Pediatric Hip

Developmental dysplasia of the hip (DDH)

Introduction

 A disorder of abnormal development resulting in subluxation or

dislocation of the hip secondary to capsular laxity and mechanical
factors
 DDH encompasses a spectrum of disease that includes:

1. dysplasia: a shallow or underdeveloped acetabulum

2. subluxation: a hip that is not totally reduced or centered
3. dislocation: totally out the a acetabulum
4. teratologic hip: dislocated in utero and not reducible in neonatal exam.
5. late (adolescent) dysplasia :mechanically stable and reduced but dysplastic

 Incidence
o most common in left hip in females
o dysplasia is 1:100
o dislocation is 1:1000
 Risk factors
o risk factors include
 first born
 female (6:1 over males)
 breech presentation
 family history
 oligohydramnios(fluid)
o associated with "packaging" deformities (congenital muscular torticollis, metatarsus adductus,
congenital knee dislocation)
o associated with certain neuromuscular disorders (arthrogryposis, spina bifida)
 Pathology
o Initial instability thought to be caused by maternal and fetal laxity, genetic laxity, and
intrauterine and postnatal malpositioning
o Initial instability leads to dysplasia
o Dysplasia leads to gradual dislocation

Physical Exam
  < 3 months

1. mainstay of physical diagnosis is palpable hip subluxation/dislocation

2. Barlow's
 adduction and depression of the femur dislocates femoral head posteriorly
3. Ortolani's
 elevation and abduction of the femur reduces femoral head into the acetabulum
4. Galeazzi (Allis)
 apparent limb length discrepancy due to dislocated hip with hip and knee flexed at 90
degrees

 > 3 months
1. limitations in motion
2. leg length discrepancy predominate

Limitation of abduction and asymmetrical skin folds were the two most common findings.

 1 year (walking child)

1. pelvic obliquity
2. lumbar lordosis (in response to hip contractures resulting from bilateral dislocations in a
child of walking age)
3. Trendelenburg limp from abductor weakness(Limited hip abduction)
4. toe walking(compensate for relative shortening of affected side)

Classification

 Can be classified as a spectrum of disease involvement (phases)

1. normal
2. dislocatable (Barlow positive)
3. dislocated and reducible (Ortolani positive)
4. dislocated and irreducible(Limited hip abduction)

Imaging

 Radiograph
o become primary imaging modality at 3-5 months after the femoral head begins to ossify
 hip dislocation
 Hilgenreiner's line - horizontal line through right and left triradiate cartilage
(femoral head ossification should be below this line)
  Perkin's line - line perpendicular line to Hilgenreiner's through point at lateral
margin of acetabulum (femoral head ossification should be medial to this line)
 Shenton's line – arc along inferior border of femoral neck and superior margin
of obturator foramen
 Ultrasound
o useful before femoral head ossification (< 5 months)
o allows for monitoring of reduction during Pavlik harness treatment
o is not cost effective for routine screening

 alpha angle (normal is greater than 60°)

 beta angle (normal is less than 55°)

 Arthrogram
o used to confirm reduction during closed reduction under anesthesia
o help identify an object that is blocking the reduction.
o

 CT
o CT study of choice to evaluate reduction after closed reduction and spica casting
 MRI
o do not play significant role in primary diagnosis

Treatment in Children

 Goal of treatment
o concentric reduction while minimizing risk to blood supply of capital femoral epiphysis
 Non operative

DDH < 6 months of age and reducible hip

o treat with abduction splinting/bracing (Pavlik harness is most popular)

  position is 90-100° flexion (anterior strap controls) and abduction of 50° (posterior
strap controls). Extremes of flexion and abduction can cause
 AVN
 transient femoral nerve palsy
 confirm position with ultrasound or x ray and monitor every 4-6 week
 overall Pavlik Harness has success rate of 90%
 abandon brace treatment if not successful after 2 to 3 weeks
o worn for 23 hours/day for at least 6 weeks or until hip is stable
 wean out of harness over 6-8 weeks after hip has stabilized until normal anatomy
develops
o confirm position with ultrasound or x-ray and monitor every 4-6 week

