Congenital hip disease Ddh Perthes disease SLIPPED CAPITAL FEMORAL EPIPHYSIS

1. CONGENITAL HIP DISEASE
DR VIVESH KR SINGH
MS ORTHOPAEDIC

2. DDH
•Dysplasia of the hip that develop during fetal life or in infancy.
•It ranges from dysplasia of the acetabulum (shallow acetabulum) to
subluxation of the joint to complete dislocation.
•Complete hip dislocation.
•Partial hip subluxation.
•Acetabular dysplasia (incomplete development).
•Dislocatable hip

4. Incidence of developmental dysplasia of the
hip has been estimated to be approximately 1
in 1000 live births.
DDH is more common among female
patients
Associated conditions:
- Torticollis
- Metatarsus adducts
- Talipes calcaneovalgus

5. •Types:
•DDH is classified into two major groups :
•Typical and teratologic .
•Typical DDH occurs in otherwise normal patients or
those without defined syndromes or genetic conditions.
•Teratologic hip dislocations usually have identifiable
causes such as arthrogyposis or a genetic syndrome and
occur before birth.

6. Teratological DDH
•Irreducible.
•False acetabulum.
•Defective anterior acetabulum “anteverted”.
•Increased femoral neck anteversion.

8. Clinical Presentation
Neonatal Presentation
Exam one hip at a time
Baby must be quiet
Barlow’s sign: provocative maneuver
Ortolani’s sign: reduces hip
Other signs not helpful in newborn

9. CLINICAL FINDINGS
•IN NEWBORNS
•Usually asymptomatic and must be screened by special
maneuvers
•1) Barlow test.
It is a provocative test that attempts to dislocate an
unstable hip.
-Flexion, adduction, posteriorly.
-“Clunk”

10. Barlow test for DDH in a neonate

11. 2) Ortolani test
It is a maneuver to reduce a recently dislocated hip.
Flexion, abduction, anteriorly.
We can`t use X-rays because the acetabulum and
proximal femur are cartilaginous and wont be shown
on X-ray.
USG is the best method to Dx.

12. ORTOLANI TEST

13. Clinical Manifestations
•In infants:
•As the baby enters the 2nd and 3rd months of life, the soft
tissues begin to tighten and the Ortolani and Barlow tests
are no longer reliable.
•Shortening of the thigh, the Galeazzi sign , is best
appreciated by placing both hips in 90 degrees of flexion and
comparing the height of the knees, looking for asymmetry

14. •The most diagnostic sign is Ortolani’s limitation of
abduction.
•Abduction less than 60 degrees is almost diagnostic.
•X-rays after the age of 3 months can be helpful
especially after the appearance of the ossific nucleus of
the femoral head
•USG is 100% diagnostic.

15. Infant Presentation
•Skin fold asymmetry
•Limited hip abduction
•Unequal femoral lengths (Galeazzi’s sign)

16. • GALEAZZI’S SIGN.

17. Skin fold Asymmetry

19. Physical examination
NEONATE INFANT WALKING CHILD
Dislocatable Dislocatable Remains dislocated
Reducible Reducible Klisic sign
Klisic sign Klisic sign Decreased abduction
Galleaxi sign Shortening
Decreased abduction Hyperlordosis

20. PERTHES DISEASE

21. Epidemiology
• Disorder of the hip in young children • Usually ages 4-8yrs
• As early as 2yrs, as late as teens
• Boys:Girls= 4-5:1
• Bilateral 10-12%

22. Etiology
• Disorder of the hip in young children • Usually ages 4-8yrs
• As early as 2yrs, as late as teens
• Boys:Girls= 4-5:1
• Bilateral 10-12%

23. Presentation
• Often insidious onset of painless limp, increases by activity.
• May complain of pain in groin, thigh, knee
• Few relate trauma history
• Can have an acute onset

