1. Dr. Fadel Naim Orthopedic Surgeon IUG
Pediatric Hip
Dr. Fadel Naim
Orthopedic Surgeon
IUG

3. Developmental Dysplasia of the Hip ( DDH )

4. The main aim of this presentation is to:
emphasize the importance of the early identification of DDH
The earlier an abnormality of the infant hip is detected, the simpler and more effective the treatment will be

5. Developmental Dysplasia of the Hip (DDH)
DDH is a term used to describe a spectrum of abnormalities affecting the relationship of the femoral head to the acetabulum.
an immature hip
a hip with mild acetabular dysplasia
a hip that is dislocatable
a hip that is subluxated
a hip that is frankly dislocated.

6. Teratologic Hip : Fixed dislocation
Occurrs prenatally
Often with other anomalies
Dislocated Hip : Completely out
May or may not be reducible
Subluxated Hip : Only partially in
Unstable Hip : Femoral head can be dislocated
Acetabular Dysplasia : Shallow Acetabulu
Head Subluxated or in place

7. Epidemiology
1 in 100 newborns examined have evidence of instability ( positive Barlow or Ortolani)
1 in 1000 live births true dislocation
most detectable at birth in nursery
60% stabilize in 1st week and 88% stabilize in first 2 months without treatment remaining 12% true dislocations and persist without treatment

8. Risk Factors associated with DDH
Breech Presentation
Family History of DDH (especially if in parent or sibling)
Female Baby (DDH is 4 X likely to occur in a female infant)
Postnatal Positioning

9. Risk Factors associated with DDH
Breech Presentation
Family History of DDH (especially if in parent or sibling)
Female Baby (DDH is 4 X likely to occur in a female infant)
Postnatal Positioning

10. Risk Factors associated with DDH
decreased intrauterine space
Large Baby (>4kg)
Overdue > 42 weeks
Oligohydramnios
Associated with Plagiocephaly, Torticollis and foot deformities
First born baby or multiple pregnancies

11. PHYSICAL EXAMINATION
The reliability of physical examination changes as the child grows, therefore examination techniques vary depending on the age of the child.

12. Diagnosis Clinical risk factors Physical exam Ortolani Test
Barlow Test

13. Neonatal Examination Ortolani (reduction test)
Feel a Clunk
Not hear a click !

14. Neonatal Examination Barlow (stress test)

15. After 3 months of age, the Ortolani and Barlow tests may be unreliable
Ortolani and Barlow tests are accurate within the first 48 hours of birth and then become increasingly less accurate.
Thus Hip examination ideally should be performed within 48 hours
After 3 months of age, the Ortolani and Barlow tests may be unreliable
therefore additional means of examination, used in combination with the Ortolani and Barlow tests, are necessary

16. Older Infants (> 3 months of age)
restricted abduction at the hips
leg length discrepancy
asymmetrical thigh and gluteal skin folds

17. Restricted Abduction At The Hips
The most sensitive sign associated with DDH in the older infant.
The examination should be performed gradually and may need to be repeated a number of times
Normal range of motion at the hip is abduction to 60˚ or more, with range less than this suggestive of DDH.

18. Leg Length Discrepancy
Total leg length discrepancy should be assessed in prone with hips and knees extended
assessing for leg length discrepancy using the Galeazzi Test.

19. Asymmetrical Skin Folds
Asymmetrical skin folds alone do not constitute a diagnosis of DDH
However this information can be used in combination with other physical signs during assessment.

20. Bilateral Dislocation
Diagnosis more diffecult
Abduction may be decreased symmetrically with bilateral dislocations.
Galeazzi Test may be negative in bilateral dislocations
There may be no asymmetrical skin folds

21. Klisic test
An imaginary line between anterior superior iliac spine and great trochanter should point towards or above the umbilicus.
If dislocated will point below

22. Late Signs In children who are walking If DDH is present in both hips
a limp may be present
the child may toe-walk on the affected side.
If DDH is present in both hips
increased lumbar lordosis
prominent buttocks
a waddling gait

23. Ultrasound Morphologic and dynamic assessment
Indications controversial due to high levels of over-diagnosis
Currently not recommended as a routine screening tool other than in high risk patients

25. Ultrasound

26. Ultrasound
Femoral head
Abductors
Ilium

27. Ultrasound
Femoral head
Abductors
Ilium

28. Ultrasound
Femoral head
Abductors
Ilium

29. Ultrasound Graf’s alpha angle >60 = normal
*line w/ ilium bisects head 50/50

30. If the child is 6 weeks to 5 months of age, Ultrasound (US) is generally the most appropriate imaging technique
If the child is 5 months or greater, X-ray is generally the most appropriate imaging technique
Between 4 and 6 months, US and X-ray are equally effective diagnostic tools

