Paediatric Orthopaedics - The Big 3

Question 1

What does DDH stand for?

Answer 1

Developmental dysplasia of the hip

Question 2

Describe the epidemiology of DDH in terms of ethnicity, sex and which hip is more commonly affected?

Answer 2

• Different incidence in different parts of world, most prevalent in Eskimo’s and least in northern Europe
• Girls:boys 6:1
• Left hip more commonly affected than right

Question 3

What are risk factors for DDH?

Answer 3

• First born
• Oligohydramnios
  
  • Reduced fluid within the uterus
• Breech presentation
• Family history
• Other lower limb deformity
• High birth weight

Question 4

What is oligohydramnios?

Answer 4

• Reduced fluid within the uterus

Question 5

What are the clinical features of DDH?

Answer 5

• Ortolani’s sign
• Barlow’s sign
• Piston motion sign
• Hamstring sign

Question 6

What investigations are done for DDH?

Answer 6

X-ray is not done due to reducing x-ray exposure, and it would show things too late anyway due to femur not ossifying until 3 months

Investigation:

• USS

Question 7

What does the treatment of DDH depend on?

Answer 7

Age of patient

Question 8

What is the treatment for DDH?

Answer 8

• If <3 months
  
  • 90% respond to splint
• 3 months to 1 year
  
  • Closed reduction and spica cast
• >1 year
  
  • Open reduction and capsule reefing
• >18 months
  
  • Open reduction with femoral shortening with or without periacetabular osteotomy
• >6 years and bilateral
  
  • Leave alone
• >10 years and unilateral
  
  • Leave alone

Question 9

How does the prognosis of DDH with treatment change with age?

Answer 9

The older the child the poorer the result

Question 10

Is any screening done for DDH in the UK?

Answer 10

Selective US screening is done in UK:

• Every baby examined at birth
• US may follow if indicated

Question 11

What is the aetiology of perthes disease?

Answer 11

• Pathologically avascular necrosis of hip
• Possible relationships to
  
  • Coagulation tendency
  • Repeated minor trauma
• Familial
• Classically low social status
• smnall stature - usually boys

Question 12

Describe the epidemiology of perthes disease in terms of sex and age?

Answer 12

• M>F
• Primary school age

Question 13

What are the clinical features of perthes disease?

Answer 13

• Limp
• Knee pain on exercise
• Stiff hip joint
• Systemically well

Question 14

What investigation is done for perthes disease?

Answer 14

• X-ray
  
  • Four Waldenstrom stages

Question 15

How is perthes disease staged on an x-ray?

Answer 15

Four Waldenstrom stages:

1) Initial stage
2) Fragmentation stage
3) Reossification stage
4) Healed stage

Question 16

What impacts the prognosis of perthes disease?

Answer 16

• Younger age at presentation do better
• The Proportion of head involved
• Herring grade (lateral Pillar classification)
• Radiographic “head at risk signs” Caterall
• The nearer the head is to round, the better the outlook (Stulberg)

Question 17

What is the treatment of perthes disease?

Answer 17

• Maintain hip motion
• Analgesia
• Restrict painful activity
• Consider osteotomy in selected groups of older children (>7 years)

Question 18

What does SUFE stand for?

Answer 18

Slipped upper femoral epithysis

Question 19

Describe the epidemiology of SUFE in terms of sex and age?

Answer 19

• M>F
• Many overweight
• Age 9-14 years

Question 20

How can SUFE be classed?

Answer 20

• Acute v chronic
• Magnitude of slip (angle or proportion)
• Stable v unstable
  
  • Unstable is unable to weight bear (poor prognosis)
  • Stable is able to bear weight (good prognosis)

Question 21

What is the difference between stable and unstable SUFE?

Answer 21

• Stable v unstable
  
  • Unstable is unable to weight bear (poor prognosis)
  • Stable is able to bear weight (good prognosis)

Question 22

How is the magnitude of SUFE classified?

Answer 22

Magnitude is classified by ratio of width of femur to amount of slip:

• Mild <1/3
• Moderate 1/3-1/2
• Severe >1/2

Question 23

Describe the pathology of SUFE?

Answer 23

• Displacement through hypertrophic zone
• Metaphysis moves anterior and proximal

Question 24

What are the clinical features of SUFE?

Answer 24

• Pain in hip or knee
• Externally rotated posture and gait
• Reduced internal rotation, especially in flexion
• Plain x-rays
  
  • Best seen on lateral x-rays

Question 25

What investigations are done for SUFE?

Answer 25

* X-ray * Slip can be identified early using Trethowan;s sign on AP film

Question 26

What is the treatment for SUFE?

Answer 26

* Operative * Pinned in situ if stable * Open reduction if severe unstable slips * AVN high risk

Question 27

What are possible complications of SUFE?

Answer 27

* AVN * Stable slips have low risk, unstable slips have high risk * Chrondolysis * Deformity * Early OA * Limb length discrepancy * Impingement