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Approach to limping child

  1. 1. Approach to limping child
  2. 2. Case Scenario • A 14 month old boy is brought to the office because the parents noticed a limp this morning when the child got out of bed…
  3. 3. Pathophysiology • Three major factors cause a child to limp: pain, weakness, and structural or mechanical abnormalities of the spine, pelvis, and lower extremities (Clark, 1997; deBoeck & Vorlat, 2003; Lawrence, 1998). • A normal gait is composed of symmetrical, alternating, rhythmical motions involving two phases: stance and swing. The stance phase normally encompasses 60% of the gait cycle. The type of gait may be helpful in identifying the etiology of the limp
  4. 4. Some Abnormal Gaits • An antalgic gait results from pain in one extremity that causes the patient to shorten the stance phase on that side with a resultant increase in the swing phase. The most common causes of an antalgic gait are trauma or infection • A Trendelenburg gait is a downward pelvic tilt away from the affected hip during the swing phase as a result of weakness of the contralateral gluteus medius muscle .The gait disturbance is commonly observed in children with developmental dysplasia of the hip, Legg-Calves-Perthes disease, or slipped capital femoral epiphysis. If the involvement is bilateral, a waddling gait results • A steppage (equinus) gait is a result of the inability to actively dorsiflex the foot, with exaggerated hip and knee flexion during the swing phase. A steppage gait is seen in children with neuromuscular diseases (eg, cerebral palsy) that cause impairment of dorsiflexion of the ankle. • A vaulting gait occurs when the knee is hyperextended and locked at the end of the stance phase and the child vaults over the extremity .A vaulting gait is seen in children with limb length discrepancy or abnormal knee mobility. • A stooped gait is characterized by walking with bilaterally increased hip flexion A stooped gait is common in children with pelvic or lower abdominal pain.
  5. 5. Differential Diagnosis Age 1-3yr Painful limp 1- Infection Septic arthritis / osteomyelitis/ cellulitis / transient synovitis 2- Trauma 3- Primary or metastatic neoplasm Painless limp 1- Developmental dyplasia of the hip 2- Neuromuscular disease -Cerebral palsy -Muscular dystrophy 3- lower limb length discrepancy
  6. 6. Differential Diagnosis Age Painful limp 4 - 10yr 1-Infection 2- inflammatory JRA, SLE 3- Trauma 4- Primary or metastatic tumor 5- hematological disease Hemophilia, leukemia 6-Legg-Calve-Perthes Disease (AVN of femoral head) Painless limp 1-Developmental dyplasia of the hip 2- Neuromuscular disease: Cerebral palsy Muscular dystrophy 3- Lower limb length discrepancy
  7. 7. Differential Diagnosis Age Painful limp 11- 18yr 1-Infection 2- inflammatory :JRA, SLE 3- Trauma 4-Primary or metastatic tumor 5-hematological disease Hemophilia, leukemia 6-Legg-Calve-Perthes Disease (AVN of femoral head) 7-acute slipped upper femoral epiphysis* Painless limp 1- Developmental dyplasia of the hip 2- Neuromuscular disease Cerebral palsy Muscular dystrophy 3- lower limb length discrepancy 4- chronic slipped upper femoral epiphysis *very tall and/or obese. Limp and pain in the hip. Leg is held in an extemal rotation position. Often painful on internal rotation of the hip. Association with hypothyroidism
  8. 8. Approach • • • • History Examination Investigation Management
  9. 9. History • • • • • • • Age Sex Onset Painful or painless? ( analysis…) Acute or chronic History of trauma Association : Night pain (ALL), arthralgia, swelling, morning stiffness(JRA), backache (malignancy or rheumatologic disease)
  10. 10. History • Systemic review – Recent illness : URTI – Weight loss, anorexia – Fever, chills – Unexplained rash (SLE) or bruising (haematology ds) – Voiding problem (neuromuscular ds)
  11. 11. Examination • • • • • General inspection + Gait Vital signs & anthropometric measurements Musculoskeletal examination +Back exam Neurological examination Evaluate leg lengths- anterior iliac spine to medial mallelous
  12. 12. Investigations • • • • • • FBC ESR, CRP TRO Infection Blood culture Coagulation profile TRO Haematological Peripheral Blood Film disorder Immunological : RF, ANA TRO Rheumatological disorder
