Age related changes in blood supply to EpiphysisAge < 4Receives blood from the metaphyseal vesselsAge 4-8Blood from separate epiphyseal vessels as the physis is barrier to blood flowAge > 8The ligamentumteres has increasing significance in supply (20%)Trueta suggested that did not supply until 3-4 years- See more at: http://www.orthofracs.com/basic-science/anatomy/blood-supply/blood-femoral-head.html#sthash.RNcjeoBT.dpuf
The lateral Epiphysial and both Metaphysial arteries usually arise from the medial femoral circumflex arteryThe medial Epiphysial is a continuation of the artery within the ligamentumteres which comes from the acetabular branch of the obturator artery
the loose hyperelastic capsule, elongated ligamentumteres, and slight eversion of the hypertrophied acetabular rim. The posterosuperior rim of the acetabulum has to have lost it sharp margin and become flattened and thicken in the area over which the femoral head slide. The femoral head normal in shape.
With hip abducted 45 degree, femoral shaft should point into acetabula.
Transcript of "Approach to limping child"
Approach to limping child
• A 14 month old boy is brought to the office
because the parents noticed a limp this
morning when the child got out of bed…
• Three major factors cause a child to limp:
pain, weakness, and structural or mechanical
abnormalities of the spine, pelvis, and lower
extremities (Clark, 1997; deBoeck & Vorlat, 2003; Lawrence, 1998).
• A normal gait is composed of
symmetrical, alternating, rhythmical motions
involving two phases: stance and swing. The stance
phase normally encompasses 60% of the gait cycle.
The type of gait may be helpful in identifying the
etiology of the limp
Some Abnormal Gaits
An antalgic gait results from pain in one extremity that causes the patient to
shorten the stance phase on that side with a resultant increase in the swing phase.
The most common causes of an antalgic gait are trauma or infection
A Trendelenburg gait is a downward pelvic tilt away from the affected hip during
the swing phase as a result of weakness of the contralateral gluteus medius muscle
.The gait disturbance is commonly observed in children with developmental
dysplasia of the hip, Legg-Calves-Perthes disease, or slipped capital femoral
epiphysis. If the involvement is bilateral, a waddling gait results
A steppage (equinus) gait is a result of the inability to actively dorsiflex the
foot, with exaggerated hip and knee flexion during the swing phase. A steppage
gait is seen in children with neuromuscular diseases (eg, cerebral palsy) that cause
impairment of dorsiflexion of the ankle.
A vaulting gait occurs when the knee is hyperextended and locked at the end of
the stance phase and the child vaults over the extremity .A vaulting gait is seen in
children with limb length discrepancy or abnormal knee mobility.
A stooped gait is characterized by walking with bilaterally increased hip flexion A
stooped gait is common in children with pelvic or lower abdominal pain.
Septic arthritis /
cellulitis / transient
3- Primary or
dyplasia of the hip
3- lower limb length
4 - 10yr
2- inflammatory JRA, SLE
4- Primary or metastatic
5- hematological disease
Disease (AVN of femoral
of the hip
2- Neuromuscular disease:
3- Lower limb length
2- inflammatory :JRA, SLE
4-Primary or metastatic tumor
(AVN of femoral head)
7-acute slipped upper femoral
1- Developmental dyplasia of
2- Neuromuscular disease
3- lower limb length
4- chronic slipped upper
*very tall and/or obese. Limp and pain in the hip. Leg is held in an extemal rotation position.
Often painful on internal rotation of the hip. Association with hypothyroidism
Painful or painless? ( analysis…)
Acute or chronic
History of trauma
Association : Night pain (ALL), arthralgia,
swelling, morning stiffness(JRA), backache
(malignancy or rheumatologic disease)
• Systemic review
– Recent illness : URTI
– Weight loss, anorexia
– Fever, chills
– Unexplained rash (SLE) or bruising (haematology
– Voiding problem (neuromuscular ds)
Peripheral Blood Film
Immunological : RF, ANA TRO Rheumatological
• Imaging studies
– Plain x ray
– Radionuclide studies
– Bone scan
21 months old Malay Boy - NKMI
- p/w refuse to bear weight using
right LL x 2/7
- previously can walk since 1 y.o. and can run
and suddenly refuse standing on right LL
- right knee joint not warm or swollen
- no h/o fall / trauma before
- Afebrile , No URTI sx
FHx: no chronic illness running in
Developmental : able to walk at 1 y.o.
