1. Good Morning!

2. 4-month-old Well Child visit

3. Illness Scripts Predisposing Conditions Pathophysiological Insult
Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc)
Pathophysiological Insult
What is physically happening in the body, organisms involved, etc.
Clinical Manifestations
Signs and symptoms
Labs and imaging

4. Hip Disease in Pediatrics

5. Developmental Dysplasia of the Hip
Spectrum of disease
Acetabular dysplasia
Hip subluxation
Hip dislocation
Typical vs tetralogic DDH
Typical: occurs in otherwise normal patients
Tetralogic: identifiable causes such as arthrogryposis or genetic syndrome

6. Developmental Dysplasia of the Hip
Some degree of hip instability in 1/100 to 1/250 births
Actual dislocated or dislocatable hips are much less common
Found in 1-1.5/1000 live births
Higher incidence in Native American and Eastern European cultures
vs Asian or African cultures
Environmental factors

7. Developmental Dysplasia of the Hip
Caused by increased laxity of the hip capsule, doesn’t maintain a stable femoroacetabular articulation
Increased laxity due to:
Physiologic: family history of joint laxity, maternal estrogens/hormones, M:F ratio of 1:9**
Mechanical: primigravida, breech presentation**, oligohydraminos, postnatal positioning

8. Developmental Dysplasia of the Hip
Clinical findings in the Neonate:
asymptomatic
requires screening with specific maneuvers
Barlow – action is dislocating an unstable hip
Ortolani – action is returning a dislocated femoral head back into the acetabulum  “CLUNK”

9. Developmental Dysplasia of the Hip

10. Developmental Dysplasia of the Hip
Clinical findings in the Infant:
Limited hip abduction
Apparent shortening of the thigh
Galeazzi sign
Proximal location of the greater trochanter
Asymmetry of the gluteal or thigh folds
Asymmetry of the hip

11. Developmental Dysplasia of the Hip
Galeazzi sign

12. Developmental Dysplasia of the Hip

13. Developmental Dysplasia of the Hip
Clinical findings in the Walking Child:
Limp
Waddling gait
Leg-length discrepancy
Affected side is shorter
Excessive lordosis

14. Developmental Dysplasia of the Hip
Diagnostic testing
Ultrasound**
Diagnostic test of choice prior to the appearance of the femoral head ossific nucleus ~ 4-6 months
High incidence of false positive from age 0-4 weeks
Provides dynamic information about stability of hip
Role of screening ultrasound

16. Developmental Dysplasia of the Hip
Diagnostic testing
X-rays
Recommended once the proximal femoral epiphysis ossifies ~ usually by 4-6 months
Lots of lines and angles and things to determine how asymmetric the hips are

17. Radiograph of a patient presenting at age 8 months with DDH
Radiograph of a patient presenting at age 8 months with DDH. The left hip is dislocated.
Radiograph of a patient presenting at age 8 months with DDH. The left hip is dislocated. Drawing a Hilgenreiner line (black) through the triradiate cartilage (black arrow) of both hips, and a Perkins line (white) perpendicular to the Hilgenreiner line at the lateral edge of the acetabulum, creates four quadrants. The medial metaphysis (white arrow) of the femur should sit within the inferomedial quadrant, as it does on the right. The position in the inferolateral quadrant on the left is consistent with dislocation. In addition, a Shenton line, drawn along the inferior edge of the femoral neck and pubic ramus, should form a contiguous arc, as on the right, but is disrupted on the left.
Nemeth B A , and Narotam V Pediatrics in Review 2012;33:
©2012 by American Academy of Pediatrics

18. Developmental Dysplasia of the Hip
Treatment
Newborn to <6 months:
Pavlik
harness

19. Developmental Dysplasia of the Hip
Treatment
6 months to 2 years:
Closed reduction
Spica cast x 12 weeks
>2 years:
Open reduction
Post-surgery spica
cast x 6-12 weeks
May require other surgical
repairs to pelvis

20. Developmental Dysplasia of the Hip
Complications
Avascular necrosis of the femoral epiphysis
Most vulnerable to damage to epiphyseal vessels before 4-6 months
Revascularization will follow but if the physis is severely damaged, can result in abnormal growth
With appropriate treatment, incidence of avascular necrosis for DDH is reduced to 5-15%

21. Legg-Calve-Perthes Disease
Idiopathic avascular necrosis of the femoral epiphysis
Overall incidence in the US ~ 1/1,200
Male:Female ratio
of 4-5:1**
Peak incidence
between 4-8 yrs old**
Bilateral involvement
in ~10%, but at
different stages

22. Legg-Calve-Perthes Disease
Temporary interruption of blood supply to the proximal femoral epiphysis
Leads to osteonecrosis
and femoral head
deformity after repair
process
Often damages the
proximal femoral physis
leading to a short neck
and trochantric
overgrowth

23. Legg-Calve-Perthes Disease
Clinical presentation
Most common presenting symptom is a LIMP**
Pain not always present
Activity related
Localized in the groin or referred to anteromedial thigh or knee region
Less commonly, onset may be acute and presents with failure to ambulate
Limited hip internal rotation and abduction
Atrophy from disuse (due to pain)
Leg-length discrepancy

24. Diagnosis
X-rays

25. Legg-Calve-Perthes Disease
Treatment
Goal: containment of the fragmented head in the acetabulum
Conservative – Petrie Abduction cast; Scottish Rite brace
Surgery

26. Slipped Capital Femoral Epiphysis
Most commonly affects adolescents
Age 11-16
Annual incidence 2/100,000
Higher in Polynesian and African-Americans
Obesity
~65% of patients are >90th percentile for weight
M > F
Left > right

27. Slipped Capital Femoral Epiphysis
Failure of the physis and displacement of the femoral head relative to the neck
Caused by combination of endocrine factors (circulating hormones) and mechanical factors (increased forces and mechanical load)

28. Slipped Capital Femoral Epiphysis
Classifications
Acute (< 3weeks) vs Chronic (several months)
Stable vs Unstable (unable to walk with or without crutches)
Degree of displacement: mild, moderate, severe

29. Slipped Capital Femoral Epiphysis
Clinical presentation**
Classically, an obese, African-American boy between the ages of 11 to 16 years
Girls present between 10 to 14 years
Some degree of limp
Complaints of groin pain, or referred thigh or knee pain (along the obturator nerve)
On exam, restriction of internal rotation, abduction, and flexion
Unstable SCFE presents more urgently

30. Slipped Capital Femoral Epiphysis
Diagnosis
X-rays
Kline’s line
Bilateral imaging!

31. Slipped Capital Femoral Epiphysis
Treatment
Once diagnosed, should be admitted and placed on bedrest
In situ pinning of the SCFE

32. Slipped Capital Femoral Epiphysis
Debate regarding prophylactic pinning of opposite hip
~20-40% of children will develop contralateral SCFE
Complications
Osteonecrosis
Chondrolysis

33. Noon Conference Today!