  13. 13. Investigations • Imaging studies – Plain x ray – U/S – CT – MRI – Radionuclide studies – Bone scan
  14. 14. Investigations • Synovial fluid aspiration normal traumatic JRA Septic Arthritis appearance Clear to yellow Bloody to straw colored Cloudy yellow Purulent WBC <200 <5,000 5,000- 80,000 50,000200,000 Polymorphs <25% <25% 50-75% 75-100% other High RBC count Bacterial culture positive Low glucose High protien
  15. 15. CASE SCENARIO 21 months old Malay Boy - NKMI - p/w refuse to bear weight using right LL x 2/7 - previously can walk since 1 y.o. and can run and suddenly refuse standing on right LL - right knee joint not warm or swollen - no h/o fall / trauma before - Afebrile , No URTI sx
  16. 16. PMH/PSHx: nil FHx: no chronic illness running in family Developmental : able to walk at 1 y.o. speak 2-3 words with meaning
  17. 17. O/E: Alert , playing with toys Right hip joint: - well flexed, abducted, externally rotated - No skin changes, no bruises seen - not warm , not swollen Right knee joint : - Able to flex , not warm or swollen, non-tender Right ankle joint: - Able to move , not warm or swollen . Non-tender IMP : transient synovitis of right hip joint
  18. 18. Ix • ESR not elevated • CRP not elevated • USG hip Joint: - no psoas abscess seen bilaterally - no hip effusion seen bilaterally
  19. 19. Transient synovitis (irritable hip) -Transient synovitis is the most common cause of acute hip pain in children aged 3-10 years. -The disease causes arthralgia and arthritis secondary to a transient inflammation of the synovium of the hip. -affects boys twice as often as girls. - Usually it is a diagnosis of exclusion, once trauma and infection are excluded
  20. 20. Symptoms - Unilateral hip or groin pain is the most common symptom. - Limp. - Recent history of an upper respiratory tract infection in 50% of patients. - Usually afebrile or have a mildly elevated temperature. - Very young children with transient synovitis may have no symptoms other than crying at night.
  21. 21. Signs - Hip kept in flexion with slight abduction and external rotation. - some may have mild restriction of motion, especially to abduction and internal rotation - The hip may be painful with passive movement and tender to palpation. - The most sensitive test for transient synovitis is the log roll, in which the patient lies supine and the examiner gently rolls the involved limb from side to side. This may detect involuntary muscle guarding of one side when compared to the other side.
  22. 22. Causes • No definitive cause of transient synovitis is known, although the following have been suggested: • Patients with transient synovitis often have histories of trauma, which may be a cause or predisposing factor. • One study found an increase in viral antibody titers in 67 of 80 patients with transient synovitis. • Postvaccine or drug-mediated reactions and an allergic disposition have been cited as possible causes.
  23. 23. Differential diagnoses Common • Septic arthritis. • Juvenile idiopathic arthritis. • Juvenile rheumatoid arthritis. • Osteomyelitis. Less common • Avascular necrosis (Perthe’s disease). • Fracture. • Gonococcal arthritis. • Lyme’s arthritis. • Soft tissue injuries. • Tumor or malignancy.
  24. 24. Investigations • Usually to rule out other diagnoses. • WBC, ESR and CRP are usually elevated in septic arthritis. • XRAYS: can exclude bony lesions. • Ultrasound guided aspiration of the effusion.
  25. 25. Sign of effusion : Widening of the joint space. Note that the space is wider on the left side. Discrepancies greater than 1 mm indicate the presence of fluid.
  26. 26. Management • Apply heat and massage . • Advise bedrest for 7-10 days, allowing the patient to rest in a position of comfort. • Advise the patient with transient synovitis not to bear weight on the affected limb. • Advise the patient with transient synovitis to avoid full unrestricted activity until the limp and pain have resolved. • Non-steroidal anti-inflammatory drugs (NSAIDs).
  27. 27. Prognosis • Usually marked improvement within 24-48 hours. • Two thirds to three fourths of patients have complete resolution within 2 weeks. • The remainder may have less severe symptoms for several weeks. • The recurrence rate is 4-17%; most recurrences develop within 6 months.