speak 2-3 words with
O/E: Alert , playing with toys
Right hip joint:
- well flexed, abducted, externally rotated
- No skin changes, no bruises seen
- not warm , not swollen
Right knee joint :
- Able to flex , not warm or swollen, non-tender
Right ankle joint:
- Able to move , not warm or swollen . Non-tender
IMP : transient synovitis of right hip joint
• ESR not elevated
• CRP not elevated
• USG hip Joint:
- no psoas abscess seen bilaterally
- no hip effusion seen bilaterally
Transient synovitis (irritable hip)
-Transient synovitis is the most common cause
of acute hip pain in children aged 3-10 years.
-The disease causes arthralgia and arthritis
secondary to a transient inflammation of the
synovium of the hip.
-affects boys twice as often as girls.
- Usually it is a diagnosis of exclusion, once
trauma and infection are excluded
- Unilateral hip or groin pain is the most common
- Recent history of an upper respiratory tract
infection in 50% of patients.
- Usually afebrile or have a mildly elevated
- Very young children with transient synovitis may
have no symptoms other than crying at night.
- Hip kept in flexion with slight abduction and
- some may have mild restriction of motion,
especially to abduction and internal rotation
- The hip may be painful with passive movement
and tender to palpation.
- The most sensitive test for transient synovitis is
the log roll, in which the patient lies supine and the
examiner gently rolls the involved limb from side to
side. This may detect involuntary muscle guarding
of one side when compared to the other side.
• No definitive cause of transient synovitis is known,
although the following have been suggested:
• Patients with transient synovitis often have histories of
trauma, which may be a cause or predisposing factor.
• One study found an increase in viral antibody titers in
67 of 80 patients with transient synovitis.
• Postvaccine or drug-mediated reactions and an allergic
disposition have been cited as possible causes.
• Septic arthritis.
• Juvenile idiopathic arthritis.
• Juvenile rheumatoid
• Avascular necrosis (Perthe’s
• Gonococcal arthritis.
• Lyme’s arthritis.
• Soft tissue injuries.
• Tumor or malignancy.
• Usually to rule out other diagnoses.
• WBC, ESR and CRP are usually elevated in
• XRAYS: can exclude bony lesions.
• Ultrasound guided aspiration of the effusion.
Sign of effusion :
Widening of the
joint space. Note
that the space is
wider on the left
greater than 1 mm
presence of fluid.
• Apply heat and massage .
• Advise bedrest for 7-10 days, allowing the patient
to rest in a position of comfort.
• Advise the patient with transient synovitis not to
bear weight on the affected limb.
• Advise the patient with transient synovitis to
avoid full unrestricted activity until the limp and
pain have resolved.
• Non-steroidal anti-inflammatory drugs (NSAIDs).
• Usually marked improvement within 24-48
• Two thirds to three fourths of patients have
complete resolution within 2 weeks.
• The remainder may have less severe
symptoms for several weeks.
• The recurrence rate is 4-17%; most
recurrences develop within 6 months.
• 32.1% of patients develop coxa magna : an
overgrowth of the femoral head and
broadening of the femoral neck. It leads to
dysplasia of the acetabular roof and
• 1-3 % develop perthe’s disease.
• Septic arthritis in children is monoarticular
more than 90% of the time.
• Knee and hip joints account for about two
thirds of all cases.
• Children less than 2 years old are more
susceptible to septic arthritis than older
• After S. aureus, group B streptococcus and Gramnegative microorganisms are important pathogens in
the neonate and young infant.
• Candida and Gram-negative bacilli are usually acquired
in the hospital or in another health care setting.
• Septic arthritis and osteomyelitis can coexist or
complicate each other in the very young child because
the metaphyseal and epiphyseal blood vessels
communicate and the metaphyses of some long bones
are within the joint capsule. (eg hip joint)
• Avascular necrosis of the femoral head is
unique to septic arthritis of the hip in children.
• Early surgical decompression to reduce the
high intra-articular pressure will restore blood
flow to the femoral head.
• Leg length discrepancy, limitation of joint
mobility, and secondary degenerative joint
disease are late sequelae in 25% of cases.
Septic arthritis - Definition
• Hematogenous bacterial infection of the
• in infants or toddlers, with or without
• the proximal femoral metaphysis.
