Hip problems

Developmental dysplasia of the hip

1 per 1000 individuals. Risk factors: Breech presentation, female, 1st born, large fetal size, +ve fam Hx, more common on Lt than Rt. Infant is asymptomatic. Check for other cong anomalies: clubfoot, spina bifida, heart defect. The neonatal hip is relatively unstable, which may lead to subluxation or dislocation; lack of concentric positions for the acetabulum & femoral head may lead to dysplasia. PE: + Ortolani (hip out, CLUNK felt with abduction & ant force), + Barlow (CLUNK of hip with adduction & post force). Essential 2b done at birth for better prognosis.

 D/D: Perthes disease, transient synovitis, cerebral palsy, coxa vera, familial primary acetabular dysplasia, multiple epiphyseal dysplasia Ix: X-ray only aft 6 mths Hip USS Ball outside socket & shallow socket Tx: 0-6 mo: Closed reduction, Pavlik harness 6-18 mo: Closed reduction under GA, spica cast 18-36 mo: Open reduction, femoral osteotomy/+ hip bone osteotomy, spica cast >36mo-5yo: As above + Klisic procedure >5yo: Leave as it is due to complication of AVN

Hip X-ray findings

1. Shenton line broken 2. Acetabular index > 30 3. CE angle < 30

Legg-Calve-Perthes disease
Idiopathic avascular necrosis of the femoral head in children aged 4-10 yo. M>F; self-limited, usually unilateral. Small for age. Child presents with a painless limp; if pain present, it may be referred to thigh or knee. PE: Hip flexion contracture or 0-30, with decreased abduction & internal rotation.

 D/D: Gaucher disease (with bilateral LCPD) Multiple epiphyseal dysplasia Tx: Children with bone age <5 y & minor involvement do not need Tx Bracing or surg is recommended for older children & those with more advanced disease Poor prognostic signs are age 8 y, abduction < 15 (stiffness), >50% of head involvement, & subluxation or lateral calcification Tx had no effect on outcome if pt has a chronologic age y at onset of the disease

 Ix: Hip X-ray

1. Small femoral epiphysis 2. Sclerosis of the femoral head with sequestration and collapse 3. Slight widening of the joint space caused by thickening of the cartilage, failure of epiphyseal growth, the presence of joint fluid, or joint laxity

 Slow separation & displacement of the femoral epiphysis posterior & medial to the neck of femur. The head of the femur bone will usually slip backward & inward relative to the shaft. 10 per 100,000 people in US; M:F = 2:1 Peak onset in early adolescence (12-15 yo in boys, 10-13 yo in girls). The opposite hip will slip in 30% of affected children within 18 months of the 1st one. Short stature. Exact cause unknown but is typically found in children who are obese (>95th percentile for their weight) & in early prepuberty. Complaint of painful limp for 1-3 mo; pain in thigh or groin, occasionally in the knee. Evaluation of hip is necessary in any child aged 9-15 yo with knee pain; children with SUFE have loss of internal rotation of hip & obligatory external rotation with flexion of hip (diagnostic).

Slipped upper femoral epiphysis (SUFE)

 D/D: Femoral neck fracture Neoplasm Knee pathology Tx: Consists of pinning the hip in situ with 1-2 pins Reduction of the slip, even in acute SUFE, risks causing AVN of the epiphysis; another complication, which may be iatrogenic from pin penetration, is chondrolysis of the articular surfaces - the higher the degree of the slip, the earlier OA develop Most cases are idiopathic, but endocrine abnormalities should be considered (i.e. hypothyroidism)

 Ix: Hip X-ray

AP radiograph: The Klein line is drawn straight up the superior aspect of the femoral neck. This should intersect the epiphysis. If not, then it is likely an SCFE .

A Klein line is a line drawn along the superior border of the femoral neck that would normally pass through a portion of the femoral head. If not, slipped capital femoral epiphysis is diagnosed

Cerebral palsy
Static encephalopathy that occurs in prenatal or perinatal period. Increased muscle tone, either spasticity (increased tone with stretch) or dystonia (increased tone without stretch). Progressive joint contractures, shortened muscles, hip or foot deformities, scoliosis and fractures due to osteomalacia or osteoporosis. 4 anatomic patterns: (1) Hemiplegia involves 1 side of body; often caused by congenital loss of parietal or cerebral cortex; intelligence & development are often normal; (2) Diplegia often associated with prematurity or intracerebral hemorrhage; typically produces symmetric involvement of lower & upper extremities (but often less severe in upper); child often has normal intelligence but development delays; (3) Quadriplegia causes severe spasticity, mental retardation, joint contractures, seizures; most common with birth asphyxia or encephalitis; (4) Mixed neurologic involvement athetosis, ballismus, ataxia, spasticity.

