Childhood hip conditions. Belen Carsi Paediatric Orthopaedic Consultant
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1 Childhood hip conditions Belen Carsi Paediatric Orthopaedic Consultant
2 Developmental Dysplasia of the Hip Legg-Calve-Perthes disease Slipped Capital femoral epiphysis Limp Arthritis
3 Developmental Dysplasia of the Hip 1-4 years
4 Legg-Calve-Perthes disease 4-10 years
5 Slipped Upper Femoral Epiphysis >10 years
6 Developmental Dysplasia of the Hip (DDH) Congenital Dysplasia of the Hip (CDH)
7 Definition Dislocation of the hip joint capsular laxity mechanical factors
8 DDH Spectrum disorder Complete dislocation Subluxation Instability Acetabular dysplasia Early : birth or neonatal Late : usually with a dislocated hip, >6mths age
9 Incidence 5-20/1000 Live births Most stabilize spontaneously by 3/52 True figure is 1-2/1000 About 1:5 are bilateral
10 Risk Factors Breech positioning Positive family history Female sex First born child Left hip (67%)
11 Developmental contributing factors
12 NIPE Guidelines: Screening for DDH All babies should be checked at birth Any with positive signs should be referred for ultrasound (2 weeks) Any with positive risk factors should be referred for ultrasound (6-8 weeks) The aim is to diagnose every case soon after birth
13 Diagnosis: Clinical Exam Barlow Ortolani
14 Other diagnostic signs Limited abduction May be symmetrical on bilateral cases! Galeazzi s sign Foreshortening of femur on affected side
15 Diagnosis: Clinical Exam
16 USS Femoral head Abductors Ilium
17 USS Femoral head Abductors Ilium
18 USS
19 Radiology: Not before 6 months Perkins Line Acetabular index Hilgenreiner Line Shenton Line U tear-drop
20 Pavlik harness Management: Infants Week 1-6 : 24h/day Week 6-10: 23h/day Week 12 : 22h/day Week : Worn at night only
21 Management: Pavlik Harness Monitoring is essential Complications avoidable Femoral nerve palsy (hyperflexion) AVN (hyperabduction) Posterior dysplasia (too long in harness without reduction) If hip not reduced in 2-3 weeks discontinue and go to open/closed reduction
22 If splint fails: 4-12 months Failed conservative treatment or late presentation Closed vs Open reduction in theatre under G/A
23 Arthrogram Obstacles to reduction Extraarticular Tight iliopsoas Intraarticular Labrum Ligamentum teres Transverse ligament Pulvinar Hourglass capsule
24 Arthrogram Concentric Eccentric
25 Closed reduction and adductor tenotomy
26 Medial open reduction
27 Treatment after surgery Reduction maintained in spica cast 100/60. Cast in place for 3 months
28
29 Treatment after 1 year Anterior open reduction: Smith-Petersen
30 Treatment Incomplete Periacetabular Acetabuloplasty
31 Management: After 2 years Closed reduction not possible or wise Anterior open reduction + femoral shortening + pelvic osteotomy
32 Management: After 2 years Indication for surgical treatment Unilateral dislocation Up to age 8, subtracting one year per procedure already done Bilateral dislocation Age 6
33 Legg-Calve-Perthes disease Perthes disease
34 Definition Temporary osteonecrosis of the femoral head of unknown origin that can lead to permanent deformity
35 Epidemiology Incidence 500 new cases per year/uk Most commonly between 4-7 years (2-15) 4 : 1 Bilateral 10-12% No evidence of inheritance
36 Pathogenesis
37 Stages Necrosis Fragmentation Reossification Healed
38 Stulberg classification
39 Treatment: Arthrogram
40
41
42
43
44 Slipped Upper femoral epiphysis >10 years
45 Slipped Upper Femoral Epiphysis Disorder of the proximal femoral physis that leads to slippage of the neck with respect to the head
46 Epidemiology Males more affected Obesity Bilateral in 20-50% cases Common in endocrine disorders (renal, hypothyroidism)
47 Classification Degree of slip: Mild, moderate or severe By duration of symptoms: acute, acute on chronic, chronic By stability: stable or unstable
48 Treatment Pinning in situ Surgical dislocation
49
50
51 Surgical dislocation
52
53 AVN: 50% in severe slips Risks
54
55 Conclusions Children with hip disorders do better if diagnosed early Better treated in a specialist unit
56 Thank you!
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