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

2. Common Pediatric Hip problems
DDH
SCFE
Perth's

3. DDH

4. Nomenclature CDH : Congenital Dislocation of the Hip
DDH : Developmental Dysplasia of the Hip

5. 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

6. 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

7. Normal pelvis
Adult
Child

8. Normal pelvis
adult
child

9. Normal pelvis
adult
child

10. Normal pelvis
adult
child

11. DDH
Normal hip Dislocated hip

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

13. 1) Femoral Head Position
Normal hip Dislocated hip

14. 2) Acetabular Development
Normal hip Dislocated hip

15. DDH
Normal hip Dislocated hip

16. Patterns of disease Dislocated Dislocatable Sublaxated
Acetabular dysplasia

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

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

21. 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

22. DDH When risk factors are present the infant should be reviewed:
Clinically
Radiologically

23. Examination
The infant should be:
Quiet
Comfortable

24. DDH Look: External rotation Lateralized contour Shortening
Asymmetrical skin folds
Anterior
Posterior

26. DDH
Move
Limited abduction

27. 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)

28. DDH- Giliazi test

29. DDH- Ortolani test

30. DDH- Barlow test

31. DDH- Barlow &Ortolani tests

32. DDH- Hamstring Stretch Test

33. DDH- Trendelenburg Test

34. DDH- Trendelenburg Test

35. 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

36. DDH- Radiology

37. Radiology
After 6 months: reliable

38. Radiology
After 6 months: reliable

39. 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

40. 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

41. 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 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

42. 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

43. 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

44. Normal Hip Arthrogram

45. Hip Arthrogram Guided Reduction
Dislocate view
Reduced view

47. Hip Spica

48. Broom-Stick Cast

50. Example: Open reduction & Acetabuloplasty

51. Example: Open reduction & Acetabuloplasty & Femoral Shortening

52. 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

53. SCFE

54. SCFE

55. 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

57. SCFE- Top View
Anterior slippage

58. 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

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

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

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

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

63. 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

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

65. 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

66. SCFE

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

68. 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

69. 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

70. SCFE- XR AP

71. SCFE- XR Frog Lateral

72. SCFE- Chronic

73. SCFE- Kline’s Line

74. SCFE- Kline’s Line

75. SCFE

77. SCFE- Example 1

78. SCFE- Example 2

79. SCFE Severity: Depends on degree of slip
The metaphysis is divided to 3 (1/3)
The more the slip the worsted the severity

80. SCFE- Severity

81. SCFE
Treatment:
Acute or chronic its an emergency  refer to Orthopedic urgently
Aim  prevent further slippage & fuse the physis

82. 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

83. SCFE

84. SCFE

85. 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

86. SCFE

87. 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

88. SCFE- Chondrolysis

89. SCFE- Chondrolysis

90. SCFE- AVN

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

93. Legg-Calve-Perth’s Disease (LCP)

94. Perthe’s Disease:

95. 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.

96. Perth’s Disease

97. Legg-Calve-Perth’s Disease

98. Perth’s Disease Typically: 4-8 years old  males  obese
Bil in 10 – 12% of patients

99. Perth’s Disease Theories of its cause: Most agree  its multifactorial
Minor trauma (hyperactive child)
A.V malformation
Virus infection
Most agree  its multifactorial

100. Perth’s Disease
Severity  depends on how much of the head is involved

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

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

103. 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)

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

105. 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

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

107. 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)

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

110. 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

111. Perth’s Disease XR changes
AP standing
Frog lateral

112. Perth’s Disease XR changes
Subchondral fracture,
one of the 1st signs of LCP,
best seen on frog lat XR
Metaphyseal cysts

113. Perth’s Disease XR changes

114. Perth’s Disease

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

116. 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

117. 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

118. Perth’s Disease

119. Perth’s Disease

120. Perth’s Disease

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

122. 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

123. Perth’s Disease Abduction Hinge

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

125. Remember

126. Common Pediatric Hip problems
DDH
SCFE
Perthe’s

127. thanks