Developmental Dysplasia of the Hip1

7/31/2019 Developmental Dysplasia of the Hip1

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LimpingChild

By : Yasmine Demirauz ,Raghda Faraj

Afnan Alghamdi, Mawadda Zwawi


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What does limping child mean?

It is defined as any deviation or asymmetry from a normal gait

pattern for the childs age.

Definition


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A limp at one hospital emergency department

was the presenting complaint in 2 % of children.

It occurs twice as commonly in boys as in girls

Epidemiology


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The gait cycle is divided to two phases:

The stance phase: 60% of all gait cycle.Heal >> foot >> toes

The swing phase: 40% of normal gait cycle.

Gait cycle


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The diagnosis of the cause of a limp is often madebased on history, physical exam findings,

laboratory tests, and radiological examination.

If a limp is associated with pain it should be

urgently investigated, while non-painful limps canbe approached and investigated more gradually.

Young children have difficult determining thelocation of leg pain thus in this population knee

pain equals hip pain. A SCFE can usually be excluded on an X-ray of the

hips. A ultrasound or xray guided aspiration of thehip joint maybe required to rule out an infectious

process within the hip.

Diagnostic approach


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Differential diagnosis


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The history for a child with a limp should be taken in details asfollowing:

Onset, duration and progression? (acute-chronic) Recent trauma and mechanism?

Associated pain and its characteristics? Accompanying weakness?

Time of day when limp is worse? ( rheumatologic-malignancy) Can the child walk or bear weight?

Has the limp interfered with normal activities? (Severity) Presence of systemic symptoms like fever, weight loss? Do not forget the medical history, BINDbirth history,

immunization history, nutritional history, and developmental

history Also include the other essentialsdrug history , allergies and

history


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1

2

Developmental Dysplasia of the Hip (DDH)

Special Conditions

Transient Synovitis

OsgoodSchlatter syndrome


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Definition: Is a self-limiting condition in which there is an inflammation of theinner lining (the synovium) of the capsuleof the hip joint. Transient synovitis usually affects children between three and tenyears old. It is the most common cause of sudden hip pain and limp in youngchildren. Boys are affected two to four times as often as girls.

Causes:1- Unknown.2- Recent viral infection(most commonly an upper respiratory tractinfection)

3- Trauma

Transient Synovitis


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Symptoms:

1- pain in the hip, thigh, groin or knee on the affected side.2-There may be a limp (or abnormal crawling in infants) with or

without pain.

3-In small infants, the presenting complaint can be unexplained

crying (for example, when changing a nappy). 4-Some children may have a slightly raised temperature; high

fever and general malaise point to other, more serious conditions.

Signs:

1- the child typically holds the hip slightly bent, turned outwards andaway from the middle line (flexion, external rotation and abduction).

2- Active and passive movements may be limited because of pain,especially abduction and internal rotation.

3-The hip can be tender to palpation.

Cont.


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Inflammatory parameters in the blood may beslightly raised (these include erythrocyte

sedimentation rate, C-reactive protein and whiteblood cell count), but raised inflammatory markers

are strong predictors of other more seriousconditions such as septic Arthritis

2-X-ray imaging

3-ultrasound scan of the hip can easily demonstrate

fluid inside the joint capsule4-magnetic resonance imaging (MRI scan) that can

differentiate between septic arthritis and transientsynovitis (for example, signal intensityof adjacent

bone marrow

Cont .


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(also known as tibial tubercle apophyseal traction injury) is anirritation of the patellar tendon at the tibial tuberosity

The condition is usually self-limiting and is caused by stress on the

patellar tendon that attaches the quadriceps muscle at the front ofthe thigh to the tibial tuberosity This can cause multiple subacute avulsion fractures along withinflammation of the tendon, leading to excess bone growth in the

tuberosity and producing a visible lump which can be very painfulwhen hit.

