Common Pediatric Hip Problems: Diagnosis and Treatment Guidelines

1. Common Pediatric Hip Problem Dr.Kholoud Al-Zain Assistant Professor Consultant, Pediatric Orthopedic Surgeon Dec 2016 Acknowledgement: Dr.Abdalmonem Alsiddiky Dr.Khalid Bakarman Prof. M. Zamzam

2. Common Pediatric Hip problems • DDH • SCFE • Perth'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 Femoral head ossific nucleus Growth plates

8. Normal hip Dislocated hip DDH

9. DDH • The pathology is of 2 components: • Femoral head position • Acetabular development

10. Normal hip Dislocated hip 1) Femoral Head Position Superior displacement Femoral head lateralization

11. Normal hip Dislocated hip 2) Acetabular Development Acetabular dysplasia

12. Patterns of Disease • Dislocated • Dislocatable • Subluxate • Acetabular dysplasia (A.D)

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

14. Mechanical Causes • Pre-natal: • Breach • Oligohydrominus • Primigravida • Twins • Post-natal  swaddling , strapping

16. Infants at Risk • Parents who are relatives (consanguinity) • Positive family history: 10X • 1st child • Breach presentation: 5-10 X • Oligohydrominus • Twins: 40% • A baby girl: 4-6 X • Torticollis: CDH in 10-20% of cases • Foot deformities: • Calcaneo-valgus • Metatarsus adductus • Knee deformities: • hyperextension and dislocation

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

18. Examination • The infant should be: • Quiet • Comfortable

19. DDH • Look: • External rotation • Lateralized contour • Shortening • Asymmetrical skin folds • Anterior • Posterior

20. Asymmetrical Creases

21. DDH • Move • Limited abduction

22. 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)

23. DDH- Giliazi test

24. Limb Length Inequality • Clinical measures of discrepancy: • Measuring tape • Giliazi test

25. DDH- Ortolani test

26. DDH- Barlow test

27. DDH- Barlow &Ortolani tests

28. DDH- Hamstring Stretch Test

29. DDH- Trendelenburg Test

30. DDH- Trendelenburg Test

31. DDH- Investigations • 3w -3m  U/S • > 3months  XR pelvis (AP + abduction) • > 5-6m: • More reliable • Is when ossification centers normally appears • If delayed or did not appear it’s one of the signs of DDH

32. DDH- Radiology Acetabular Index Perpendicular Line Horizontal Line Shenton's Line

33. 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 • Parents education about inheritance That is why: Refer to pediatric orthopedic surgeon

34. 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

35. 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

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

37. Abduction splint • It’s a rigid splint • This is to: • Maintain the reduction, • And wait for improvement of the acetabular cover to be: • A.I < 30° • & with concavity

38. Normal Hip Arthrogram Acetabular cartilage Concentrically reduced femoral head

39. Hip Arthrogram Guided Reduction Dislocate view Reduced view

40. Hip Spica

41. Broom-Stick Cast

42. Open reduction & Acetabuloplasty

43. Open reduction & Acetabuloplasty & Femoral Shortening

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

45. SCFE

46. SCFE • Slipped Capital Femoral Epiphysis • At the level of  physis • As if it is a  Salter-Harris fracture, type-1 • So it is an emergency

48. SCFE- Top View Anterior slippage

49. 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 some weight (walk) • When it’s acute or unstable  urgent surgery

50. SCFE • Causes (multifactorial): • Unknown • Hormonal: • Hypothyroid • Abnormal G.H • Hypogonadisum • Metabolic  Chronic renal failure • Mechanical (obesity) • Trauma