  28. 28. Complications • 32.1% of patients develop coxa magna : an overgrowth of the femoral head and broadening of the femoral neck. It leads to dysplasia of the acetabular roof and subluxation. • 1-3 % develop perthe’s disease.
  29. 29. SEPTIC ARTHRITIS IN CHILDREN • Septic arthritis in children is monoarticular more than 90% of the time. • Knee and hip joints account for about two thirds of all cases. • Children less than 2 years old are more susceptible to septic arthritis than older children.
  30. 30. • After S. aureus, group B streptococcus and Gramnegative microorganisms are important pathogens in the neonate and young infant. • Candida and Gram-negative bacilli are usually acquired in the hospital or in another health care setting. • Septic arthritis and osteomyelitis can coexist or complicate each other in the very young child because the metaphyseal and epiphyseal blood vessels communicate and the metaphyses of some long bones are within the joint capsule. (eg hip joint)
  31. 31. • Avascular necrosis of the femoral head is unique to septic arthritis of the hip in children. • Early surgical decompression to reduce the high intra-articular pressure will restore blood flow to the femoral head. • Leg length discrepancy, limitation of joint mobility, and secondary degenerative joint disease are late sequelae in 25% of cases.
  32. 32. Septic arthritis - Definition • Hematogenous bacterial infection of the hip, usually • in infants or toddlers, with or without involvement of • the proximal femoral metaphysis. • Synonym: Septic coxitis
  33. 33. • Hip - commonest septic joint • condition during growth, reaching a distinct peak in frequency during infancy. • via hematogenous transmission, resulting in colonization of the joint with bacteria • in infants - occur from propagation of adjacent proximal femoral osteomyelitis
  34. 34. Any OM changes, widening of joint space
  35. 35. • Kocher criteria: (for child with painful hip) - includes: 1) non-weight-bearing on affected side 2) ESR greater than 40 mm/hr 3)Fever 4)WBC count of >12,000 mm3 • when 4/4 criteria are met, there is a 99% chance that the child has septic arthritis • when 3/4 criteria are met, there is a 93% chance of septic arthritis • when 2/4 criteria are met, there is a 40% chance of septic arthritis • when 1/4 criteria are met, there is a 3% chance of septic arthritis
  36. 36. Organisms
  37. 37. • epiphyseal plate prevents infection from entering joint space in older children • but apparently does not act as a barrier in infants • synovial membrane inserting distally to epiphysis, • allowing bacteria to spread directly from the metaphysis to joint space;
  38. 38. • metaphysis of shoulder, hip, radial head, and ankle remain intracapsular during early childhood • the hip joint seems especially prone to sepsis from adjacent osteomyelitis • synovial reflections over the metaphyseal bone decrease with age;
  39. 39. Examination • Limp • pain in groin area that occasionally radiates down the medial side of thigh; - progressive accompanied by spasm of the hip muscles - hip in flexion and external rotation & decreased internal rotation compared to the normal hip - patient resists all attempts to move hip; - palpate the SI joint for local tenderness;
  40. 40. Differential diagnosis • Acute osteomyelitis - tenderness and swelling over the metaphysis • Transient synovitis • Tuberculosis • Acute rheumatic fever • Haemarthrosis
  41. 41. Investigations • Joint fluid aspiration analysis: AFB, Gram stain, C&S, protein, glucose, wcc and crystal. • FBC : leukocytosis • Blood C&S • C-reactive protein • ESR • X-ray • Ultrasound
  42. 42. Investigations Investigations Explaination Full blood count Elevated white blood cell count ESR > 40 mm/hr CRP > 20 mg/dL Blood culture May be positive
  43. 43. Synovial fluid analysis Aseptic technique is used during aspiration of synovial fluid. Avoid taken from infected site of skin. The fluid is then analyzed by gross and microscopic examination and culture. Gross examinations include appearance, volume, viscosity, mucin clotting (amount of proteoglycans). Microscopic examinations include leucocyte count, staining of smears, serum glucose ratio, protein. Finally, culture and sensitivity for definitive diagnosis and treatment.