OsgoodSchlatter syndrome
http://en.wikipedia.org/wiki/Tibial_tuberosityhttp://en.wikipedia.org/wiki/Patellar_ligamenthttp://en.wikipedia.org/wiki/Quadriceps_femoris_musclehttp://en.wikipedia.org/wiki/Thighhttp://en.wikipedia.org/wiki/Tibiahttp://en.wikipedia.org/wiki/Avulsion_fracturehttp://en.wikipedia.org/wiki/Avulsion_fracturehttp://en.wikipedia.org/wiki/Tibiahttp://en.wikipedia.org/wiki/Thighhttp://en.wikipedia.org/wiki/Quadriceps_femoris_musclehttp://en.wikipedia.org/wiki/Patellar_ligamenthttp://en.wikipedia.org/wiki/Tibial_tuberosity


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Sign and symptoms of Osgood-

Schlatter disease include: Pain, swelling and tenderness at the bony

prominence on the upper shinbone, just below thekneecap

Knee pain that worsens with activity especiallyrunning, jumping and climbing stairs and improves

with rest

Tightness of the surrounding muscles, especiallythe thigh muscles (quadriceps)

Risk factors

Cont.


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How is Osgood-Schlatter disease

diagnosed?

the disease can be diagnosed clinically basedon the typical symptoms and physical

examination findings.

X-ray testing is sometime performed inorder to document the status of the

calcification at the insertion of kneecap(patellar) tendon. Sometimes a tiny piece of

the bone of the tibia actually is pulled away

Cont.


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Lateral radiograph of the knee demonstratingfragmentation of the tibial tubercle with overlying

soft tissue swelling


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Radiograph of a patient who is skeletally immature.The tubercle is elongated and fragmented


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Radiograph of a patient who is skeletally mature. Notethat the tibial tubercle is enlarged and there is an

ossicle. A bursa was overlying this


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(SCFE) is a hip problem that starts if the epiphysis (growing end) of the

femur slips from the ball of the hip joint. SCFE may develop in

one leg or it may occur in both legs but The left hip is affectedmore commonly than the right

Males have 2.4 times the risk compared with females.

Risk factors Mechanical: local trauma, obesity.

Inflammatory conditions: neglected septic arthritis.

Hypothyroidism,hypopituitarism, growth hormone deficiency,pseudohypoparathyroidism.

Slipped capital femoral epiphysis

(SCFE)
http://www.patient.co.uk/DisplayConcepts.asp?WordId=OBESITY&MaxResults=50http://www.patient.co.uk/DisplayConcepts.asp?WordId=HYPOTHYROIDISM&MaxResults=50http://www.patient.co.uk/DisplayConcepts.asp?WordId=HYPOPITUITARISM&MaxResults=50http://www.patient.co.uk/DisplayConcepts.asp?WordId=HYPOPITUITARISM&MaxResults=50http://www.patient.co.uk/DisplayConcepts.asp?WordId=HYPOTHYROIDISM&MaxResults=50http://www.patient.co.uk/DisplayConcepts.asp?WordId=OBESITY&MaxResults=50


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Symptoms and signs

Limping

Stiffness in the hip

One leg may appear shorter than the other

Knee pain

Hip pain

Hip stiffness

Outward-turning leg and Rotated foot

More severe cases of hip conditions areaccompanied by extreme pain and the inability to

move the affected leg
http://www.nlm.nih.gov/medlineplus/ency/article/003187.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003179.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003261.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003261.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003179.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003187.htm


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Anteroposterior and 'frog-leg' lateral X-rays showwidening of epiphyseal line or displacement of the

femoral head.

Earliest findings include globular swelling of the

joint capsule, irregular widening of the epiphysealline and decalcification of the epiphyseal border of

the metaphysis.

Epiphysis normally extends slightly cephalad to the

upper border of the femoral neck. Small amounts of slippage can be detected by the

epiphyseal edge, becoming flush with the superiorborder of the neck.

Investigations


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A Klein line is a line drawn along the superior border of the femoralneck that would normally pass through a portion of the femoral

head. If not, slipped capital femoral epiphysis is diagnosed

Lateral view showing an early slipped capital femoral


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Lateral view showing an early slipped capital femoralepiphysis. Note the subtle posterior step-off of the

epiphysis on the metaphysis at the physeal level(arrow).


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No medical therapy is available for the treatmentof slipped capital femoral epiphysis (SCFE) except

symptomatic pain relief. Medications may includeacetaminophen, nonsteroidal anti-inflammatory

drugs, or narcotics, depending on the physician'spreference

Possible Complications

This disorder is associated with a greater risk ofosteoarthritis later in life

Chondrolysis (degeneration of the articularcartilage),

avascular necrosis of the epiphysis,.