 D/D: Arthrogryposis, myelomeningocele, familial spastic parapesis, nonstatic encephalopathy (ongoing metabolic, infectious, or ischemic insult), toxicities (lead poisoning) Tx: Requires coordinated Tx effort of providers & parents PT & OT may be beneficial early in life & after surgical releases; bracing often helps control spasticity & decrease deformity; medication (e.g. oral baclofen & botulinum toxin or phenol injections can help decrease spasticity Surgery (adductor release; Achilles, hamstring, gastrocnemius, or iliopsoas lengthening) can help control spasticity; reconstructive surgery is used to correct hip subluxation or dislocation & scoliosis)

Physiological & Pathological Genu Varus & Genu Valgus

Children aged 0-2 yo may have physiologic, bilateral, symmetric bowing of legs (physiologic genu varum); normal is 10-15; max deformity at 18mo. Children aged 3-6 yo may hv exaggerated knock-kneed condition (physiologic genu valgum), up to 15 degrees of valgus may be normal; max deformity at 3-3.5 yo). After that, it should straighten. Distance between 2 knees of a child should not be >6cm & between 2 medial malleoli not >8cm - if it is, it is pathological (most probably due to rickets) Radiographs show symmetric flaring of tibia & femur

 D/D: Genu varum: Blount disease, internal tibial torsion, osteogenesis imperfecta, osteochondroma, trauma, dysplasia, rickets Genu valgum: Renal osteodystrophy, tumor (osteochondroma, Ollier disease), infection, trauma (physeal injury), fibrous dysplasia, NF Tx: Leg bowing in infants & excessive knock knees in 6 yo are normal phenomena: observe Asymmetric bowing or knock knee is not normal further evaluation Genu varum that progresses shows >50% of the deformity on the tibia in almost all pts Bowing that persists beyond 3 yo of age requires further evaluation; rule out structural abnormality Internal tibial torsion spontaneously resolves by age 4yo Consider surgery (hemiepiphysiodesis, physeal stapling) for genu valgum in children >10 yo with >10cm between medial malleoli or >15-20 degrees of valgus

Congenital clubfoot (talipes equinovarus)

Congenital, fixed deformity of the foot characterized by plantar flexion (equinus, inversion, axial internal rotation of subtalar joint (varus), & medial subluxation of talonavicular & calcaneocuboid joints (adductus). 1 in 1000 births; more commonly in males; polygenic inheritance pattern; bilateral in 50% of cases Always associated with decrease in calf circumference related to muscle fibrosis; to rule out presence of an associated spinal deformity, observe for caudal dimpling, hairy patches, or other associated findings

 Often diagnosed prenatally with US In infants, radiographs are usually unnecessary bcos foot bones have not ossified; radiographs may be taken when the child presents at walking age; ant talocalcaneal angle is reduced (normal = 30-55 deg) on AP view, talocalcaneal angle is reduced (normal = 25-50 deg) on lateral view. D/D: Myotonic muscular dystrophy, poliomyelitis, cerebral palsy, metatarsus adductus, spinal deformities with neurologic sequelae (e.g. spina bifida, myelomeningocele)

 Tx: Serial manipulation & casting is 1st line Tx; initially, casts are molded to correct cavus deformity, followed by correction of forefoot adduction & heel varus, & finally, correction of equinus (Ponseti technique); if technique is unsuccessful after 12 wks, consider operative correction Mild recurrence is fairly common; advise parents that fully corrected foot will have some residual stiffness, calf size will remain small, & foot will be smaller than contralateral foot

Obstetric Brachial Plexus Injury

Injury to all or a portion of the brachial plexus noted at the time of delivery. Upper brachial plexus injury - Erb palsy, lower brachial plexus injury - Klumpke palsy. Associated with large weight at birth and shoulder dystocia.

Obstetric brachial plexus injury

Erbs palsy Klumpkes palsy

Erbs palsy (C5-C6 nerve roots)

Nerves affected: suprascapular, musculocutaneous, axillary Muscles affected:
Supraspinatous (shoulder abductor) Infraspinatous (shoulder lateral rotator) Subclavius (depresses the clavicle) biceps brachii (forearm supinator, elbow flexor) Brachialis (elbow flexor) Coracobrachialis (shoulder flexor) Deltoid (shoulder abductor) teres minor (shoulder lateral rotator)

Manifestation
Upper limb will
hang limply by the side (no shoulder abductor) medially rotated (by the unopposed sternocostal part of the pectoralis major) forearm pronated (loss of the action of the biceps)

Klumpkes palsy (C8-T1)

Nerve affected: median & ulna nerve Muscles affect: small muscles of the hand Manifestation: claw hand
hyperextension of metacarpophalangeal joints flexion of the interphalangeal joints Results from unopposed
Extensor digitorum Flexor digitorum superficialis & profundus

May manifest as Horners syndrome

Management & Outcome

Outcome generally good
>90% spontaneous recoveries

physical therapy and observation for evidence of recovery Surgical intervention may be required if functional recovery does not ensue in 3 to 9 months

Radial Club Hand

The forearm is short and bowed; the hand is underdeveloped and markedly deviated towards the radial side (radial club hand) and the thumb may be missing. The elbow too is often abnormal. In about half the cases the condition is bilateral. The clinical deformity may look bizarre but children often acquire excellent function. If this seems unlikely, operative reconstruction may be advisable. This could involve pollicisation of a digit and other complex reconstructive procedures. In the young child simple stretching and splinting may help to