  44. 44. Suspected condition Appearanc e Viscosity White cells Crystals Biochemistry Normal Clear yellow High Septic arthritis Purulent Tuberculous arthritis Few - As for plasma - Low + - Glucose low + Turbid Low + - Glucose low + Rheumatoid arthritis Cloudy Low ++ - - - Gout Cloudy Normal ++ Urate - - Pseudogout Cloudy Normal + Pyropho sphate - - Osteoarthrit is Clear yellow High Often + - - few Bacteriology
  45. 45. Imaging X ray  Early Stage – Normal Look for soft tissue swelling, loss of tissue planes, widening of joint space  Late stage – Narrowing and irregularity of joint space  Plain film findings of superimposed osteomyelitis may develop (periosteal reaction, bone destruction, sequestrum formation).
  46. 46. Narrowing of joint space and irregularity of subchondral bone. Joint space loss subchondral erosions and sclerosis of the femoral head osteonecrosis and complete collapse of the femoral head
  47. 47. Ultrasonography • More reliable in revealing a joint effusion in early cases. • Widening of space between capsule and bone of > 2mm indicates effusion. • Echo-free  transient synovitis • Positively echogenic  septic arthritis
  48. 48. Treatment General supportive care -Analgesics -IV fluids Splintage - The joint must be rested either on a splint or in a widely split plaster -In neonates and infants, with hip infection the joint is held abducted and 30 degree flexed, on traction to prevent dislocation. Antibiotics Treatment is started once the blood and samples are obtained without waiting for the detail results. Choice of antibiotic depends on the most likely pathogen
  49. 49. Surgical Management  Surgical Drainage (serial needle aspiration + antibiotics)  Arthroscopic debridement and copious irrigation with normal saline (Arthrotomy washout) Indications for Arthrotomy washout • Joint does not respond to serial aspirations • No improvement in 48hrs of tx • Frank pus is aspirated • Loculations noted on MRI or U/S
  50. 50. Complications • Bone destruction and dislocation of the joint (esp Hip) •Cartilage destruction -may lead to either fibrosis or bony ankylosis - secondary osteoarthritis •Growth disturbance - presenting as either localised deformity or shortening of the bone
  51. 51. Legg-Calvé-Perthes disease (LCPD)coxa plana • Legg-Calvé-Perthes disease (LCPD) is the name given to idiopathic osteonecrosis of the capital femoral epiphysis in a child. • • • • • Usually ages 4-8yo As early as 2yo, as late as teens Boys:Girls= 4-5:1 Bilateral 10-12% No evidence of inheritance
  52. 52. Pathogenesis • Up to 4 years Metaphyseal vessels,lateral epiphyseal vessels,scanty vessels from ligamentum teres Between 4-7 years,femoral head depends entirely on the lateral epiphysael vessels. • 7 years old Vessels of ligamentum teres has developed
  53. 53. *Lateral epiphyseal vessels situated in the retinacula makes them susceptible to streching and pressure from an effusion.The precipitating cause is an effusion into the hip joint following: Etiology 1)idiopathic 2) slipped capital femoral epiphysis 3) Trauma 4)steroid use 5)sickle-cell crisis 6)Synovitis 7) congenital dislocation of the hip.
  54. 54. Pathology Takes 2-4 years to complete.Involve 3 stages. Stage 1:bone death Episodes of ischemia leads to part of bony femoral head dies,x-ray looks normal bt it stops enlarging. Stage 2:revascularization and repair New blood vessels enter the necrotic area and new bone is laid down on the dead trabeculae,x-ray-increased in density.If only part of the epiphysis is involved & the repair is rapid bony architecture is completely restored. Stage 3:distortion and remodelling If large part of the bony epiphysis is damaged & the repair process is slow,epiphysis may collapse and growth of the head and neck will be distorted Epiphysis ends up flattened(coxa plana),flat and enlarged(coxa magna) and the femoral head will be incompletely covered by the acetabulum.
  55. 55. Clinical features • Male • 4-8 years old • Hip pain, may be referred to the medial aspect of the ipsilateral knee or to the lateral thigh. • All ROM are limited • The quadriceps muscles and thigh soft tissues may undergo atrophy • the hip may develop adduction flexion contracture • The patient may have an antalgic gait with limited hip motion. • passive range of motion are limited, especially internal rotation and abduction. • Children can have a Trendelenburg gait resulting from pain in the gluteus medius muscle.