Manegment
http://www.nlm.nih.gov/medlineplus/ency/article/000423.htmhttp://www.patient.co.uk/DisplayConcepts.asp?WordId=AVASCULAR%20NECROSIS&MaxResults=50http://www.patient.co.uk/DisplayConcepts.asp?WordId=AVASCULAR%20NECROSIS&MaxResults=50http://www.nlm.nih.gov/medlineplus/ency/article/000423.htm


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Differences between the lengths of the upperand/or lower arms and the upper and/or lower legs.

There are many causes ofLLD. Some include:

Previous injury to a bone in theleg

Bone infection Bone diseases (dysplasias)

Inflammation (arthritis) other

Limb Length Discrepancy


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Symptoms

It depends on the causeand size of the

difference..

Continued


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1- a shoe lift

2-surgical repair

Treatment Options

D l l D l i f


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Its abnormal development of the hip with respect toinstability of the hip joint and dysplasia (abnormal

shape) of the acetabulum.

Developmental Dysplasia of

the Hip (DDH)


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Presentation ranges from: Instability on the newborn examination slight limited abduction in the infant. Asymmetric gait in the toddler. Activity-related pain in the adolescent. Osteoarthritis in the adult.

Clinical manifestation


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History of presenting illness (who notice,affect his life severity-, when noticefirst time).

Risk factors: Limited fetal mobility(breech position,

oligohydramnios, and firstborn infan). Breech positioning: the greatest risk factor.

Female sex: four times more than male infants. Family history of DDH.

Other factors to be considered: birth orderand musculoskeletal abnormalities related to

tight intrauterine packaging (eg, torticollis andmetatarsus adductus .

History


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3 -12 months: Limitation of hip abduction in 90 of flexion

Marked asymmetry of leg creases

After the child begins to walk: Excessive lumbar lordosis

Prominent greater trochanter

Gluteus medius lurch +ve Trendelenburg sign

Short leg limp, with toe-heel gait >>> out-toeing


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Barlow and Ortolani


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A. Normal inguinal folds do not extend beyond the anal aperture (*).

B. The inguinal fold on the right extends beyond the anal aperture,suggesting possible developmental dysplasia of the right hip.

C. The inguinal folds on both sides extend beyond the anal aperture,suggesting bilateral developmental dysplasia of the hip.

Asymmetric inguinal folds


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The patient is positioned as shown. The knee is loweron the affected side because of posterior displacement in

the developmentally dysplastic hip (arrow).

Galeazzi test


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Trendelenburg test


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Ultrasonography: Primary technique for assessing the morphology and stability of the

hip until three to five months of age.

Investigation


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Plain radiographs: After three months of age, plain radiographs are more

valuable in the evaluation.

radiographic findings include:

Lateral and superior positioning of the ossified portion of the femoralhead and neck

Increased acetabular index (>40 in newborn or infant)

Delayed appearance of the femoral ossific nucleus on the involved sideor dissimilar sizes of the femoral ossific nuclei

Other imaging: computed tomography (CT)


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Goals of treatment :

Obtain and maintain concentric reduction of the hip to

provide an optimal environment for the development of thefemoral head and acetabulum.

TREATMENT


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AGE LESS THAN SIX MONTHS: Abduction splints (Pavlik harness)


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AGE 6 TO 18 MONTHS: Closed or open reduction usually necessary.

The success rate for the Pavlik harness treatment in children

in this age group is less than 50 percent, and there is a higherrisk of osteonecrosis.

AGE 18 MONTHS AND OLDER : Open reduction is usually needed. long-term problems (stiffness, failure of treatment, residual

dysplasia, and osteonecrosis) are greater in older patients thanin those who are treated earlier.


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Limping in children is never normal. Physiciansproviding care to children need to be

knowledgeable regarding the diagnosis andmanagement of limping. A systematic approach

should include a thorough history and physicalexamination, and, if necessary, appropriate imagingstudies and laboratory testing. A timely diagnosis

will result in a more optimal outcome

Summary


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ThankYou !


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DevelopmentalDysplasia of theHip(DDH)


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Introduction

Its abnormal development of the hip withrespect to instability of the hip joint anddysplasia (abnormal shape) of theacetabulum.


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Clinical manifestation

Presentation ranges from: Instability on the newborn examination slight limited abduction in the infant. Asymmetric gait in the toddler. Activity-related pain in the adolescent. Osteoarthritis in the adult.


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History

History of presenting illness (who notice,affect his life severity-, when notice firsttime).

