1. Common Pediatric Hip Problem
Dr.Kholoud Al-Zain
Assistant Professor
Consultant, Pediatric Orthopedic Surgeon
Dec 2016
Acknowledgement:
Dr.Abdalmonem Alsiddiky
Dr.Khalid Bakarman
Prof. M. Zamzam

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. Femoral head ossific nucleus
Normal pelvis
Adult
Child
Femoral head ossific nucleus
Growth plates

8. DDH
Normal hip Dislocated hip

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

10. 1) Femoral Head Position
Normal hip Dislocated hip
Superior displacement
Femoral head lateralization

11. 2) Acetabular Development
Normal hip Dislocated hip
Acetabular dysplasia

12. Patterns of Disease Dislocated Dislocatable Subluxate
Acetabular dysplasia (A.D)

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

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

16. 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

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

18. Examination
The infant should be:
Quiet
Comfortable

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

20. Asymmetrical Creases

21. DDH
Move
Limited abduction

22. 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)

23. DDH- Giliazi test

24. Limb Length Inequality
Clinical measures of discrepancy:
Measuring tape
Giliazi test

25. DDH- Ortolani test

26. DDH- Barlow test

27. DDH- Barlow &Ortolani tests

28. DDH- Hamstring Stretch Test

29. DDH- Trendelenburg Test

30. DDH- Trendelenburg Test

31. 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

32. DDH- Radiology Acetabular Index Perpendicular Line Horizontal Line
Shenton's Line

33. 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
Parents education about inheritance
That is why:
Refer to pediatric orthopedic surgeon

34. 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

35. 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

36. 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

37. 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

38. Concentrically reduced femoral head
Normal Hip Arthrogram
Acetabular cartilage
Concentrically reduced femoral head

39. Hip Arthrogram Guided Reduction
Dislocate view
Reduced view

40. Hip Spica

41. Broom-Stick Cast

42. Open reduction & Acetabuloplasty

43. Open reduction & Acetabuloplasty & Femoral Shortening

44. 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
Secondary scoliosis

45. SCFE

46. 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

48. SCFE- Top View
Anterior slippage

49. 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

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

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

52. 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

53. 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

54. SCFE- Spontaneous Hip External Rotation When flexing

55. 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

56. SCFE- XR AP

57. SCFE- XR Frog Lateral

58. SCFE- Chronic

59. SCFE- Kline’s Line

60. SCFE- Kline’s Line

61. SCFE- Decreased Vascularity of Lt Femoral Head with Effusion

62. SCFE- Example 1

63. SCFE- Example 2

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

65. SCFE- Severity

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

67. 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

68. SCFE

69. SCFE

70. SCFE

71. 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
Secondary scoliosis

72. SCFE- Chondrolysis

73. SCFE- Chondrolysis

74. SCFE- AVN

75. Legg-Calve-Perth’s Disease (LCP)

76. 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.

77. Perth’s Disease

78. Legg-Calve-Perth’s Disease

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

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

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

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

83. Perth’s Disease Prognosis: ( < 6y) of age: (6-8y) of age:
Good prognosis (heals well)
Usually conservative treatment
(6-8y) of age:
Various outcomes
Majority of patients present in this age gp
( > 8y) of age:
Usually bad prognosis
Needs surgical treatment (may be >1 operation)

84. Example of Good Prognosis
At 3y of age 5y 7y 9y

85. 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

86. 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)

87. 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

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

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

90. Perth’s Disease- Irregular Head

91. Perth’s Disease- Decreased Head Vascularity

92. 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

93. 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

94. Perth’s Disease

95. Perth’s Disease

96. 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
Secondary scoliosis

97. Perth’s Disease Abduction Hinge

98. Any Questions?

99. Remember

100. Take Home Message DDH: SCFE & Perth’s: Types  mainly idiopathic
The earlier diagnosed the better the results
Risk factors & red flags
How to read XR & draw the lines
Refer to Ortho once “suspect” DDH
SCFE & Perth’s:
Both are serious & needs urgent referral to Ortho
Acute SCFE is an emergency
If knee pain examination in a child is normal must assess the hip
Radiological workup & importance of frog lateral XR
Complications are serious