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Pediatric Hip

Steven L. Frick, MD Carolinas Medical Center Charlotte, NC. Pediatric Hip. Pediatric Hip Problems. Common, age related differences in presentation Traction rarely used now as treatment If used, often in-line skin traction (Buck’s) for comfort temporarily

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Pediatric Hip

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  1. Steven L. Frick, MD Carolinas Medical Center Charlotte, NC Pediatric Hip

  2. Pediatric Hip Problems • Common, age related differences in presentation • Traction rarely used now as treatment • If used, often in-line skin traction (Buck’s) for comfort temporarily • Remember to limit weight, watch skin • DDH, LCP, SCFE, trauma

  3. Normal DDH

  4. Developmental Hip DysplasiaDDH- definition • Developmental instead of congenital- more reflective of etiology • Any hip which can be provoked to subluxate (partial contact between femoral head and acetabulum) or dislocate (no contact between femoral head and acetabulum), or any subluxated or dislocated hip that can be reduced

  5. DDH Incidence • Depends on criteria • 2-9/1000 births • 70% female • Left > Right, 20% bilateral • some populations at higher risk

  6. Risk Factors • 1st born • Female • Breech • + family history • Torticollis, MTA – some debate • Some populations- swaddling

  7. Barlow positive

  8. Ortolani positive

  9. Treatment Goals • Obtain and maintain reduction to provide optimal environment for hip development • Potential for remodeling/development present for many years • Intervene to alter otherwise unfavorable natural history • AVOID ischemic necrosis

  10. Treatment: Newborn - 6 mo. CR => Pavlik harness • Arnold Pavlik, MD 1945 • “functional” treatment • 531/632 dislocated hips reduced with no AVN

  11. Pavlik Harness Mubarak et al. – JBJS 1981- Pitfalls

  12. Success-Pavlik Harness • Dislocated- 85% • Dislocatable- 95-100% • Residual Dysplasia- may have acetabular dysplasia in up to 15% after successful reduction/stabilization

  13. “Failed Pavlik” Hip • Arthrogram • closed vs. open reduction • spica cast 6-12 weeks • Can try rigid abduction bracing- about 50% of Pavlik failures will dock and stabilize

  14. Plastizote abduction brace for failed Pavlik harness reduction • >50% success at reduction • Boston Children’s series 13/15 success

  15. Ultrasound • Static angles (Graf)‏ • % fem head coverage (Morin – 58% normal)‏ • Dynamic stability (Harcke)‏

  16. Ultrasound - DynamicHarcke Evaluate stability, real time, no radiation, document success/failure of reduction, easy to perform in harness

  17. Ultrasound Disadvantages • Only < 9mos (ossific nucleus)‏ • Expense • Technique/expertise dependent • not good at quantifying dysplasia • May lead to overtreatment (stable hips dysplastic by US become normal)

  18. Pavlik Success

  19. Newborn male B dislocated hips • Pavlik for 4 weeks • Ultrasound to document reduction

  20. Closed Reduction – age 6 to 18 mos

  21. Keep Hip in Socket while... Avoiding AVN is goal

  22. Ogden’s anatomic dissections

  23. Ogden’s anatomic dissections

  24. To assess closed reduction after spica cast : Check CT scan or MRI scan

  25. Repeat arthrogram 6 weeks after closed reduction- normal

  26. Open Reduction • For failure to achieve acceptable closed reduction, late presentation (>18 mos) • Anterior (capsulorrhaphy) or anteromedial (remove obstacles, no capsulorrhaphy)‏ • Higher % ON (mild) with anteromedial approach

  27. Radiographs in DDH

  28. X-Rays

  29. Follow until skeletal maturity • Make sure acetabulum develops properly • Goal = normal motion and normal radiograph at maturity • radiographic assessment 6-12 mo intervals, then 2-3 year intervals • acetabular index, lateralization ratio, teardrop, subluxation, femoral head ossification

  30. 42 months 21 months 38 years 24 years Courtesy of S. Weinstein, MD Univ. of Iowa

  31. Persistent Acetabular Dysplasia • Scoles – normal values for AI- 20 deg by 2 yrs • Lindseth/Ponseti/Wenger – acetabular development may proceed up to age 8 after CR • Lalonde/Frick/Wenger – residual hip dysplasia treated < age 8 more normal radiographic anatomy • AI>35 2 yrs post CR- 80% Severin III or IV

  32. Subluxation • Those with subluxation more symptomatic • Usually symptomatic by mid 30’s for women

  33. Salter Pelvic Osteo-tomy • Redirects acetabulum to give more coverage to femoral head

  34. Peri-acetabular osteotommiesDega, Pemberton, Tonnis, Albee

  35. Exam - Older Infant > 3 Months • Limited abduction • Asymmetric thigh folds • Galeazzi or Allis sign- short femoral segment with hip and knee flexed

  36. Limited Abduction Galeazzi sign

  37. 4 yr old missed bilat DDH Waddling gait Lumbar lordosis Trendelenberg

  38. DDH Older child • Treatment principles the same • reduce hip without excessive pressure • operative treatment • shorten femur – traction out of favor • femoral and pelvic osteotomies • older, bilateral - ? No treatment • Unilateral – up to age 10, bilateral age 6

  39. 4 yo late dx DDH

  40. No femoral shortening - AVN

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