1. Common Pediatric Hip Problem
Prepared by
Pediatric Orthopedic gruop Surgeons
KKUH

2. Common Pediatric Hip problems
DDH
SCFE
Perthe’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
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
Normal hip Dislocated hip

13. Patterns of disease Dislocated Dislocatable Sublaxated
Acetabular dysplasia

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

16. Mechanical Causes Pre natal Post natal
Breach , oligohydrominus , primigravida , twins
(torticollis , metatarsus adductus )
Post natal
Swaddling , strapping

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

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

20. Examination
The infant should be
Quiet
Comfortable

21. DDH Look: External rotation Lateralized contour Shortening
Asymmetrical skin folds
Anterior – posterior

23. DDH
Move
Limited abduction

24. 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)

25. DDH- Giliazi test

26. DDH- Ortolani test

27. DDH- Barlow test

28. DDH- Hamstring Stretch Test

29. DDH- Trendelenburg Test

30. DDH- Investigations 3w -3m U/S
> 3months X-ray pelvis (AP + abduction)

31. Radiology
After 6 months: reliable

32. DDH The pathology is of 2 componants: Femoral head position.
Acetabular development.

33. Femoral Head Position
Normal hip Dislocated hip

34. Acetabular Development
Normal hip Dislocated hip

35. Radiology
After 6 months: reliable

36. DDH- Radiology
> 6m: reliable & ossification center normally appears (5-6m) of age, if delayed or did not appear it’s one of the signs of DDH

37. 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

38. 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

39. 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

40. Pavlik Harness
Maximum to start it is  6m of age, if older use other method
Is kept on for 6w continuous, then use a rigid abduction splint
This is to achieve stable reduction
It’s a dynamic splint

41. Abduction splint It’s a rigid splint
This is to maintain the reduction & wait for improvement of the acetabular cover to be < 30° & with concavity

42. Normal Hip Arthrogram

43. Hip Arthrogram Guided Reduction
Dislocate view
Reduced view

45. Hip Spica

46. Broom-Stick Cast

48. Example: Open reduction & Acetabuloplasty

49. Example: Open reduction & Acetabuloplasty & Femoral Shortening

50. DDH Late complications if not treated: Severe pain (hip area, back)
Early hip arthritis
LLD (leg length discrepancy)
Pelvic inequality (tilt)
Early Lumbar spine degeneration

51. SCFE

52. SCFE

53. SCFE Slipped Capital Femoral Epiphysis At the level of  physis
Its considered as  Salter-Harris fracture, type-1
So it is an emergency

55. SCFE- Top View
Anterior slippage

56. SCFE Types: When its 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 weight (walk)
When its acute or unstable  urgent surgery

57. SCFE Causes: Hormonal  hypothyroid, abnormal G.H, hypogonadisum
Metabolic  Chronic renal failure
Mechanical (obesity)
Trauma
Unknown

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

59. SCFE
Typically:
8 – 12y old
Male
Obese
Black
% to affect the other hip, within 18m post affection

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

61. 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

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

63. 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

64. SCFE

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

66. 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

67. 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

68. SCFE- XR AP

69. SCFE- XR Frog Lateral

70. SCFE- Chronic

71. SCFE- Kline’s Line

72. SCFE- Kline’s Line

73. SCFE

75. SCFE- Example 1

76. SCFE- Example 2

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

78. SCFE- Severity

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

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

81. SCFE

82. SCFE

83. 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

84. SCFE

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

86. SCFE- Chondrolysis

87. SCFE- Chondrolysis

88. SCFE- AVN

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

91. Legg-Calve-Perth’s Disease (LCP)

92. Perthe’s Disease:

93. 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.

94. Perth’s Disease

95. Legg-Calve-Perth’s Disease

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

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

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

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

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

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

102. Perth’s Disease
At 3y of age 5y 7y 9y

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

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

105. Perth’s Disease Examination: Antalgic 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)

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

108. 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

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

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

111. Perth’s Disease XR changes

112. Perth’s Disease

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

114. 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

115. 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

116. Perth’s Disease

117. Perth’s Disease

118. Perth’s Disease

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

120. Perth’s Disease Complications: Abduction hinge  may need Chelectomy
Heals in coxa  magna (big), brevia (short), plana (wide)
Stiff hip joint
LLI (leg length inequality)
Pelvic obliquity
Early hip OA
Early Lumbar spine degeneration

121. Perth’s Disease Abduction Hinge

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

123. Remember

124. Common Pediatric Hip problems:
DDH
SCFE
Perthe’s

125. thanks