31. Radiography

32. Radiographs Summary Femoral head appears 4 - 7 months Shenton’s line
Perkin’s and Hilgenreiner’s lines
Inferomedial quadrant
Acetabular index
Normal < 30 (Weintroub et al)

33. Radiography

34. Radiological Diagnosis
X-ray findings
Delayed appearance of ossific nucleus
Small ossific nucleus
Dysplastic acetabulum
Proximal displacement of femur
Increased acetabular index ( n=27, >30-35 dysplasia)
Disruption Shenton line

35. Radiography

36. Radiography

37. Radiography in
out

38. Radiography
39o
27o

39. Imaging

40. Imaging

41. Imaging

42. Imaging

43. Imaging

44. Imaging

45. Imaging
< 30 wnl

46. Imaging

47. Imaging

48. Imaging

49. Imaging

50. Treatment Options Age of patient at presentation Family factors
Reducibility of hip
Stability after reduction
Amount of acetabular dysplasia

51. Treatment
The presence of the spherical femoral head within the acetabulum is critical for stimulating normal development of the acetabulum
Aims
Obtain and Maintain concentric reduction
In an Atruamatic fashion
Without disrupting the blood supply

52. Treatment Method depends on Age
The earlier started, the easier the treatment
The earlier started, the better the results
Should be detected EARLY

53. Treatment Birth to 6 months : Pavlik harness or hip spica cast
6 months – 12 months :
closed reduction UGA and hip spica casts
12 months – 18 months :
possible closed / possible open reduction
Above 18 months :
open reduction and ? Acetabuloplasty
Above 2 years :
open reduction,acetabulplasty, and femoral osteotomy
Above 8 years :
open reduction,acetabulplasty cutting three bones, and femoral osteotomy

54. Treatment Hip instability in the neonatal period
Most resolve spontaneously
Observation
Pavlik harness
Double /triple diapers ??

55. Treatment Hip instability in the neonatal period
Double / Triple Diapers
Often inadequate : therefore inappropriate
Gives illusion patient is in “treatment” while wasting valuable time
Most hip instability improves spontaneously in early infancy , giving this ineffective management credit

56. Treatment Birth – 6 months
Hip instability (dislocatable)
Established dislocation (reducible)
Should be actively treated until hip is normal clinically and radiographically
Pavlik harness
Hip Spica Cast

57. Treatment Birth – 6 months Pavlik harness

58. Treatment Birth – 6 months
Other Devices
- Frejka pillow
- Craig
- Von Rosen splint
Soft abduction splints:
Not good enough
Rigid abduction splints:
Risk AVN

59. Treatment 6 – 12 months Initially non operative – closed reduction
Reduction under anesthesia and immobilization in hip spica cast
Position:
Human
Avoid severe abduction
Avoid Frog position
Must be stable and concentrically reduced otherwise needs open reduction

60. Treatment Above 18 months
Open reduction
? and acetabulplasty
? And femoral shortening – if high

61. Treatment Above 3 years
Open reduction
And acetabulplasty
And femoral shortening

62. Salter Osteotomy

63. Redirectional Acetabuloplasty Salter’s

64. Adolescent or Adult
Femoral osteotomy should only be used in conjunction with pelvic procedure as no potential for acetabular growth or remodeling but changing orientation of femur shifts the weight-bearing portion

65. Complications of Treatment
Worst complication is disturbance of growth in proximal femur including the epiphysis and physeal plate
AVN may be due to vascular insults to epiphysis or physeal plate or pressure injury
“ frog leg position “ uniformly results in proximal growth disturbance

66. Legg Calve Perthes Disease
Prepared by
Dr fadel Naim MD
Orthopedic surgeon

67. Legg-Calvé-Perthes disease (LPD) is a childhood hip disorder that results in infarction of the bony epiphysis of the femoral head.
LPD represents idiopathic avascular necrosis of the femoral head.

68. Epidemiology Disorder of the hip in young children Usually ages 4-8yo
As early as 2yo, as late as teens
Boys:Girls= 4-5:1
Bilateral 10-12%
No evidence of inheritance
incidence of positive family hx ranges from 1.6% to 20%

69. Etiology
Unknown
Past theories: infection, inflammation, trauma, congenital
Most current theories involve vascular compromise

70. Pathophysiology
The primary pathologic abnormality is osteonecrosis resulting in flattening and collapse of the femoral head.
The basic underlying cause of LPD is insufficient blood supply to the femoral head.
Healing occurs by revascularization of the necrotic femoral head.

