMP**
– Pain not always present
• Activity related
• Localized in the groin or referred to anteromedial thigh
or knee region
– Less commonly, onset may be acute and presents
with failure to ambulate
– Limited hip internal rotation and abduction
– Atrophy from disuse (due to pain)
– Leg-length discrepancy
• Diagnosis
– X-rays
• Treatment
– Goal: containment of the fragmented head in the
acetabulum
– Conservative – Petrie Abduction cast; Scottish Rite
brace
– Surgery
• Most commonly affects adolescents
– Age 11-16
• Annual incidence 2/100,000
– Higher in Polynesian and African-Americans
• Obesity
– ~65% of patients are >90th percentile for weight
• M>F
• Left > right
• Failure of the physis and displacement of the
femoral head relative to the neck
• Caused by combination of endocrine factors
(circulating hormones) and mechanical factors
(increased forces and mechanical load)
• Classifications
– Acute (< 3weeks) vs Chronic (several months)
– Stable vs Unstable (unable to walk with or without
crutches)
– Degree of displacement: mild, moderate, severe
• Clinical presentation**
– Classically, an obese, African-American boy
between the ages of 11 to 16 years
– Girls present between 10 to 14 years
– Some degree of limp
– Complaints of groin pain, or referred thigh or knee
pain (along the obturator nerve)
– On exam, restriction of internal rotation,
abduction, and flexion
– Unstable SCFE presents more urgently
• Diagnosis
– X-rays
– Kline’s line
– Bilateral imaging!
• Treatment
– Once diagnosed, should be admitted and placed
on bedrest
– In situ pinning of the SCFE
• Debate regarding prophylactic pinning of
opposite hip
– ~20-40% of children will develop contralateral
SCFE
• Complications
– Osteonecrosis
– Chondrolysis
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