• Synonym: Septic coxitis
• Hip - commonest septic joint
• condition during growth, reaching a distinct
peak in frequency during infancy.
• via hematogenous transmission, resulting in
colonization of the joint with bacteria
• in infants - occur from propagation of
adjacent proximal femoral osteomyelitis
• Kocher criteria: (for child with painful hip)
1) non-weight-bearing on affected side
2) ESR greater than 40 mm/hr
4)WBC count of >12,000 mm3
• when 4/4 criteria are met, there is a 99% chance
that the child has septic arthritis
• when 3/4 criteria are met, there is a 93% chance
of septic arthritis
• when 2/4 criteria are met, there is a 40% chance
of septic arthritis
• when 1/4 criteria are met, there is a 3% chance
of septic arthritis
• epiphyseal plate prevents infection from
entering joint space in older children
• but apparently does not act as a barrier
• synovial membrane inserting distally to
• allowing bacteria to spread directly from
the metaphysis to joint space;
• metaphysis of shoulder, hip, radial head, and
ankle remain intracapsular during early
• the hip joint seems especially prone to sepsis
from adjacent osteomyelitis
• synovial reflections over the metaphyseal bone
decrease with age;
• pain in groin area that occasionally radiates
down the medial side of thigh;
- progressive accompanied by spasm of
the hip muscles
- hip in flexion and external rotation &
decreased internal rotation compared to the
- patient resists all attempts to move hip;
- palpate the SI joint for local tenderness;
• Acute osteomyelitis - tenderness and swelling
over the metaphysis
• Transient synovitis
• Acute rheumatic fever
Full blood count
Elevated white blood cell count
> 40 mm/hr
> 20 mg/dL
May be positive
Synovial fluid analysis
Aseptic technique is used during aspiration of synovial fluid.
Avoid taken from infected site of skin.
The fluid is then analyzed by gross and microscopic
examination and culture.
Gross examinations include appearance, volume,
viscosity, mucin clotting (amount of proteoglycans).
Microscopic examinations include leucocyte count,
staining of smears, serum glucose ratio, protein.
Finally, culture and sensitivity for definitive diagnosis
As for plasma
Early Stage – Normal
Look for soft tissue swelling, loss of tissue planes,
widening of joint space
Late stage – Narrowing and irregularity of joint space
Plain film findings of superimposed osteomyelitis may
develop (periosteal reaction, bone destruction, sequestrum
Narrowing of joint space and irregularity of
Joint space loss
subchondral erosions and
sclerosis of the femoral
complete collapse of
the femoral head
• More reliable in revealing a joint effusion in early cases.
• Widening of space between capsule and bone of > 2mm
• Echo-free transient synovitis
• Positively echogenic septic arthritis
General supportive care
- The joint must be rested either on a splint or in a widely split
-In neonates and infants, with hip infection the joint is held
abducted and 30 degree flexed, on traction to prevent dislocation.
Treatment is started once the blood and samples are obtained
without waiting for the detail results.
Choice of antibiotic depends on the most likely pathogen
Surgical Drainage (serial needle aspiration + antibiotics)
Arthroscopic debridement and copious irrigation with normal
saline (Arthrotomy washout)
Indications for Arthrotomy washout
• Joint does not respond to serial aspirations
• No improvement in 48hrs of tx
• Frank pus is aspirated
• Loculations noted on MRI or U/S
• Bone destruction and dislocation of the joint (esp
-may lead to either fibrosis or bony ankylosis
- secondary osteoarthritis
- presenting as either localised deformity or shortening
of the bone
Legg-Calvé-Perthes disease (LCPD)coxa plana
• Legg-Calvé-Perthes disease (LCPD) is the name given to
idiopathic osteonecrosis of the capital femoral epiphysis
in a child.
Usually ages 4-8yo
As early as 2yo, as late as teens
No evidence of inheritance
• Up to 4 years
Metaphyseal vessels,lateral epiphyseal
vessels,scanty vessels from ligamentum teres
Between 4-7 years,femoral head
depends entirely on the lateral
• 7 years old
Vessels of ligamentum teres has developed
*Lateral epiphyseal vessels situated in the
retinacula makes them susceptible to streching
and pressure from an effusion.The precipitating
cause is an effusion into the hip joint following:
2) slipped capital femoral epiphysis
7) congenital dislocation of the hip.
Takes 2-4 years to complete.Involve 3 stages.