Risk factors:

Limited fetal mobility(breech position,oligohydramnios, and firstborn infan).

Breech positioning: the greatest risk factor.

Female sex: four times more than male infants.

Family history of DDH.

Other factors to be considered: birth order andmusculoskeletal abnormalities related to tightintrauterine packaging (eg, torticollis andmetatarsus adductus).


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Physical

The examination findings of DDH varyaccording to age:

Birth- 3 m.: +ve Ortolani and Barlow tests

Asymmetric leg folds (inguinal, gluteal, thigh,popliteal)

Apparent shortening of the femur (Galeazzi,sign)

Associated findings: Metatarsus adducts,

Clubfoot, Torticollis.


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3 -12 months: Limitation of hip abduction in 90 of flexion

Marked asymmetry of leg creases

After the child begins to walk: Excessive lumbar lordosis

Prominent greater trochanter

Gluteus medius lurch

+ve Trendelenburg sign

Short leg limp, with toe-heel gait >>> out-toeing


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Barlow and Ortolani


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Asymmetric inguinal folds

A. Normal inguinal folds do not extend beyond the anal

aperture (*).B. The inguinal fold on the right extends beyond the anal

aperture, suggesting possible developmental dysplasia ofthe right hip.

C. The inguinal folds on both sides extend beyond the analaperture, suggesting bilateral developmental dysplasia of

the hip.

Galeazzi test


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Galeazzi test

The patient is positioned as shown. The knee is lower onthe affected side because of posterior displacement in thedevelopmentally dysplastic hip (arrow).


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d l b


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Trendelenburg test


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The Klisic test for hip dislocation

Placing the index finger on ASIS and the middlefinger on the greater trochanter.

An imaginary line between these two points shouldpoint toward or above the umbilicus. The line will

pass below the umbilicus if the hip is dislocated.


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Plain radiographs: After three months of age, plain radiographs are

more valuable in the evaluation.

radiographic findings include: Lateral and superior positioning of the ossified portion of

the femoral head and neck

Increased acetabular index (>40 in newborn or infant)

Delayed appearance of the femoral ossific nucleus on theinvolved side or dissimilar sizes of the femoral ossific

nuclei

Other imaging: computed tomography (CT)

TREATMENT


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TREATMENT

Goals of treatment :Obtain and maintain concentric reduction of the hip to

provide an optimal environment for the development of thefemoral head and acetabulum.


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AGE LESS THAN SIX MONTHS: Abduction splints (Pavlik harness)


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AGE 6 TO 18 MONTHS: Closed or open reduction usually necessary.

The success rate for the Pavlik harnesstreatment in children in this age group is lessthan 50 percent, and there is a higher risk ofosteonecrosis.

AGE 18 MONTHS AND OLDER : Open reduction is usually needed.

long-term problems (stiffness, failure oftreatment, residual dysplasia, and osteonecrosis)are greater in older patients than in those who

are treated earlier.


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Irritable hipTransient synovitis

I t d ti


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Introduction

Irritable hip is a common childhoodcondition that causes symptoms such as hippain and limping.

Affect boys and girls of any age. Affects

boys twice than girls. It's most often seen in boys aged 4-10.

Usually a mild condition & don't requirespecific treatment.

S t


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Symptoms

Symptoms for less than a week Main symptom is pain in one of the hips. The pain

isn't usually severe, but it may prevent the childfrom placing weight on the affected leg, and it maycause them to limp.

Children unable to speak, the only noticeablesymptom may be them crying at night.

Slightly higher temperature than normal.

E i ti


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Examination

the affected leg tends to be held in theposition of greatest ease, typically, one offlexion, abduction and slight externalrotation.

Movement is restricted especiallyextension and adduction which bothincrease intracapsular pressure.

The child is otherwise well.

Laboratory:


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Laboratory: May be mild elevation of: WBC, ESR,CRP

Radiology: Plain x-ray

Usually normal.

Performed to exclude other conditions.

Ultrasound

May show effusion

Bone scan Shows variable pattern

Routine use not indicated

Treatment


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Treatment

Conservative. Bed rest and analgesia until full ROM

achieved

NSAIDs.

Traction only for severe cases that fail tosettle.

Partial weight bearing on crutches untillimp resolves.

Usual resolve within 2 weeks.

Documents

Developmental Dysplasia of the Hip1