  56. 56. Investigation 1)Plain radiograph • hip radiographs, anteroposterior and frog-leg lateral views of the pelvis to establish the diagnosis. • Initial radiographs can be normal, • Early changes-increased density of the bony epiphysis and widening of the joint space. • Late changes-flattening,fragmentation and lateral displacement of the epiphysis with rarefraction at the metaphysis.
  57. 57. Herring classification The Herring classification addresses the integrity of the lateral pillar of the femoral head. • A: there is no loss of height in the lateral one third of the head and there is little density change. • B: there is a lucency and less than 50% loss of lateral height. • C: there is a more than 50% loss of lateral height.
  58. 58. Herring classification Coxa magna Coxa plana
  59. 59. Lateral Pillar Classification • 3 groups: – A) no lateral pillar involvment – B) >50% lat height intact – C) <50% lat height intact
  60. 60. • CT scan: allow early diagnosis of bone collapse and also demonstrate subtle changes in the bone trabecular pattern. • Ultrasonography :preliminary diagnosis of transient synovitis of the hip and the onset of CP.Hip effusion with capsular distension is well depicted on sonographic images. • MRI: allows more precise localization of the femoral head.
  61. 61. Treatment • Skin traction as long as the hip is painful(usually takes 3 weeks) • Further treatment is taken by assessment of the prognostic value: Good prognosis 1)Onset under age 6 2)Partial involvement of femoral head 3)Absence of metaphyseal involvement 4)Normal femoral head shape No active Tx needed Poor prognosis 1)Age over 6 years old 2)Involve the whole femoral head 3)Severe metaphyseal rarefraction 4)Lateral displacement of femoral head containment
  62. 62. • Containment means keeping the femoral head well seated within the acetabulum • Can be achieved by: 1) holding the hips widely abducted in plaster or removable splint.(at least will take a year). 2) Varus osteotomy of the femur or innominate osteotomy of the pelvis.
  63. 63. Osteotomies
  64. 64. Slipped capital femoral epiphysis (SCFE)
  65. 65. INTRODUCTION The capital femoral epiphysis is somewhat unique. It is one of the few epiphyses in the body that is inside the joint capsule. (The joint capsule is the tissue that surrounds the joint.)
  66. 66. SLIPPED CAPITAL FEMORAL EPIPHYSES Slipped upper femoral epiphysis" term refer to slippage of the overlying epiphysis of proximal femur posteriorly and inferiorly due to weakness of the growth plate in relation to metaphysis. Most often, it develops during periods of accelerated growth, shortly after the onset of puberty. The femoral epiphyses maintains its relation with acetabulum ,it’s the femoral neck and shaft upward and anterior movement on epiphyses thus epiphyses displaces relatively posterior
  67. 67. EPIDEMIOLOGY AND RISK FACTORS  Most common in adolescent period with rapid growth plate (boys aged 10-16 y, girls aged 12-14 y).  Obesity is a risk factor because it places more shear forces around the proximal growth plate in the hip at risk.  Bilateral slippage is common of which 2nd slip is about 12-18mths later to 1st (left hip is more common than right).  Etiology: 1. Local trauma 2. obesity 3. Endocrine disorders (e.g primary or secondary hypothyroidism, adiposogenital dystrophy(hypogonadal male), 4. Deficiency or increase of androgens. 5. Growth hormone deficiency  Slipping of the upper femoral epiphysis occurs predominantly in obese children with underdeveloped sexual characteristics and less commonly, in tall, thin children.
  68. 68. CLASSIFICATION • Based on onset of symptoms-acute -chronic -acute on chronic FUNCTIONAL CLASSIFICATION-stable -Unstable MORPHOLOGICAL CLASSIFICATION-mild -moderate -severe
  69. 69. BASED ON SYMPTOMS - SYMPTOMS X-RAY <2WKS displaced epiphyses >2WKS grdual remodelling and no remodelling healing noted ACUTE ON CHRONIC SLIPS-Symptoms lasting longer than 1mth and recent sudden exacerbation pain after trivial trauma
  70. 70. FUNCTIONAL CLASSIFICATIONIt is important to determine ability of the patient to bear weight. According to LODER1. "Stable" SCFEs allow the patient to (walk) with or without crutches (walking aids). 2. "Unstable" SCFEs do not allow the patient to ambulate at all regardles of duration of symptoms; these cases carry a higher rate of complication, particularly of AVN.
