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Hip pain

Legg Calve’ Perthes' disease (COXA PLANA )

Perthes' disease Disorder of childhood characterized by necrosis of the femoral head. Although the incidence is only 1 in 10 000. Should always be considered in the differential Diagnosis of hip pain in young children.

Patients are usually 4-8 years old and show delayed skeletal maturity. Boys are affected four times as often as girls. 4

Pathogenesis

femoral head may depend for its blood supply almost entirely on the lateral epiphyseal vessels. whose situation in the retinacula makes them susceptible to stretching and pressure from an effusion.

Factors implicated in the pathogenesis of Perthes’ disease Low birthweight High birth order Delayed bone age Low socioeconomic status

The precipitating cause

Probably an effusion into the hip joint following either trauma. A non-specific synovitis. THIS LEAD TO A temporary, and possibly repeated, local disturbance of blood supply is believed to be the major factor, but the precise cause of the vascular disturbance is unknown.

Causes of avascular necrosis of the femoral head Steroids Infection Perthes’ disease Sickle cell disease Hypothyroidism Skeletal dysplasia – classically multiple epiphyseal dysplasia

Pathology

The pathological process takes 2-4 years to complete, passing through three stages. Bone death. revascularization and repair. Distortion and remodelling. In consequence of interrupted growth at the femoral neck and the limb as a whole may be shorter. the femoral discripency not great. Though the limb shorter than on the normal side. femoral head deformity occurs. This is not reversible and has a permanent effect on the health of the hip joint.

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Clinical feature

The patient - usually a boy of 4-8 years . Complains of pain and Starts to limp.

The hip looks normal. Although there may be a little wasting of the thigh. Movements are diminished and their extremes painful.

later, abduction is nearly always limited and usually internal rotation.

X-rays

Before x-ray changes appear, the ischaemic area with decrease uptake ,can sometimes be demonstrated as a 'void' on radioisotope scanning.

The earliest changes on X RAY: are increased density of the bony epiphysis . apparent widening of the joint space. Flattening. fragmentation .

lateral displacement of the epiphysis follow, with rarefaction and broadening of the metaphysis.

MRI

Differential diagnosis

non-specific transient synovitis the so-called irritable hip. Symptoms last for a week or two and clear up completely. Ultrasound may show a joint effusion, but the x-rays are always normal. The child should be kept in bed until pain disappears and the effusion resolves.

Treatment

Treatment aims to minimise femoral head deformity, and thus the likelihood of secondary acetabular dysplasia. This is achieved by maintaining a good range of joint movement, with some restriction in activity level, and using analgesia and physiotherapyas required

As long as the hip is painful, the child should be in bed with skin traction applied to the affected leg. For about 3 weeks. Then to follow up it is essential that they attend periodically for radiological review .

Favourable prognostic signs We have either patients with Favourable prognostic signs

(l) onset under the age of 6. (2) only partial involvement of the femoral head. (3) absence of metaphyseal rarefaction. (4) normal femoral head shape. while

Unfavorable signs are:

(1) onset over the age of 6. (2) involvement of the whole femoral head. (3) severe metaphyseal rarefaction. (4) lateral displacement of the femoral head. Children in this category need treatment by containment of the femoral head.

TREATMENT

Containment

This means keeping the femoral head well seated within the acetabulum This means keeping the femoral head well seated within the acetabulum. Surrounded by its socket.

Containment can be achieved by holding the hips widely abducted in plaster.

A removable splint until the bone changes have run their course (at least a year).

OR by performing a varus osteotomy of the femur.

An innominate osteotomy of the pelvis.

SLIPPED UPPER FEMORAL EPIPHYSIS

Physiological or pathological conditions a ‘stress fracture’ through the physis allows the epiphysis to displace as it would with an intracapsular femoral neck fracture. Displacement of the proximal femoral epiphysis ­also known as epiphysiolysis . is uncommon and virtually confined to children going through The pubertal growth spurt.

Incidence and aetiology Boys ate affected more often than girls. Slip of the upper (capital) femoral epiphysis (SUFE or SCFE) an incidence of 5:100 000 population. the peak incidence is related to the start of puberty, hence it is earlier in girls.

Factors increase the incidence hypothyroidism,. renal failure . and previous radiotherapy treatment (local or to the pituitary region) also increase the risk.

Cause and pathology

A slipped epiphysis is an insufficiency fracture through the hypertrophic zone of the cartilaginous growth plate.

Normal forces, exacerbated by obesity with delayed gonadal development. and repetitive minor trauma, precipitate a slip. Puberty. Tall children .

pituitary growth hormone (which stimulates bone growth). Perhaps this means that these children have an imbalance between pituitary growth hormone (which stimulates bone growth). and gonadal hormone (which promotes physeal fusion).

Thus, during the pubertal growth spurt, the relatively immature physis might be too weak to resist the stress imposed by the increased body weight.

Clinical features

The patient - usually a boy of 14 or 15 years . presents with pain in the groin, the anterior part of the thigh or the knee (referred pain). he may also limp. The onset may be sudden and in 30 per cent there is a history of trauma (acute slip').

However, in the majority symptoms are chronic I.e. chronic slip, or else a long period of pain may culminate in a sudden climax following minor trauma acute-on chronic slip.

On examination

the leg is externally rotated and is 1 or 2 cm short. Characteristically there is limitation of abduction and medial (internal) rotation. Following an acute slip, the hip is irritable and all movements are accompanied by pain.

Hip Flexion Causes Abduction & External Rotation

OR SCFE Associations with , Obesity Endocrine issues Hypothyroidism

Classification Slip severity can be graded on the lateral x-ray. or classified according to the onset of symptoms: Acute. chronic . acute-on-chronic.

Mild <33% Moderate 33–66% Severe >66% Grading of the severity of slip of the upper (capital) femoral epiphysis. Slip severity Metaphysis uncovered (%) Mild <33% Moderate 33–66% Severe >66%

X-rays

In the anteroposterior view the epiphyseal plate seems to be too wide and too 'woolly'.

Trethowan's sign A line drawn along the superior surface of the neck remains superior to the head instead of passing through it .

In the lateral view the femoral epiphysis is tilted backwards; small degrees of tilt can be detected by measuring the angle between the epiphyseal base and the femoral neck . Slip angle

Complications

A vascular necrosis is the most serious complication A vascular necrosis is the most serious complication. This complication is usually a consequence of attempted reduction of the slip by manipulation or of operation, but it may occur spontaneously, especially after a sudden acute slip

Coxa vara deformity may result if the displacement is not reduced and the epiphysis fuses in its deformed position.

Cartilage necrosis. Osteoarthritis: If severe displacement is allowed to remain uncorrected is likely to develop in later life.

Slipping at the opposite hip occurs in a third of cases - sometimes while the patient is in bed.

Treatment

Manipulation is dangerous and should be avoided. Minor displacement Displacement of less than one-third the width of the epiphysis is treated by accepting the position and

fixing the epiphysis with two thin threaded pins or screws fixing the epiphysis with two thin threaded pins or screws. This is always done under x-ray control. fixation in position

Severe displacement If the displacement is more than half the epiphyseal width, corrective surgery will be needed.