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Common Pediatric Hip Problem. Prepared by Pediatric Orthopedic gruop Surgeons KKUH. Common Pediatric Hip problems. DDH SCFE Perthe ’ s. DDH. Nomenclature. CDH : Congenital Dislocation of the Hip DDH : Developmental Dysplasia of the Hip. Pediatric Hips Dislocation. Types:
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Common Pediatric Hip Problem Prepared by Pediatric Orthopedic gruop Surgeons KKUH
Common Pediatric Hip problems • DDH • SCFE • Perthe’s
Nomenclature • CDH : Congenital Dislocation of the Hip • DDH : Developmental Dysplasia of the Hip
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
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
Normal pelvis adult child ADULT CHILD
Patterns of disease • Dislocated • Dislocatable • Sublaxated • Acetabular dysplasia
Causes (multi factorial) Unknown • Hormonal • Relaxin, oxytocin • Familial • Lig.laxity diseases • Genetics • F 4-6x > M • Twins 40% • Mechanical • Pre natal • Post natal
Mechanical Causes • Pre natal • Breach , oligohydrominus , primigravida , twins (torticollis , metatarsus adductus ) • Post natal • Swaddling , strapping
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)
DDH • When risk factors are present the infant should be reviewed: • Clinically • Radiologically
Examination • The infant should be • Quiet • Comfortable
DDH • Look: • External rotation • Lateralized contour • Shortening • Asymmetrical skin folds • Anterior – posterior
DDH • Move • Limited abduction
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)
DDH- Investigations • 3w -3m U/S • > 3months X-ray pelvis (AP + abduction)
DDH • The pathology is of 2 componants: • Femoral head position. • Acetabular development.
Normal hip Dislocated hip Femoral Head Position
Normal hip Dislocated hip Acetabular Development
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
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
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
Treatment • Birth – 6m • In OPD: reduce + maintain with Pavlik harness or hip spica (H.S) • 6-12 m: • GA + closed (? Open) reduction + maintain with H.S • 12 - 18 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
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
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
Hip Arthrogram Guided Reduction Dislocate view Reduced view
Example: Open reduction & Acetabuloplasty & Femoral Shortening
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
SCFE • Slipped Capital Femoral Epiphysis • At the level of physis • Its considered as Salter-Harris fracture, type-1 • So it is an emergency
SCFE- Top View Anterior slippage
SCFE • Types: • 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
SCFE • Causes: • Hormonal hypothyroid, abnormal G.H, hypogonadisum • Metabolic Chronic renal failure • Mechanical (obesity) • Trauma • Unknown
SCFE • Typically: • 8 – 12y old • Male • Obese • Black • 20 - 25 % to affect the other hip, within 18m post affection
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
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