  71. 71. MORPHOLOGICAL CLASSIFICATION-Grading Severity of SCFE according to AP and Lateral Xray views PRESLIP-irregularity,widening,and indistinctness of physes Grade-1 Grade-II Grade-III
  72. 72. ANTERIOR AND VALGUS SLIP • the displacement is either superior and posterior (socalled valgus slip)or, even more rarely, anterior. • In valgus slips there is a restriction of adduction as well as of flexion. • In anterior slips there is a limitation of extension and external rotation—exactly the opposite of what is found in typical slips. • X-RAY of valgus slip show -superior or lateral displacement of the capital epiphysis on the femoral neck on the AP projection -posterior displacement on the lateral projection.  Anterior slips may appear little different from typical slips on the AP projection, but the anterior displacement of the capital epiphysis is identified on the lateral projection.
  73. 73. SYMPTOMS 1. Pain : in the groin and around the knee(d/t referred pain from the hip) 2. Limb looked shortened, held in external rotation 3. Flexion, abduction, medial rotation are limited 4. External rotation, adduction are increased. 5.Axis deviation – pathognomonic – when hip is flexed, the limb goes into external rotation
  74. 74. INVESTIGATIONS • • • • • • • • • X-RAYS-AP VIEW-thretowan’s sign[kleins line] -steel metaphysel blanch sign -sham’s sign -capner’s sign -widening of growth plate -decrease of epiphyseal height X-RAY -frog-leg [lowenstein]lateral view CT-SCAN MRI SCAN
  75. 75. A.P. VIEWinferior, And medial translation of epiphyses LATERAL VIIEW-to measure lateral epiphyseal shaft angle, anterior or posterior translation
  76. 76. TRETHOWAN’S SIGN- • In normal hip a line drawn tangential to superior femoral neck[klein’s line] intersects small portion of lateral capital epiphyseal. • In posterior displacement of epiphyses the line doesn’t intersect.
  77. 77. METAPHYSEAL BLANCH SIGN• In AP VIEW-crescent-shaped area of increased density overlying the metaphysis adjacent to the physis • This increased density is due to the overlapping of the femoral neck and the posteriorly displaced capital epiphysis
  78. 78. SHAM’S SIGN In the normal hip the inferiomedial femoral neck overlaps the posterior wall of the acetabulum producing triangular radiographic density • With displacement of capital epiphysis this dense triangle is lost because this portion of the femoral neck is located lateral to the acetabulum.
  79. 79. CAPENERS SIGN- In pelvic AP view in the normal hip, the posterior acetabular margin cuts across the medial corner of the upper femoral metaphysis With slipping, the entire metaphysis is lateral to the posterior acetabular margin
  80. 80. LATERAL VIEW • Very early slips may appear to be normal in AP VIEW but may be clearly noted in lateral view • CHRONIC CASE OF SCFE X-RAY• Reactive bone formation along superolateral aspect of neck • Bone remodelling and broadening of neck resulting in PISTOL GRIP like appearance[hordons hump]
  81. 81. USG-It has been useful in the detection of early slips -joint effusion and a “step” between the femoral neck and the epiphysis created by slipping. • Absolute displacement of 6 mm, >2 mm is diagnostic of a slipped epiphysis. • CT-useful in documenting presence of decreased upper femoral neck anteversion or true retroversion. • it’s more accurate measure head–neck angle. • CT is useful in the management of slips. • First, CT of the hip can be very helpful in demonstrating whether penetration of the hip joint by fixation devices has occurred (Fig. 18-9). • CT is also used to confirm closure of the proximal femoral physis and also when reconstructive osteotomy is being considered. • MRI-useful to assess AVN
  82. 82. COMPLICATIONS 1. Avascular necrosis. 2. Chondrolysis. 3. Secondary Osteoarthritis. 4. Coxa vara (is a deformity of the hip, whereby the angle between the ball and the shaft of the femur is reduced to less than 120 degrees). 5. Slipping of the opposite hip ≈ 20% to 80% of cases
