Hip problems

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Hip problems

• Slipped Capital Femoral Epiphysis
• Perthes Disease
• Developmental Dysplasia of Hip

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Slipped Capital Femoral Epiphysis
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Introduction

• The most common hip abnormality presenting in
  adolescence and a primary cause of early
  osteoarthritis.
• SCFE is a Salter-Harris type 1 fracture through
  the proximal femoral physis.
• The femoral head gradually slip posteriorly,
  medially and intefriorly with respect to the neck.

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Incidence

• Incidence is 1 case per 100,000 people.
• SCFE occurs most frequently in
• adolescents
• overweight boys
• African American children
• Left hip more common than right.
• Bilateral involvement 20-40

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Etiology

• Unknown!
• Any condition that decreases physeal strength
• Increased shear forces due to obesity
• ?weight during growth spurt?strain on growth
  plate
• More vertical proximal femoral physis
• Retroversion ? shear forces with walking

• Disease processes that weaken physis
• Hypothyroidism
• Renal disease
• Hypogonadism
• Hypopituitarism
• GH deficiency treated with HGH
• lt10 years of age
• Other factors that contribute
• Marfans disease
• Posttransplant medications
• Radiation therapy

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Clinical presentation

• Clinical presentation often is misleading, with
  only 50 of patients presenting with hip pain and
  25 presenting with knee pain.

• Antalgic limp Knee pain 46
• Severe pain unable to walk
• Extremity externally rotated/adducted/ shortened
• Lack of Internal Rotation
• Flex hip ? externally rotate

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Symptoms and Clinical Findings

• Antalgic limp Knee pain 46
• Severe pain unable to walk
• Extremity externally rotated/adducted/ shortened
• Lack of Internal Rotation
• Flex hip ? externally rotate

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Radiology

• Diagnosis is made using AP pelvis and lateral
  frog-leg radiographs.
• Abduction of the femur for the frog-leg view may
  result in increased slippage and should be
  performed with caution.

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Radiographs

• AP
• May not detect the slip!
• Widening early dz
• Irregular growth plate
• Steels metaphyseal blanching
• No remodeling acute unstable
• Change in Kleins line

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Radiology Signs

• Loss of triangular sign of capener
• Blurring of physis
• Relative decreased height of epiphysis
• Loss of intersection of epiphysis by lateral
  cortical line of femoral neck.

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Radiographs

• Head-Shaft angle by Southwick,
• Determine degree of slip/stability on frog-leg
  lateral
• Angle between femoral head and shaft (HSA)
• HSA of affected side minus HSA of nl side
• Determine long-term px
• Mild 1-29
• Mod 30-60
• Severe gt60

• CT Scan
• Assess magnitude of deformity
• Post-op check of physeal closure
• MRI
• Dx of AVN or chrondrolysis

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• 13-year-old female adolescent
• anteroposterior pelvic view increased opacity of
  her right metaphysis and the subtle widening of
  the physis

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• 14-year-old male adolescent who came to the
  emergency department with complaints of thigh and
  knee pain
• A relatively subtle medial slip at AP view.
• A more obvious posterior slip at frog-leg lateral
  view

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Classification

• Traditional Classification
• Fahey and OBrian, 1965
• no rationale for this selection of time
• Acute lt 3 weeks of symptoms
• Chronic gt 3 weeks of symptoms
• Acute on Chronic gt 3 weeks of symptoms
• sudden
  exacerbation

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Surgical Treatment

• Goals
• primum non nocere
• Pain relief
• Prevent slip progression
• Accelerate epiphsiodesis
• Avoid AVN and chondrolysis

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Pinning In-Situ

• Single-screw in-situ
• High success rate
• Low incidence of slippage
• Minimal complications with proper placement
• Placement of single screw
• 1980s Morrissey
• Center of femoral head/- to physis
• Enhance rate of physeal closure (Ward, JBJS,
  1992)
• Avoid posterosuperior quadrant (Brodetti, JBJS,
  1960)
• Injury to lateral epiphyseal vessels AVN

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Pinning In-Situ

• Placement of single screw
• Proper start point important
• anterior on neck
• pin start below lesser troch ? fx incidence
• Multiple drill holes weaken bone
• 5 screw threads into the epiphysis

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Pre-Op
Screw Placement
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2-Bone-Graft Epiphysiodesis
3-Osteotomy
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Complication

• AVN

• Chondrolysis

• Continued Slip
• Because of smooth pins
• Poor primary fixation not perpendicular to
  physis
• Pin Breakage unstable fixation
• Subtrochanteric fracture
• OA/Pistol grip deformity

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Perthes Disease

• LEGG-CALVE-PERTHES DISEASE

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Perthes Disease

• Idiopathic Avascular Necrosis of Capital Femoral
  Epiphysis (CFE)
• An ischaemic episode of the lateral epiphyseal
  arteries initiates avascular necrosis of the
  capital femoral epiphysis. The lateral
  epiphyseal arteries supply an extensive area of
  the capital femoral epiphysis.
• Cause is unknown

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Perthes Disease

• More common in boys than girls 4-51
• Age range 3-11yo more usually 5-6 yo
• Often lower socio-economic groups (?nutrition
  factors)

Perthes in Lt. femoral head
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Perthes Disease

• Etiology
• interruption of blood supply to CFE
• ossification ceases temporarily
• articular cartilage continues to grow (nourished
  by synovial fluid)
• subchondral bone is revascularised and becomes
  weak
• results in subchondral fracture which can allow
  the femoral head to become flattened and
  mis-shapen

