Common Pediatric Hip Problem Dr.Abdulmonem Al-Siddiky Dr.Kholoud Al-Zain Dr.Khalid Bakarman Assistant Professors Consultant Pediatric Orthopedic Surgeons

Common Pediatric Hip problems DDH SCFE Perth'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 Child

Normal pelvis adult child

Normal pelvis adult child

Normal pelvis adult child

DDH Normal hip Dislocated hip

DDH The pathology is of 2 components: Femoral head position Acetabular development

1) Femoral Head Position Normal hip Dislocated hip

2) Acetabular Development Normal hip Dislocated hip

DDH Normal hip Dislocated hip

Patterns of disease Dislocated Dislocatable Sublaxated Acetabular dysplasia

Causes (multi factorial) Unknown Hormonal Relaxin, oxytocin Familial Lig.laxity diseases Genetics F 4-6x > M Twins 40% Mechanical Pre natal Post natal

Mechanical Causes Pre-natal: Post-natal  swaddling , strapping Breach Oligohydrominus Primigravida Twins Post-natal  swaddling , strapping

Infants at Risk Parents who are relatives (consanguinity) Positive family history: 10X 1st child Breach presentation: 5-10 X Oligohydrominus Twins: 40% A baby girl: 4-6 X Torticollis: CDH in 10-20% of cases Foot deformities: Calcaneo-valgus Metatarsus adductus Knee deformities: hyperextension and dislocation

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- Barlow &Ortolani tests

DDH- Hamstring Stretch Test

DDH- Trendelenburg Test

DDH- Trendelenburg Test

DDH- Investigations 3w -3m  U/S > 3months  XR pelvis (AP + abduction) > 5-6m: More reliable Is when ossification centers normally appears If delayed or did not appear it’s one of the signs of DDH

DDH- Radiology

Radiology After 6 months: reliable

Radiology After 6 months: reliable

A concentrically, reduced, stable, painless, mobile hip joint. 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 6-12 m: 12 - 18 m: 18 – 24 m: 2-8 years: 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 This is to achieve stable reduction It’s a dynamic splint Is kept on for 6w continuous, then use a rigid abduction splint

Abduction splint It’s a rigid splint This is to: Maintain the reduction, And wait for improvement of the acetabular cover to be: A.I < 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) LLD (leg length discrepancy) Pelvic inequality (tilt) Early hip arthritis Early Lumbar spine degeneration

SCFE

SCFE

SCFE Slipped Capital Femoral Epiphysis At the level of  physis As if it is a  Salter-Harris fracture, type-1 So it is an emergency

SCFE- Top View Anterior slippage

SCFE Types: When it’s acute or unstable  urgent surgery 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 some weight (walk) When it’s acute or unstable  urgent surgery

SCFE Causes (multifactorial): Unknown Hormonal: Hypothyroid Abnormal G.H Hypogonadisum Metabolic  Chronic renal failure Mechanical (obesity) Trauma

SCFE: Slipped Capital Femoral Epiphysis Where  at level of growth plate Why: ? Hormonal ? Metabolic ? Mechanical, obesity ? Trauma ? Unknown

SCFE Typically: (8 – 12y) old Male Obese Dark skinned 20 - 25 % chance that the other hip will be affected, within 18m post the 1st hip affection

SCFE: Typical : > 8-12y >  in males >  in obese >  in black >  if other side affected

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: History: > Hip pain/knee pain > Minor trauma > no trauma > Limping (painful)

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 Thigh muscle wasting (disuse), esp. in chronic cases

SCFE

Hip in ER (external rotation)  IR (internal rotation) On Examination: Hip in ER (external rotation)  IR (internal rotation)  Abduction Usually painful ROM Limping (painful)

SCFE Investigation: XR pelvis: XR knee  is normal 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

Investigations X-ray: If not clear but still doubtful MRI can help Pelvis: Slippage positive or   growth plate space (pre slip phase) Knee  normal If not clear but still doubtful MRI can help

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: Chronic  salvage corrective osteotomies Emergency in-situ fixation (no reduction done) Using 1 or 2 (6mm) screws Screw threads pass the physis to fuse it Screw stops 5mm before the articular surface to prevent “Chondrolysis” Do hormonal essay  if any abnormality refer to endocrine Chronic  salvage corrective osteotomies

SCFE

SCFE

Treatment: Refer to orthopedic as emergency case What they will do? In situ pinning – to prevent further damage to the vascularity Protected weight bearing for 3-4 weeks then full weight bearing No sport for 6 months

SCFE

SCFE Complications: Chondrolysis  that causes early hip OA Femoral AVN FAI ( Femoral Acetabular Impingement) Stiff hip joint Premature (early) hip O.A If not treated  coxa vara (or valga) LLI (leg length inequality) Pelvic obliquity Early Lumbar spine degeneration

SCFE- Chondrolysis

SCFE- Chondrolysis

SCFE- AVN

Late complications : FAI ( femoral Acetabular Impingement) Early arthritis LLD (leg length discrepancy) Pelvic inequality Early Lumbar spine degeneration

Legg-Calve-Perth’s Disease (LCP)

Perthe’s Disease:

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: Most agree  its multifactorial 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

Of the disease depends on the amount of femoral head involvement Severity Of the disease depends on the amount of femoral head involvement

Perth’s Disease Stages (weeks-years per stage): Vasculitis Fragmentation Reossification / Healing Reossified / Healed

Perth’s Disease Prognosis: ( < 6y) of age: (6-9y) of age: Good prognosis (heals well) Usually conservative treatment (6-9y) of age: Various outcomes Majority of patients present in this age gp ( > 9y) of age: Usually bad prognosis Needs surgical treatment (may be >1 operation)

Perth’s Disease- example At 3y of age 5y 7y 9y

Perth’s Disease History: Pain  hip, anterior thigh, knee Antalgic gait C/O since weeks to months Trauma  minor or none URTI few weeks earlier The usual  a minor trauma few months ago with initial antalgic gait & now pain is better but still limping

History: Hip pain or knee pain Minor or no trauma Painful limping

Perth’s Disease Examination: Antalgic or limping 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)

On Examination:  Abduction  IR (internal rotation) Usually painful range of motion    Limping (painful)

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

Investigations: X-ray: - knee  normal - pelvis   head size irregular shape If early – MRI can help

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

Treatment: Very controversial Refer to Orthopedics as an urgent case Guidelines of treatment: > Control pain > Maintain ROM > Hip containment options

Perth’s Disease Complications: FAI ( Femoral Acetabular Impingement)  may need Chelectomy Heals in coxa  magna (big), brevia (short), plana (wide) Stiff hip joint LLI (leg length inequality) Pelvic obliquity Premature (early) hip O.A Early Lumbar spine degeneration

Perth’s Disease Abduction Hinge

Late complications : Early arthritis LLD (leg length discrepancy) Pelvic inequality Early Lumbar spine degeneration

Remember

Common Pediatric Hip problems DDH SCFE Perthe’s

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