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

25. Imaging
• AP pelvis
• Frog leg view and lateral view
• Bone scan - shows decreased uptake

26. Radio graphic stages
• Four Waldenstrom stages:
• 1) Ischaemia and bone death(stage of avascular necrosis)
• 2) Fragmentation stage
• 3) Reossification stage
• 4)Remodelling

27. Stage of Avascular necrosis

28. Crescent sign
Stage of revasculaization

29. Stage of ossification

30. Sagging Rope sign
• Radio dense line overlying proximal
femoral metaphysis, a result of growth
plate damage with metaphysial response

31. Salter Thompson classification
• BASED ON EXTENT OF SUBCHONDRAL
FRACTURE-
• A> LESS THAN HALF OF FEMORAL HEAD
INVOLVED
• B> MORE THAN HALF OF THE FEMORAL HEAD
INVOLVED

33. Catterall classification
• Based on extent of
epiphyseal involvement
and percentage of
collapse as seen in x-
ray (both AP and
Lateral view)

34. SLIPPED CAPITAL FEMORAL EPIPHYSIS

35. SLIPPED CAPITAL FEMORAL EPIPHYSIS
• Femoral neck and shaft displace relative to the femoral epiphysis and the
acetabulum
• Usually, upward & anterior
• Head remains posterior and downward in the acetabulum.

36. Displacements
• Femoral epiphysis displacing relative femoral neck :
• i) Posterior-a varus relation M.C
• ii) Forward (anteriorly)
• iii) Laterally (into a valgus position)

37. Displacement

38. Patho-anatomy

39. Growth plate
• Reserve Zone
• Composed of chondrocytes
• Type II collagen is present in its highest amount
• Oxygen tension is low
• Proliferative Zone
• Chondrocytes form matrix
• Oxygen tension is high
• Rich vascular supply.
• The majority of the longitudinal growth of the growth plate occurs in this zone.

40. • Hypertrophic Zone
• The zone is avascular,
• low oxygen tension (similar to the reserve zone).
• Chondrocytes prepare matrix for mineralization and calcification.
• Slip occurs through the weakest structural area of the plate, the hypertrophic
zone.

41. ETIOLOGY
• Often unknown
• Majority are normal by current endocrine work-up
• Etiologic –
• Altering the strength of the zone of hypertrophy
• Affecting the shear stress to the plate
• 1)Endocrine
• 2)Mechanical

42. Mechanical Factors
• Predisposing features:
• Thinning of perichondral ring complex
• Retroversion of femoral neck
• Change in inclination of prox femoral physis relative to
femoral neck/shaft

43. CLINICAL FEATURES
• Preslip phase-
• i)Weakness in the leg
• ii) limping on exertion;
• iii)On physical examination,
• Lack of medial rotation of hip , hip in extension.
• Affected leg is fixed, the thigh goes into abduction and external rotation.

44. Unstable Acute or Acute-on-Chronic Slipped Capital Femoral Epiphysis
• The clinical criterion- acute onset of symptoms < 2 weeks
• Prodromal symptoms - weakness, limp, and intermittent groin, medial thigh, or knee
pain , Uable to weight bear.
• Antalgic gait
• An external rotation deformity
• Shortening
• limitation of motion.
• The greater the amount of slip, the greater is the restriction of motion.

45. CHRONIC SLIP/ STABLE SLIP
• i) Groin or medial thigh/knee pain for months to years.
• ii) Exacerbations and remissions of the pain or limp
• iii) Limitation of motion(particularly medial rotation) the leg fixed external
rotation
• iv) Increased- hip extension, external rotation, Adduction
• Decreased: Flexion , internal rotation ,abduction.

46. • v) Antalgic limp
• vi) Local tenderness over the hip joint
• vii) Shortening
• viii) Thigh or calf atrophy.
• ix) Hip flexion contracture -Chondrolysis.

47. Causes of Limp & Hip, Thigh or Knee Pain in Children

48. THANK YOU