Stage 1:bone death
Episodes of ischemia leads to part of bony femoral head dies,x-ray looks normal bt it
Stage 2:revascularization and repair
New blood vessels enter the necrotic area and new bone is laid down on the dead
trabeculae,x-ray-increased in density.If only part of the epiphysis is involved & the
repair is rapid bony architecture is completely restored.
Stage 3:distortion and remodelling
If large part of the bony epiphysis is damaged & the repair process is slow,epiphysis
may collapse and growth of the head and neck will be distorted
Epiphysis ends up flattened(coxa plana),flat and enlarged(coxa magna) and the
femoral head will be incompletely covered by the acetabulum.
• 4-8 years old
• Hip pain, may be referred to the medial aspect of the ipsilateral
knee or to the lateral thigh.
• All ROM are limited
• The quadriceps muscles and thigh soft tissues may undergo
• the hip may develop adduction flexion contracture
• The patient may have an antalgic gait with limited hip motion.
• passive range of motion are limited, especially internal rotation and
• Children can have a Trendelenburg gait resulting from pain in the
gluteus medius muscle.
• hip radiographs, anteroposterior and frog-leg
lateral views of the pelvis to establish the
• Initial radiographs can be normal,
• Early changes-increased density of the bony
epiphysis and widening of the joint space.
• Late changes-flattening,fragmentation and lateral
displacement of the epiphysis with rarefraction at
The Herring classification addresses the integrity
of the lateral pillar of the femoral head.
• A: there is no loss of height in the lateral one
third of the head and there is little density
• B: there is a lucency and less than 50% loss of
• C: there is a more than 50% loss of lateral
Lateral Pillar Classification
• 3 groups:
– A) no lateral pillar
– B) >50% lat height
– C) <50% lat height
• CT scan: allow early diagnosis of bone collapse
and also demonstrate subtle changes in the bone
• Ultrasonography :preliminary diagnosis of
transient synovitis of the hip and the onset of
CP.Hip effusion with capsular distension is well
depicted on sonographic images.
• MRI: allows more precise localization of the
• Skin traction as long as the hip is
painful(usually takes 3 weeks)
• Further treatment is taken by assessment of
the prognostic value:
1)Onset under age 6
2)Partial involvement of
3)Absence of metaphyseal
4)Normal femoral head shape
No active Tx needed
1)Age over 6 years old
2)Involve the whole femoral
4)Lateral displacement of
• Containment means keeping the femoral head
well seated within the acetabulum
• Can be achieved by:
1) holding the hips widely abducted in plaster
or removable splint.(at least will take a year).
2) Varus osteotomy of the femur or innominate
osteotomy of the pelvis.
The capital femoral epiphysis is
somewhat unique. It is one of the few
epiphyses in the body that is inside the
joint capsule. (The joint capsule is the
tissue that surrounds the joint.)
SLIPPED CAPITAL FEMORAL EPIPHYSES
Slipped upper femoral epiphysis" term refer to slippage
of the overlying epiphysis of proximal femur posteriorly
and inferiorly due to weakness of the growth plate in
relation to metaphysis.
Most often, it develops during periods of accelerated
growth, shortly after the onset of puberty.
The femoral epiphyses maintains its relation with
acetabulum ,it’s the femoral neck and shaft upward and
anterior movement on epiphyses thus epiphyses
displaces relatively posterior
EPIDEMIOLOGY AND RISK FACTORS
Most common in adolescent period with rapid growth plate
(boys aged 10-16 y, girls aged 12-14 y).
Obesity is a risk factor because it places more shear forces around the
proximal growth plate in the hip at risk.
Bilateral slippage is common of which 2nd slip is about 12-18mths later to
1st (left hip is more common than right).
1. Local trauma
3. Endocrine disorders (e.g primary or secondary hypothyroidism,
adiposogenital dystrophy(hypogonadal male),
4. Deficiency or increase of androgens.
5. Growth hormone deficiency
Slipping of the upper femoral epiphysis occurs predominantly in obese
children with underdeveloped sexual characteristics and less commonly,
in tall, thin children.
• Based on onset of symptoms-acute
-acute on chronic
BASED ON SYMPTOMS -
ACUTE ON CHRONIC SLIPS-Symptoms lasting longer than 1mth and
recent sudden exacerbation pain after trivial trauma
FUNCTIONAL CLASSIFICATIONIt is important to determine ability of the patient to bear weight.
