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Good Morning!. 4-month-old Well Child visit Illness Scripts Predisposing Conditions – Age, gender, preceding events (trauma, viral illness, etc), medication.

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Presentation on theme: "Good Morning!. 4-month-old Well Child visit Illness Scripts Predisposing Conditions – Age, gender, preceding events (trauma, viral illness, etc), medication."— Presentation transcript:

1 Good Morning!

2 4-month-old Well Child visit

3 Illness Scripts Predisposing Conditions – Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc) Pathophysiological Insult – What is physically happening in the body, organisms involved, etc. Clinical Manifestations – Signs and symptoms – Labs and imaging

4 Hip Disease in Pediatrics

5 Spectrum of disease – Acetabular dysplasia – Hip subluxation – Hip dislocation Typical vs tetralogic DDH – Typical: occurs in otherwise normal patients – Tetralogic: identifiable causes such as arthrogryposis or genetic syndrome

6 Some degree of hip instability in 1/100 to 1/250 births Actual dislocated or dislocatable hips are much less common – Found in 1-1.5/1000 live births Higher incidence in Native American and Eastern European cultures – vs Asian or African cultures – Environmental factors

7 Caused by increased laxity of the hip capsule, doesn’t maintain a stable femoroacetabular articulation Increased laxity due to: – Physiologic: family history of joint laxity, maternal estrogens/hormones, M:F ratio of 1:9** – Mechanical: primigravida, breech presentation**, oligohydraminos, postnatal positioning

8 Clinical findings in the Neonate: – asymptomatic – requires screening with specific maneuvers Barlow – action is dislocating an unstable hip Ortolani – action is returning a dislocated femoral head back into the acetabulum  “CLUNK”


10 Clinical findings in the Infant: – Limited hip abduction – Apparent shortening of the thigh Galeazzi sign – Proximal location of the greater trochanter – Asymmetry of the gluteal or thigh folds – Asymmetry of the hip

11 Galeazzi sign


13 Clinical findings in the Walking Child: – Limp – Waddling gait – Leg-length discrepancy Affected side is shorter – Excessive lordosis

14 Diagnostic testing – Ultrasound** Diagnostic test of choice prior to the appearance of the femoral head ossific nucleus ~ 4-6 months High incidence of false positive from age 0-4 weeks Provides dynamic information about stability of hip Role of screening ultrasound


16 Diagnostic testing – X-rays Recommended once the proximal femoral epiphysis ossifies ~ usually by 4-6 months Lots of lines and angles and things to determine how asymmetric the hips are

17 Radiograph of a patient presenting at age 8 months with DDH. The left hip is dislocated. Nemeth B A, and Narotam V Pediatrics in Review 2012;33: ©2012 by American Academy of Pediatrics

18 Treatment – Newborn to <6 months: Pavlik harness

19 Treatment – 6 months to 2 years: Closed reduction Spica cast x 12 weeks – >2 years: Open reduction Post-surgery spica cast x 6-12 weeks May require other surgical repairs to pelvis

20 Complications – Avascular necrosis of the femoral epiphysis Most vulnerable to damage to epiphyseal vessels before 4-6 months Revascularization will follow but if the physis is severely damaged, can result in abnormal growth With appropriate treatment, incidence of avascular necrosis for DDH is reduced to 5-15%

21 Idiopathic avascular necrosis of the femoral epiphysis Overall incidence in the US ~ 1/1,200 Male:Female ratio of 4-5:1** Peak incidence between 4-8 yrs old** Bilateral involvement in ~10%, but at different stages

22 Temporary interruption of blood supply to the proximal femoral epiphysis – Leads to osteonecrosis and femoral head deformity after repair process – Often damages the proximal femoral physis leading to a short neck and trochantric overgrowth

23 Clinical presentation – Most common presenting symptom is a LIMP** – Pain not always present Activity related Localized in the groin or referred to anteromedial thigh or knee region – Less commonly, onset may be acute and presents with failure to ambulate – Limited hip internal rotation and abduction – Atrophy from disuse (due to pain) – Leg-length discrepancy

24 Diagnosis – X-rays

25 Treatment – Goal: containment of the fragmented head in the acetabulum – Conservative – Petrie Abduction cast; Scottish Rite brace – Surgery

26 Most commonly affects adolescents – Age Annual incidence 2/100,000 – Higher in Polynesian and African-Americans Obesity – ~65% of patients are >90 th percentile for weight M > F Left > right

27 Failure of the physis and displacement of the femoral head relative to the neck Caused by combination of endocrine factors (circulating hormones) and mechanical factors (increased forces and mechanical load)

28 Classifications – Acute (< 3weeks) vs Chronic (several months) – Stable vs Unstable (unable to walk with or without crutches) – Degree of displacement: mild, moderate, severe

29 Clinical presentation** – Classically, an obese, African-American boy between the ages of 11 to 16 years – Girls present between 10 to 14 years – Some degree of limp – Complaints of groin pain, or referred thigh or knee pain (along the obturator nerve) – On exam, restriction of internal rotation, abduction, and flexion – Unstable SCFE presents more urgently

30 Diagnosis – X-rays – Kline’s line – Bilateral imaging!

31 Treatment – Once diagnosed, should be admitted and placed on bedrest – In situ pinning of the SCFE

32 Debate regarding prophylactic pinning of opposite hip – ~20-40% of children will develop contralateral SCFE Complications – Osteonecrosis – Chondrolysis

33 Noon Conference Today!

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