1. ADOLESCENT HIPADOLESCENT HIPADOLESCENT HIPADOLESCENT HIP

5. What does the parents
complain of ?
Limping
Pain in hip
Knee pain

6. What could it be due to ?
 Transient synovitis
 Perthes disease
 Slipped capital femoral epiphysis
 Idiopathic Chondrolysis
 Septic arthritis
 Tuberculous arthritis
 Trauma
 Tumours

7. TRANSIENT SYNOVITIS HIPTRANSIENT SYNOVITIS HIP
Benign self limiting
Most common cause of hip
pain in children

8. AETIOLOGYAETIOLOGY
 Unknown
 Trauma
 Allergic manifestation
 infection

9. SYNOVITIS HIPSYNOVITIS HIP
 Unilateral hip pain
 3 – 18 years
 Limb and antalgic gait
 ROM restricted

10. DIAGNOSIS IS BY
EXCLUSION

11. INVESTIGATIONSINVESTIGATIONS
Usually within normal limits
USG – joint effusion

12. Complete resolution is theComplete resolution is the
rule usually within 3-4rule usually within 3-4
weeksweeks

13. TREATMENTTREATMENT
 Strict bed rest and non-weight
bearing
 Skin traction – recurrent symptoms

14. SEPTIC ARTHRITISSEPTIC ARTHRITIS
True orthopaedic emergency
Any age – common in infants
and children

15. Clinical features
Febrile and toxic
Swollen and painful joint
Pseudoparalysis

16. The key to treatment
is early diagnosis
with a high index of
suspicion and early
removal of pus from
the joint.

17. Investigations
Raised total count
Raised ESR
Raised CRP

18. TREATMENT
Early diagnosis
Arthrotomy
Antibiotics
Splintage – rest -- traction

19. Complications
Osteomyelitis
Dislocation
Avascular necrosis
Late osteoarthritis

22. SLIPPED CAPITALSLIPPED CAPITAL
FEMORAL EPIPHYSISFEMORAL EPIPHYSIS
A true adolescent problem

23. Gradual or acute slip
through the capital
femoral physis

24. SLIPPING

25. SLIPPED CAPITAL FEMORALSLIPPED CAPITAL FEMORAL
EPIPHYSISEPIPHYSIS
clinical profile pictureclinical profile picture

26. SCFE
Boys more than girls
Left more than right
Bilateral – 20 %

27. Etiology
Exact cause – unknown
Hormonal
Trauma
Mechanical factors

28. Classification
Preslip
Acute
Chronic
Acute on chronic

29. Preslip
Weakness or pain in the thigh or
knee
Limitation of internal rotation
X-ray – widening of the physis

31. Acute
 Less than 3 weeks duration
 Trauma – may be insignificant
 Bedridden – antalgic gait
 Shortening
 External rotation deformity
 Axis deviation

33. Acute on chronic
Mild trauma results in
increase in the prodromal
pain present for more than 3
weeks

34. Chronic
Intermittent pain present for
more than 3 weeks.

35. Investigations
X-ray – AP
Frog leg lateral view
( contraindicated when
suspecting acute slip)

36. Eyes
do not see
what mind
does not know
It is true
about reading
x-rays also

42. Goal of treatment
 Promote early physeal closure
 Prevent additional slipping
 Relieve pain
 Correct deformity
 Restore function of hip
 Prevent complications

43. Conservative management
Rest
Analgesics

44. Surgical treatment is the
standard

45. Surgical options
Insitu pinning
Reduction and fixation
Corrective osteotomies

46. Insitu pinning
Image intensifier control
Cannulated screw fixation

47. C-ARMC-ARM

52. Complications
Chondrolysis
Avascular necrosis
Secondary osteoarthritis

54. PERTHES DISEASE
Common problem
4 – 12 years of age
Male > female (4:1)
Low socioeconomic status

55. Late onset Perthes after
the age of 9 years.

56. Etiology
Exact etiology – unknown
Current theory – vascular
embarrassment
Increased intra-osseous
pressure

57. This results in avascular
necrosis of the capital
femoral epiphysis.

58. Clinical features
Painless limping

59. CLINICAL PROFILE
Abduction-Internal rotation
limited
Flexion variably limited
Adduction deformity
Limb-length discrepancy

60. INVESTIGATIONS
X-ray --- AP & FROG LEG
LATERAL
Sclerosis of the epiphysis
Collapse of the epiphysis
Subchondral fracture

61. MRI – to know the shape
of the cartilage
ARTHROGRAM

62. ARTHROGRAM

63. Subchondral fracture
heralds the onset of
clinical Perthes.

69. MANAGEMENT
Depends on stage of disease
Shape of the head
Management of complications

70. CATERALLCATERALL CLASSIFICATIONCLASSIFICATION
 Group I only ant. part of
epiphysis involved
 Group II ¼ to ½ involved
 Group III upto ¾ involved
head at risk sign
 Group IV whole epiphysis
sequestrated

71. Guiding principle in the
treatment is the
containment of the
femoral head in the
acetabulum.

72. Treatment options
Conservative
Surgical
Supervised neglect

73. In the initial synovitis stage
treatment is by skin
traction

74. Conservative treatment
Time consuming
Difficult for parents and child
Psychological problems

76. Surgical treatment
Contain head by osteotomies
Femoral or acetabular
Varus derotation osteotomy of
femur commonly done

77. VARUS DEROTATION
OSTEOTOMY
 Redistributes the
load on the femoral
head more
uniformly
 Relaxes the
muscles by
increasing the
functional length
of the femoral neck
 Enhances the
reciprocal
moulding of the
head-
BIOLOGICAL
PLASTICITY
 Improves blood
supply & healing

103. Complications
Hinged abduction
Chondrolysis
Secondary osteoarthritis

105. TB HIPTB HIP
Not so uncommon in our
practice
Family history of TB

106. TB HIPTB HIP
Limp – commonest presentation
Night cries
Stiffness
Wasting
Fever
Weight loss

107. TB HIPTB HIP
Raised ESR
Mantoux test
X-ray
PCR
IgM antibody assay
Biopsy

108. TB HIP- X-RAYTB HIP- X-RAY
 Osteoporosis
 Travelling acetabulum
 Dislocated hip
 Mortar and pestle appearance
 Perthes type
 Protrusio acetabuli
 Destruction of head

109. TB HIPTB HIP
 ATT
 Traction
 Splintage
 Surgery – last resort

110. IDIOPATHIC
CHONDROLYSIS

111. Progressive destruction
of articular cartilage with
effusion and joint space
narrowing.

112. Girls -- 9 – 18 years
Insidious onset
Pain
Limping
Stiffness

113. Investigations
X-ray -- joint space
narrowing
Blood – within normal limits
MRI

114. TREATMENT
NSAID’s
Aggressive physical therapy
(CPM)
Periodic traction
Bed rest
Prolonged non - weight bearing

115. Questions & Comments