According to LODER1. "Stable" SCFEs allow the
patient to (walk) with or
without crutches (walking aids).
2. "Unstable" SCFEs do not
allow the patient to ambulate
at all regardles of duration of
symptoms; these cases carry a
higher rate of
complication, particularly of
Severity of SCFE according to AP and Lateral Xray views
ANTERIOR AND VALGUS SLIP
• the displacement is either superior and posterior (socalled valgus slip)or, even more rarely, anterior.
• In valgus slips there is a restriction of adduction as well as
• In anterior slips there is a limitation of extension and
external rotation—exactly the opposite of what is found
in typical slips.
• X-RAY of valgus slip show
-superior or lateral displacement of the capital epiphysis
on the femoral neck on the AP projection -posterior
displacement on the lateral projection.
Anterior slips may appear little different from typical slips
on the AP projection, but the anterior displacement of the
capital epiphysis is identified on the lateral projection.
1. Pain : in the groin and around the knee(d/t referred pain from the hip)
2. Limb looked shortened, held in external rotation
3. Flexion, abduction, medial rotation are limited
4. External rotation, adduction are increased.
5.Axis deviation – pathognomonic – when hip is flexed, the limb goes into
And medial translation of
angle, anterior or
• In normal hip a line drawn tangential to superior
femoral neck[klein’s line] intersects small portion
of lateral capital epiphyseal.
• In posterior displacement of epiphyses the line
METAPHYSEAL BLANCH SIGN• In AP VIEW-crescent-shaped area of increased
density overlying the
metaphysis adjacent to
• This increased density is
due to the overlapping of
the femoral neck and the
SHAM’S SIGN In the normal hip the inferiomedial femoral neck overlaps
the posterior wall of the acetabulum producing triangular
• With displacement of capital epiphysis this dense triangle
is lost because this portion of the femoral neck is located
lateral to the acetabulum.
In pelvic AP view in the normal hip, the posterior acetabular margin
cuts across the medial corner of the upper femoral metaphysis
With slipping, the entire metaphysis is lateral to the posterior
• Very early slips may appear to be normal in AP
VIEW but may be clearly noted in lateral view
• CHRONIC CASE OF SCFE X-RAY• Reactive bone formation along superolateral
aspect of neck
• Bone remodelling and broadening of neck
resulting in PISTOL GRIP like
USG-It has been useful in the detection of early slips -joint
effusion and a “step” between the femoral neck and the
epiphysis created by slipping.
• Absolute displacement of 6 mm, >2 mm is diagnostic of a
• CT-useful in documenting presence of decreased upper
femoral neck anteversion or true retroversion.
• it’s more accurate measure head–neck angle.
• CT is useful in the management of slips.
• First, CT of the hip can be very helpful in demonstrating
whether penetration of the hip joint by fixation devices
has occurred (Fig. 18-9).
• CT is also used to confirm closure of the proximal femoral
physis and also when reconstructive osteotomy is being
• MRI-useful to assess AVN
1. Avascular necrosis.
3. Secondary Osteoarthritis.
4. Coxa vara (is a deformity of the hip,
whereby the angle between the ball
and the shaft of the femur is
reduced to less than 120 degrees).
5. Slipping of the opposite hip ≈ 20% to
80% of cases
•Prevent further slippage
•Stimulate early physeal closure
•Reduction of epiphyseal displacement
•Avoid complications like osteonecrosis , chondrolysis and
•Any child with SCFE and open epiphyses needs treatment ,without
stabilisation it progresses.
•In a patient with closed physes, the only surgical
treatment in the absence of severe degenerative
changes is proximal femoral osteotomy. Indications are
functional limitations, unacceptable gait, or cosmetic
• Conservative management-rest and traction
- Rest for at least 12wks and traction can be an alternative to surgical treatment
- Indicated in – temporary measure before operative mx or slip due to
• Closed manipulative reduction
- High risk of ischemic necrosis of head.
- So, manipulate only acute severe slips that may be technically difficult or
impossible to pin in situ.
• Only for acute and acute on chronic severe slips
• Within 24 hours of slip
• Operative management
- In situ pinning
• 1 cannulated screw for both stable and unstable
- ORIF: open reduction, limited osteotomy, and internal
fixation, if necessary, have been recommended if a severe
acute or chronic slip which cannot be reduced by closed
- Osteotomy: moderately or severely displaced chronic slips
produce permanent irregularities in the femoral head and
acetabulum, some form of realignment procedure often is
indicated to restore the normal relationship of the femoral
head and neck and possibly delay the onset of degenerative
Developmental Dysplasia of
A spectrum of disorder including :
Acetabular dysplasia without displacement
Reported incidence is 5 – 20 per 1000 live births.
