Common Pediatric Hip Problems: Causes, Diagnosis & Treatment

1. Common Pediatric Hip Problem Dr.Kholoud Al-Zain Assistant Professor Consultant, Pediatric Orthopedic Surgeon Dec 2017 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 (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. Patterns of Disease • Acetabular dysplasia (A.D) • Subluxated • Dislocated

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

11. Infants at Risk • Parents who are relatives (consanguinity) • Positive family history: 10X • Pre-natal: • 1st child • Baby girl: 4-6 X • Breach presentation: 5-10 X • Oligohydrominus • Twins: 40% • Torticollis: CDH in 10-20% pt • Foot deformities: • Calcaneo-valgus • Metatarsus adductus • Knee deformities: • hyperextension and dislocation • Post-natal: • Swaddling, strapping

13. DDH • When risk factors are present infant should be reviewed: • Clinically • Radiologically

14. DDH • Look: • Shortening • External rotation • Lateralized contour

15. DDH • Look: • Asymmetrical skin folds • Anterior • Posterior

16. DDH • Look: • Lumber lordosis

17. DDH • Move • Limited abduction

18. 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)

19. DDH- Giliazi test

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

21. DDH- Ortolani test

22. DDH- Barlow test

23. DDH- Barlow &Ortolani tests

24. DDH- Hamstring Stretch Test

25. DDH- Trendelenburg Test

26. DDH- Trendelenburg Test, Rt side positive

27. DDH- Investigations • 3w - 3m  U/S • > 5-6 months  XR pelvis (AP + abduction) • Is when ossification centers normally appears (delayed & small in DDH) • More reliable

28. DDH- Radiology • The pathology is of 2 components: • Femoral head position • Acetabular development

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

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

31. DDH- Radiological Lines Acetabular Index Horizontal Line Perpendicular Line Shenton's Line

32. Von Rosen View DDH- Radiological Lines Von Rosen 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 • Refer to pediatric orthopedic immediately • Parents education about inheritance

34. DDH- Treatment • Method depends on age • The earlier started: • Its easier • Treatment is mainly non-operative • Better the results (higher remodeling potential)

35. DDH- Treatment • Conservative: • Pavlik harness • Spica cast • Broom-stick cast • Minimally invasive: • Arthrogram guided closed reduction • Operative: • Open reduction • Acetabuloplasty • Femoral shorting • Salvage pelvic osteotomy

36. Pavlik Harness • Maximum to start it is  6m of age, if older use other method • This is to maintain the stable concentric 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. Treatment • Birth – 6m • In OPD: reduce + maintain with Pavlik harness 6w, then abduction splint • In OPD if unreducible: treat as 6-12m • 6-12 m: • GA + arthrogram closed (? open) reduction + H.S 6w, then B.S for months • 12 - 18 m: • GA + open reduction + H.S 6w, then B.S cast for months • 18 – 24 m: • GA + open reduction + acetabuloplasty + H.S 6w, B.S 6w • 2-8 years: • GA + open reduction + acetabuloplasty + femoral shortening + H.S 6w, B.S 6w • Above 8 years: • GA +open reduction + acetabuloplasty (advanced) + femoral shortening N.B: H.S (hip spica), B.S (broom-stick)

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

46. SCFE

47. 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 • 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

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

50. SCFE • Typically: • (8 – 12y) old • Male • Obese • Dark skinned • 20 - 25 % chance  other hip affection, within 18m