DDH 6-18 months of age or irreducible hip

o treat with closed reduction and spica casting (general anesthesia)

 indications
 DDH in 6 - 18 months of age
 failure of Pavlik treatment

o
 perform arthrogram to confirm reduction and dynamic stability
 following reduction immobilize in a spica cast with hip flexion of 100 deg. and
abduction of 45 deg for 3 to 4 months.
 confirm reduction with CT scan in spica cast
 change cast at 6 months

• Operative
 DDH > 18 months of age or has failed closed reduction

 open reduction and spica casting

o indications
 DDH in patient >18 months of age
 failure of closed reduction
 AFTER TREATMENT
o The cast is worn for 10 to 12 weeks.
o After removal of the total cast, an abduction brace is worn full-time for 4 to 8 weeks;
o then it is worn only at night and during naps for 1 to 2 years, until normal acetabular
development is evident

DDH > 2 years with residual hip dysplasia

o treat with open reduction and osteotomies

 femoral osteotomy (VDRO)
 best in younger children (< 4 yrs.)
 pelvic osteotomies
 can be done in older children (> 4 yrs.)

Dislocated hip in children > 6 years

o no intervention (leave hip dislocated because the acetabulum cannot remodel) if :

 bilateral dislocation in a child > 6 yrs.
 unilateral dislocation in a child > 8 yrs.

Late or adolescent dysplasia

 (hip is reduced and mechanically stable but dysplastic)
o treat with periacetabular pelvic osteotomy +/- a femoral osteotomy
 indications
 failure of improvement with growth
 symptomatic dysplasia in an adolescent
Complications

 Ischemic Necrosis
o seen with all forms of treatment
o increased rates associated with
 excessive or forceful abduction
 previous failed closed treatment
 repeat surgery
o diagnosis based on radiographic findings that include
 failure of appearance or growth of the ossific nucleus 1 yr. after reduction
 broadening of femoral neck 1 yr. after reduction
 increased density and fragmentation of ossified femoral head

Screening

 All infants require screening

 Physical exam
o successful screening requires repetitive screening until walking age
 Ultrasound
o ultrasound screening of all infants occurs in many countries.
o USA recommendations is to perform ultrasound at 4 to 6 weeks in patients with
 risk factors
 positive physical findings
 Slipped capital femoral epiphysis (SCFE)
Introduction

 Disorder of the proximal femoral epiphysis that leads

to slippage of the epiphysis off the physis
o epiphysis stays in the acetabulum and the neck
displaces anteriorly and externally rotates
(epiphysis is posterior).
 More common in
o males (male to female ratio is 3:2)
o obese children
o during period of rapid growth
o bilateral in 17 to 50%
 Average age is
o 13.5 for boys
o 12 for girls
o associated with puberty
 Associated endocrine disorders.
o endocrine disorders to look for
 hypothyroidism
 osteodystrophy of chronic renal failure
 growth hormone treatment

Classification

 Stable vs. unstable

o stable
 able to bear weight or use crutches
 minimal risk of osteonecrosis
o unstable
 unstable is unable to ambulate (not even with crutches)
 associated with high rate of osteonecrosis (~47%)

Presentation

 Presentation
o hip pain
o knee pain (15%)
 Physical exam
o all patients have obligatory external rotation with flexion of hip
o usually loss of internal rotation
o externally rotated gait
o thigh atrophy

Imaging

 Radiographs
o frog-lateral of right and left hip
  lateral radiograph is best way to identify a subtle slip
o AP of pelvis
 Klein's line - line drawn along superior border femoral neck will not intersect femoral
head in a child with SCFE (does in a normal hip)