  83. 83. IDEAL TREATMENT •Prevent further slippage •Stimulate early physeal closure •Reduction of epiphyseal displacement •Avoid complications like osteonecrosis , chondrolysis and osteoarthritis •Any child with SCFE and open epiphyses needs treatment ,without stabilisation it progresses. •In a patient with closed physes, the only surgical treatment in the absence of severe degenerative changes is proximal femoral osteotomy. Indications are functional limitations, unacceptable gait, or cosmetic deformity
  84. 84. MANAGEMENT- • Conservative management-rest and traction - Rest for at least 12wks and traction can be an alternative to surgical treatment - Indicated in – temporary measure before operative mx or slip due to hypothyroidism • Closed manipulative reduction - High risk of ischemic necrosis of head. - So, manipulate only acute severe slips that may be technically difficult or impossible to pin in situ. • Only for acute and acute on chronic severe slips • Within 24 hours of slip • Operative management - In situ pinning • 1 cannulated screw for both stable and unstable hip
  85. 85. Operative management - ORIF: open reduction, limited osteotomy, and internal fixation, if necessary, have been recommended if a severe acute or chronic slip which cannot be reduced by closed methods - Osteotomy: moderately or severely displaced chronic slips produce permanent irregularities in the femoral head and acetabulum, some form of realignment procedure often is indicated to restore the normal relationship of the femoral head and neck and possibly delay the onset of degenerative joint disease
  86. 86. Developmental Dysplasia of Hip A spectrum of disorder including : Acetabular dysplasia without displacement Subluxation Dislocation
  87. 87. Epidermiology Reported incidence is 5 – 20 per 1000 live births. Re – examination 3 weeks after birth is only 1 or 2 per 1000 infants. ( i.e spontaneous correction) Girls are more common with ratio 7:1 Left hip is more often affected, 1 in 5 cases is bilateral.
  88. 88. Aetiology 1- Genetic factors( families, even in entire populationgeneralized join laxity, shallow acetabulum) 2- Hormonal changes in late pregnancy→ lig. laxity 3- Intrauterine malposition( breech + extended legs) 4- Postnatal factors( swaddling- simultaneous hip and knee extension may lead to hip dislocation during early development)
  89. 89. Pathology Femoral head dislocate posteriorly and later lies superolateral to acetabulum Cartilagenous socket is shallow and anterverted Capsule is stretched Ligamentum teres is elongated and hypertrophied
  90. 90. Clinical Features Every newborn child should be examined for signs of hip instability esp. in children with positive family history or with breech presentation Methods in testing instability: Ortolani’s test (reducible) Barlow’s test (dislocatable)
  91. 91. Ortolani’s Test 1. Baby’s thighs are held with the thumbs medially and fingers resting on the greater trochanters 2. Hip are flexed to 90°and gently abducted 3. Normally, there is smooth abduction to almost 90°but in congenital dislocation the movement usually impede 4. If pressure is applied to greater trochanter there is soft ‘clunk’ as the dislocation reduce (the jerk of entry) 5. If abduction stops halfway and there is no jerk of entry, they may be an irreducible dislocation
  92. 92. When test is positive, the dislocated femoral head will fall back into acetabulum with palpable ‘clunk’ as the hip abducted. When hip is adducted, the examiner will feel the head dislocate posteriorly.
  93. 93. Barlow’s Test • Thumb is placed in groin • Grasping the upper thigh, an attempt is made to lever the femoral head out of the acetabulum by fully adduct hips and push posteriorly • Indicate unstable hip When the test is positive, the examiner will feel the femoral head make a small jump out of acetabulum. When the pressure is release, the head is felt to slip back into place.
  94. 94. Clinical Features The infant Limitation of abduction - < 50-60° Shortening of the femur by Galeazzi sign placing both hip in 90° of flexion and comparing the height of knee and look for asymmetry
  95. 95. Clinical Features Increase thigh folds on the affected side than the normal side because of the foreshortened the thigh.