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Perthes Disease

• Signs Symptoms
• Limp
• Pain in knee, thigh
• ? hip ROM abduction internal rotation
• Affected leg may become shorter and thinner over
  time

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Perthes Disease

• Physical Exam - Shows
• 1. Decrease ROM in hip abduction and internal
  rotation.
• 2. Hip stiffness
• 3. Knee pain
• X-rays Four stages
• 1. Synovitis
• 2. Aseptic necrosis- increased joint space and
  small femoral head
• 3. Fragmentation - increased bone density
• 4. Residual - increased bone density

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Radiograph LCP
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Perthes Disease

• Management
• Many (approx 60) do well without treatment of
  any kind, especially younger boys under 5 years
  of age.
• Some (approx. 15) do badly even with active
  management.
• Remaining 25 benefit from active management.
• Factors that determine which group children will
  fall into has been difficult to determine.

• Following principles are generally agreed.
• Management Principles
• reduce hip irritability, pain and spasm if
  present
• prevent deformity of the femoral head (reduces
  risk for osteoarthritis in later years)
• Congruity of hip joint.

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Perthes Disease

• Rest in bed with pain relief
• Traction to relieve muscle spasm
• Slings/springs to regain ROM
• Containment of femoral head in acetabulum through
• use of abduction brace (eg. Scottish Rite or
  Toronto). Continue to ambulate.
• surgically increasing acetabular coverage
  (innominate and/or varus osteotomy) followed by
  period in broomstick plasters.

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Perthes Disease

• Avoid high impact activities eg running, jumping
  until fem. head is healed.
• Hydrotherapy may also be useful.
• Recovery is a slow process (2-5 years)
  therefore chn. need emotional support and
  reassurance that they will recover and be able to
  resume "normal" activities.

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Developmental Dysplasia of Hip
DDH
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Developmental Dysplasia of the Hip

• Femoral head has an abnormal relationship with
  acetabulum
• Includes unstable, subluxated (excessive movement
  in the socket), and dislocated hips
• Risk Factors
• Female
• Breech
• Family History

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DDH

• Recommendations
• Serial physical screening exams
• Hip imaging for females born breech (120/1000)
• Optional imaging for males born breech (26/1000)
• Optional imaging for females with FH
• If positive Ortalani or Barlow on initial PE,
  refer to orthopedic doctor
• If exam is equivocal (soft clicks)?check in 2
  wks

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DDH

• DDH
• Developmental Dysplasia of the Hip
• CDH
• Congenital Dislocation of the Hip

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Radiological Diagnosis

• classic features
• increased acetabular index ( n27, gt30-35
  dysplasia)
• disruption shenton line ( after age 3-4 should be
  intact on all views)
• absent tear drop sign
• delayed appearance ossific nucleus and decreased
  femoral head coverage
• failure medial metaphyseal beak of proximal femur
  , secondary ossification center to be located in
  lower inner quadrant
• center-edge angle useful after age 5 ( lt 20)
  when can see ossific nucleus

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DDH

• Physical findings
• Girl
• Asymmetrical skin folds
• Limited abduction
• Short leg
• Pistoning
• Ortolanis sign
• Barlows sign

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DDH

• X-ray findings
• Delayed appearance of ossific nucleus
• Small ossific nucleus
• Dysplastic acetabulum
• Proximal displacement of femur

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DDH

• Pavlik Harness
• Check at 3 weeks to confirm reduction
• Adjust position every 6 12 weeks
• Continue until the hips are clincally and
  radiologically normal

• Treatment
• 0 ½ Pavlik harness
• ½ 1½ Closed reduction, cast
• 1 ½ - 5 or 8 Open reduction, pelvic osteotomy
• Older Leave dislocated

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Management of DDH

• Newborn
• Splintage in abduction (Pavlik harness)
• 6 - 18 months
• Closed reduction - Traction
• Splintage
• Open reduction and Splintage
• Late diagnosed dislocations
• Persistent dislocation in adults

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Treatment of DDH

• Group I - Neonate to 6 weeks - positive Ortolani
  and Barlows tests and skin fold discrepancies.
  Also dislocated side can be extended all the way
  down to the level of the exam table, because it
  is lacking the normal hip flexion tightness that
  newborn have. Refer this child to Orthopedics
  for treatment most likely with a Pavlik harness.

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Treatment of DDH

• Group II - 6 weeks - 12 months - Hip capsular and
  soft tissue have now tightness up and the
  Ortolani test may not be positive. Will see
  limited abduction in this age and skin fold
  asymmetry. Again referral to Ortho for treatment
  with Pavlik harness, traction, adductor
  tenotomy, or closed reduction.

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Treatment of DDH

• Group III - 12 months - 3 years - Walking with a
  painless limp. Galeazzi sign positive, and
  limited abduction. X-rays positive by this age.
  Again referral to Ortho for possible treatment by
  arthrography, traction, adductor tenotomy, open
  reduction, and pelvic versus femoral osteotomy.

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Treatment of DDH

• Group IV - 3 years to skeletal maturity- Same as
  group III and X-ray is positive. Referral to
  Ortho for treatment. Usually need to have
  surgery to corrected at this age.
• FYI - Bilateral dislocations over 6 years old and
  unilateral over 8 years old do better left ALONE.