71. Radiographic Stages Four Waldenstrom stages: 1) Initial stage
2) Fragmentation stage
3) Reossification stage
4) Healed stage

72. Initial Stage Early radiographic signs: Widening of medial joint space
“Crescent sign”
Irregular physeal plate
Blurry/ radiolucent metaphysis

73. -

74. Fragmentation Stage
Bony epiphysis begins to fragment

75. Reossification Stage

76. Presentation Often insidious onset of a limp
C/O pain in groin, thigh, knee
17% relate trauma hx
Can have an acute onset

77. Legg-Calve-Perthes Disease
CLINICAL FINDINGS
Prolonged limp
Waddling gait
Pain in groin or thigh
Limited painful motion
Tenderness to palpation over hip
Gluteal Atrophy
Trendelenberg sign Positive
Leg Length Discrepancy

78. Physical Exam
Decreased ROM, especially abduction and internal rotation
Adductor contracture
Trendelenburg test often positive
Muscular atrophy of thigh/buttock/calf
Limb length discrepency

79. Imaging AP pelvis Frog leg lateral
Key= view films sequentially over course of dz
Arthrography
MRI

80. Differential Diagnosis
Important to rule out infectious etiology (septic arthritis, toxic synovitis)
Others:
Chondrolysis -Neoplasm
JRA Sickle Cell
Osteomyelitis Traumatic AVN
Lymphoma Medication

81. Lateral Pillar Classification
3 groups:
A) no lateral pillar involvment
B) >50% lat height intact
C) <50% lat height intact

82. Prognosis 60% of kids do well without tx AGE is key prognostic factor:
<6yo= good outcome regardless of tx
6-8yo= not always good results with just containment
>9yo= containment option is questionable, poorer prognosis, significant residual defect
Flat femoral head incongruent with acetabulum= worst prognosis

83. The Goal of Treatment The goal of treatment is four-fold:
I) to reduce hip irritability
2) restore and maintain hip mobility
3) to prevent the ball from extruding or collapsing
4) to regain a spherical femoral head

84. Non-operative Tx Improve ROM 1st
-abduction usually affected most of ROM
-use PT to regain abduction (overcome spasm) and internal rotation
-may require several weeks of abduction traction

85. Non-operative Tx Bracing: Not necessarily NWB
Removable abduction orthosis
Pietrie casts
Hips abducted and internally rotated
Not necessarily NWB
Hips braced in abd/ int rotation to transmit weight over wide area of acetabulum, prevents head collapse
Wean from brace when improved x-ray healing signs

86. Bracing

87. Non-operative Tx Check serial radiographs Continue bracing until:
Q3-4 mos with ROM testing
Continue bracing until:
Lateral column ossifies
Sclerotic areas in epiphysis gone
Cast/brace uninvolved side

88. Operative Tx If non-op tx cannot maintain containment
Surgically ideal pt:
6-9yo
Catterral II-III
Good ROM
In collapsing phase

89. Surgical Tx Surgical options:
Excise lat extruding head portion to stop hinging abduction
Acetabular (innominate) osteotomy to cover head
Varus femoral osteotomy
Arthrodesis

91. Late Effects of LCP Coxa magna Physeal arrest patterns
Irregular head formation
Osteochondritis dessicans

92. Slipped Capital Femoral Epiphysis
SCFE

93. Definition
The femoral neck and shaft displace upward and anteriorly on the capital epiphysis, which displaces primarily posteriorly relative to the femoral neck

96. Classification According to the onset:
1-acute
2-chronic
3-acute on chronic
According to ability to bear weight:
1-stable
2-unstable
According to the displacement extent:
1-mild
2-moderate
3-severe

97. Etiology Endocrine Mechanical Hypothyroid Growth hormone treatment
63% > 95th percentile weight

98. Klein’s Line

101. GRADING
Grade I
Grade II
Grade III

102. GRADE I
< 1/3 Slip

103. Grade II

104. GRADING
Grade III

105. Frog Pelvis Radiograph
Posterior slip
Wide, irregular physis

106. Pre-Op

107. Early Post-Op

108. Post-Op (14y/o)

109. COMPLICATIONS AVN Chondrolysis Hardware Penetration
Long-term results are dependent upon avoiding these complications

110. Thank you for attention