Common Pediatric Hip Problem
Prepared by
Pediatric Orthopedic gruop Surgeons
KKUH
Common Pediatric Hip problems
DDH
SCFE
Perthe’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
ADULT
child
CHILD
DDH
Normal hip
Dislocated hip
Patterns of disease
1)
2)
3)
4)
Dislocated
Dislocatable
Sublaxated
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 head
That 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 Disease
At 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 changes
Subchondral 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:
DDH
SCFE
Perthe’s