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Common Pediatric Hip Problem

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

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  1. Common Pediatric Hip Problem Prepared by Pediatric Orthopedic gruop Surgeons KKUH

  2. Common Pediatric Hip problems • DDH • SCFE • Perthe’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 ADULT CHILD

  8. Normal hip Dislocated hip DDH

  9. Patterns of disease • Dislocated • Dislocatable • Sublaxated • Acetabular dysplasia

  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. Mechanical Causes • Pre natal • Breach , oligohydrominus , primigravida , twins (torticollis , metatarsus adductus ) • Post natal • Swaddling , strapping

  12. 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)

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

  14. Examination • The infant should be • Quiet • Comfortable

  15. DDH • Look: • External rotation • Lateralized contour • Shortening • Asymmetrical skin folds • Anterior – posterior

  16. DDH • Move • Limited abduction

  17. 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)

  18. DDH- Giliazi test

  19. DDH- Ortolani test

  20. DDH- Barlow test

  21. DDH- Hamstring Stretch Test

  22. DDH- Trendelenburg Test

  23. DDH- Investigations • 3w -3m U/S • > 3months X-ray pelvis (AP + abduction)

  24. DDH • The pathology is of 2 componants: • Femoral head position. • Acetabular development.

  25. Normal hip Dislocated hip Femoral Head Position

  26. Normal hip Dislocated hip Acetabular Development

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. Normal Hip Arthrogram

  34. Hip Arthrogram Guided Reduction Dislocate view Reduced view

  35. Hip Spica

  36. Broom-Stick Cast

  37. Example: Open reduction & Acetabuloplasty

  38. Example: Open reduction & Acetabuloplasty & Femoral Shortening

  39. 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

  40. SCFE

  41. SCFE • Slipped Capital Femoral Epiphysis • At the level of  physis • Its considered as  Salter-Harris fracture, type-1 • So it is an emergency

  42. SCFE- Top View Anterior slippage

  43. 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

  44. SCFE • Causes: • Hormonal  hypothyroid, abnormal G.H, hypogonadisum • Metabolic  Chronic renal failure • Mechanical (obesity) • Trauma • Unknown

  45. SCFE • Typically: • 8 – 12y old • Male • Obese • Black • 20 - 25 % to affect the other hip, within 18m post affection

  46. 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

  47. 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

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