 MRI
o can help diagnose a preslip condition when x-rays are negative

Treatment

 Operative
o in situ screw pinning of epiphysis
 indications
 both stable and unstable slips
o bilateral hip screw pinning of epiphysis (contralateral prophylactic pinning)

Complications

 Osteonecrosis of femoral head

o most common complication
o increased risk with unstable slip (47%)
 Chondrolysis
 Residual proximal femoral deformity & limb length discrepancy
 Slip progression
 Hip stiffness
 Degenerative arthritis
 Perth’s disease (coxa plana)
(Perthe’ s disease or Legg-Calve- Perthe’s disease)
Introduction
 Idiopathic avascular necrosis of the proximal femoral
epiphysis
 Epidemiology
o 4-8 years most common age presentation
o male to female ratio is 5:1
o bilateral in 12% (never simulatenous)
 Increased incidence with
o positive family history
o low birth weight
o abnormal birth presentation
o children exposed to second hand smoke
 Prognosis correlates
o bone age at onset
 onset at < 6 years has good prognosis
 > 6 years has a much worse prognosis
o lateral pillar classification

Pathophysiology

Stages of Legg-Calves-Perthe’s
Initial Infarction occurs.
Radiographs may remain occult for 3 to 6 mos.
Fragmentation Femoral head appears to fragment or dissolve.
Result of a revascularization process and bone resorption.
Lateral pillar classification based on this stage.
Reossification New bone appears.
Healed or Femoral head reossifies back to normal bone density.
reossified

Presentation
 Symptoms
o painless limp
o knee, hip, or thigh pain
  Physical exam
o hip stiffness with loss of internal rotation and abduction
o Trendelenburg gait (head collapse leads to decreased tension of abductors)
o limb length discrepancy is a late finding

Imaging
 Radiographs
o early findings include
 joint space widening (earliest)
 irregularity of femoral head ossification
 cresent sign (represents a subchondral fracture)

Classification
 Herring lateral pillar classification
o determined on AP x-ray at start of fragmentation stage
 Group A - lateral pillar maintains full height, uniformly good outcome
 Group B - maintains 50 to 100% height, poor outcome in patients > 6 years
 Group C - maintains < 50% height, poor outcomes in all patients

Treatment
 Main goals of treatment is to keep femoral head contained and maintain good motion
o good outcome correlates with spherical femoral head
 < 6 years of age
o leave alone
 > 6 years of age (treatment is controversial)
o nonoperative
 activity restriction, partial weight bearing with crutches, NSAIDS, physical therapy
to regain motion
 casting or bracing to produce containment
o operative
 femoral or pelvic osteotomy for late symptoms
 usually reserved for patients > 8 years

Complications
 Residual head and neck deformity
 Osteochondritis dissecans of hip
 Coxa vara
Introduction

 A decreased neck-shaft angle that is associated

with an ossification defect in inferior femoral neck
 Cause can be
o congenital
o acquired (secondary to trauma, SCFE, Perthe’s dis.)
 Males and females affected with equal frequency
 Bilateral in 33 to 50% of cases

Presentation

 Presents with
o painless waddling Trendelenburg gait (when bilateral)
o painless limp (when unilateral)
o leg length discrepancy if unilateral
o excessive lumbar lordosis if bilateral
 Physical exam shows
o high riding greater trochanter
o restricted hip range of motion in all planes

Imaging

 Radiographs
o neck shaft angle ~ 90 degrees (normal is 130 degrees)
o Hilgenreiner's epiphyseal angle > 25 degrees (normal < 25 degrees)
 determined on AP as angle between Hilgenreiner's line and a line through the
proximal femoral physis
o triangular metaphyseal fragment in inferior femoral neck (looks like inverted-Y
radiolucency)

Treatment

 Hilgenreiner's physeal angle is < 45°

o observation only
o usually will correct spontaneously without surgery
 Hilgenreiner's physeal angle is > 60 (neck shaft angle < 110 °)
o treat with corrective valgus derotation osteotomy (VDRO)