Hip
Disorders
Developmental
Dysplasia of the Hip/Congenital Dislocation of the Hip
Developmental
dysplasia is preferred term – varies from a displacement of
femoral head from acetabulum to a radiographic abnormality of acetabulum
formation. Dislocation occurs in 1.5 per 1000 births. 1 in 60 at
risk. F>M. L>R. 20% bilateral. Usually picked up at birth
due to screening. A few may be detected later as a gait problem.
Aetiology
Unknown
(higher risk for breach presentation; flattened acetabulum; females;
family history; higher levels of relaxin during labour; first born;
Down syndrome).
Clinical
tests (high number of false positive and false negatives):
* Barlow’s test: - Test for ligamentous laxity; place infant
on back with hips and knees fully flexed; apply thumb pressure in
an anterior-posterior direction over the lessor trochanter to dislocate
femoral head posteriorly; release thumbs - allows head to slip back
into socket; if dislocation/relocation occurs - unstable hips.
* Ortolani Manoeuvre: - Knees flexed, hips flexed to 90 degrees
and abducted; during abduction of the hips, a previously dislocated
femoral head “clunks” in over the posterior rim of the
acetabulum.
* Limitation of abduction: - Limitation of 50 degrees or less is
a reliable sign
* Less significant clinical tests: - Asymmetry of skin fold in thigh
and buttocks; telescoping – pushing the leg beyond the usual
hip joint articulation; Galeazzi’s sign – apparent shortening
of the affected limb when the dislocation is unilateral; Trendelenburg
test – when reach weightbearing age; femoral head palpation;
bulging of flesh near the femoral head; delayed locomotion.
Radiographic:
- definitive. Can also be detected by ultrasound. X-rays will also
detect the maldevelopmental problems of the acetabulum (acetabular
dysplasia).
Treatment:
Less than one year of age – splinting hip in flexed and abducted
position
After one year – traction to force femoral head back into
acetabulum
Up to five years – rotational osteotomy of femur usually needed
After seven years – arthroplasty of hip and later a hip prothesis
may be needed.
Online
resources:
Developmental
Dislocation of the Hips by Dr David Little
Screening
for Developmental Dysplasia of the Hip - full text from the
American Family Physician
Coxa Vara
Decrease
in angle of head and neck to shaft of femur (<125 degrees). Thought
to be due to a defect in ossification/development of femoral neck.
Bilateral in up to 50%. Usually present between ages 2 to 6. Lurching/waddling
gait type gait that is not painful – may just be a limp if
unilateral. Abduction and internal rotation of leg is restricted.
Genu valgum is common.
Surgical
management indicated if significant/severe.
Coxa Valga
Increase
in angle between head/neck of femur and shaft (>140 degrees)
in the frontal plane. The angle is normally about 150 degrees at
births, but weightbearing and muscle pull should decrease this to
125-130 degrees by adulthood. If not - limb on affected side is
in a position of outward rotation and abducted, usually have genu
varus.
Slipped capital femoral epiphysis
(SCFE)
Relatively
rare surgical emergency. Most common in ages 12 - 15. 25% bilateral.
M>F. Characterised by disruption of structural integrity of the
epiphyseal plate of femur - displacement of head relative to neck
of femur - potential for vascular disruption. Similar to Salter
Harris type 1 fracture. Present with limp and pain over anterior
aspect of hip – gait is often antalgic and externally rotated;
usually unable to bear weight on affected side. Joint is tender
and internal rotation is restricted. May get referred pain to knee.
On examination leg appears shorter, hip abduction and internal rotation
is restricted. Surgical intervention is needed (pinning and maybe
osteotomy).
Transient synovitis
Common
cause of hip pain and limping in children – severe cases account
for 0.5% of all paediatric admissions to hospital.
Benign
form of synovial irritation of unknown cause.
Clinical
features:
3 – 8 years of age; M>F; 5% bilateral; pain in hip and
groin – can be referred to medial knee; tender to palpation;
may have muscle spasm; hip range of motion is limited; limp; occasional
low grade fever
Treatment:
Usually self-limiting – lasts 3-10 days.
NSAID’s for symptomatic relief.
Online
resources:
ePodiatry's
links to online resources on hip
problems |