  96. 96. Clinical Features Walking children Abnormal gait – due to shortened of the affected leg Trendelenburg gait Waddling gait - if bilateral hip affected (walk with short steps and a clumsy swaying motion) Excessive lordosis – secondary to hip flexion contracture
  97. 97. Investigation 1. Ultrasonography Neonate’s hip is composed primarily of cartilage – difficult by using radiographic techniques Shows the shape of cartilaginous socket Position of femoral head
  98. 98. Investigation 2. Plain X-ray In newborn the unstable hip may appear radiographically normal, as the child reach 3 to 6 month of age the dislocated hip will be evident radiographically.
  99. 99. X- Ray (A) Acetabulum : Shallow and sloping (Acetabular roof angle < 30) (B)Femoral head : Underdeveloped and out Perkin’s lines = Vertical line at the outer edge of acetabulum Hilgenreiner’ line = Horizontal line through the triradiate cartilages. Normally the head is medial to vertical and below the horizontal
  100. 100. (C) Shenton’line is broken (Inferior border of superior ramus and inferior border of the neck) (D) Von Rozen line = Hips abducted 45 Femoral shaft should point into the acetabulum
  101. 101. A B C
  102. 102. Management 0-6 months +ve Ortolani +ve Barlow +ve US Double napkins OR Abduction pillow for 6 weeks Stable hip = follow-up for 6 months Persistent instability = Splint for 3-6 months (Pavlic harness) Splintage Hold the hips flexed and abducted 3 Golden Rules for splintage: Hip must be properly reduced before splintage Avoid extreme position Hips should be able to move Types: Von Rosen’s Splint (easy to apply) Pavlik Harness (difficult to apply but more freedom to move)
  103. 103. Management Von Rosen’s Splint
  104. 104. Management Persistent dislocation: 6-18months Failed early treatment or missed dislocation Hip must be reduced by closed method or operation Closed reduction Performed under GA with arthrogram Gradual traction to minimize avascular necrosis Plastic spica for 6 weeks (60° flexion, 40° abduct, 20° int rotate) Reassess and spica for another 6 weeks checking by x-ray – to ensure femoral head concentrically reduced and acetabular roof develop normally
  105. 105. Management Operation Indicated when concentric reduction failed Psoas tendon is divided Redundant tissue is removed Hip is reduced (60° flexion, 40° abduct, 20° int rotate) Spica is applied (6wks) and hip is splinted
  106. 106. Management 18months-4 years Closed reduction is less likely to succeed. Traction: help to loosen the tissue and bring the femoral head down opposite the acetabulum Arthrography: clarify anatomy of hip shows whether there is an inturned limbus or any marked degree of acetabular dysplasia. Operation remove redundant capsule Usually require derotation femoral osteotomy held by a plate and screw 1cm segment removed from proximal femur to reduce pressure on hip If there is marked acetabular dysplasia, may require acetabuloplasty After operation, hip is held in a plaster spica for 3 months Keep under clinical and radiological surveillance
  107. 107. Management Children >4 years Up to 8 y/o; reduction and stabilization as above, risk of AVN and hip stiffness (>25%) Over 8 y/o; – unilateral [mobile hip, little pain, abnormal gait.] • no intervention @ open reduction + acetabular reconstruction. – bilateral [deformity + waddling gait not so noticeable] • non-intervention unless painful/severe deformity. (fail leads to asymmetrical deformity.)
  108. 108. -THANK YOU-

Notas del editor

  • Age related changes in blood supply to EpiphysisAge &lt; 4Receives blood from the metaphyseal vesselsAge 4-8Blood from separate epiphyseal vessels as the physis is barrier to blood flowAge &gt; 8The ligamentumteres has increasing significance in supply (20%)Trueta suggested that did not supply until 3-4 years- See more at:
  • The lateral Epiphysial and both Metaphysial arteries usually arise from the medial femoral circumflex arteryThe medial Epiphysial is a continuation of the artery within the ligamentumteres which comes from the acetabular branch of the obturator artery
  • the loose hyperelastic capsule, elongated ligamentumteres, and slight eversion of the hypertrophied acetabular rim. The posterosuperior rim of the acetabulum has to have lost it sharp margin and become flattened and thicken in the area over which the femoral head slide. The femoral head normal in shape.
  • With hip abducted 45 degree, femoral shaft should point into acetabula.