Re – examination 3 weeks after birth is only 1 or 2
per 1000 infants. ( i.e spontaneous correction)
Girls are more common with ratio 7:1
Left hip is more often affected,
1 in 5 cases is bilateral.
1- Genetic factors( families, even in entire populationgeneralized join laxity, shallow acetabulum)
2- Hormonal changes in late pregnancy→ lig. laxity
3- Intrauterine malposition( breech + extended legs)
4- Postnatal factors( swaddling- simultaneous hip and
knee extension may lead to hip dislocation during
Femoral head dislocate posteriorly and later
lies superolateral to acetabulum
Cartilagenous socket is shallow and
Capsule is stretched
Ligamentum teres is elongated
Every newborn child should be examined for signs of
hip instability esp. in children with positive family history or
with breech presentation
Methods in testing instability:
Ortolani’s test (reducible)
Barlow’s test (dislocatable)
1. Baby’s thighs are held with the thumbs medially and
fingers resting on the greater trochanters
2. Hip are flexed to 90°and gently abducted
3. Normally, there is smooth abduction to almost 90°but
in congenital dislocation the movement usually impede
4. If pressure is applied to greater trochanter there is soft
‘clunk’ as the dislocation reduce (the jerk of entry)
5. If abduction stops halfway and there is
no jerk of entry, they may be an
When test is positive, the dislocated femoral head will
fall back into acetabulum with palpable ‘clunk’ as the
hip abducted. When hip is adducted, the examiner will
feel the head dislocate posteriorly.
• Thumb is placed in groin
• Grasping the upper thigh, an attempt is made to lever
the femoral head out of the acetabulum by fully adduct
hips and push posteriorly
• Indicate unstable hip
When the test is
positive, the examiner will
feel the femoral head make a
small jump out of
acetabulum. When the
pressure is release, the head
is felt to slip back into place.
Limitation of abduction - < 50-60°
Shortening of the femur by Galeazzi
placing both hip in 90° of flexion and
comparing the height of knee and look
Increase thigh folds on the
affected side than the normal
because of the foreshortened the
Abnormal gait – due to shortened of the affected
Waddling gait - if bilateral hip affected
(walk with short steps and a clumsy swaying
Excessive lordosis – secondary to hip flexion
Neonate’s hip is composed primarily of cartilage –
difficult by using radiographic techniques
Shows the shape of cartilaginous socket
Position of femoral head
2. Plain X-ray
In newborn the unstable hip may appear radiographically
normal, as the child reach 3 to 6 month of age the
dislocated hip will be evident radiographically.
(A) Acetabulum : Shallow and sloping
(Acetabular roof angle < 30)
(B)Femoral head : Underdeveloped and out
Perkin’s lines = Vertical line at the outer edge of
Hilgenreiner’ line = Horizontal line through the
Normally the head is medial to vertical
and below the horizontal
(C) Shenton’line is broken
(Inferior border of superior ramus
and inferior border of the neck)
(D) Von Rozen line = Hips abducted 45
Femoral shaft should point into the acetabulum
Double napkins OR Abduction pillow for 6 weeks
Stable hip = follow-up for 6 months
Persistent instability = Splint for 3-6 months (Pavlic harness)
Hold the hips flexed and abducted
3 Golden Rules for splintage:
Hip must be properly reduced before splintage
Avoid extreme position
Hips should be able to move
Von Rosen’s Splint (easy to apply)
Pavlik Harness (difficult to apply but more freedom to move)
Persistent dislocation: 6-18months
Failed early treatment or missed dislocation
Hip must be reduced by closed method or operation
Performed under GA with arthrogram
Gradual traction to minimize avascular necrosis
Plastic spica for 6 weeks (60° flexion, 40° abduct, 20° int rotate)
Reassess and spica for another 6 weeks
checking by x-ray – to ensure femoral head concentrically
reduced and acetabular roof develop normally
Indicated when concentric reduction failed
Psoas tendon is divided
Redundant tissue is removed
Hip is reduced (60° flexion, 40° abduct, 20° int rotate)
Spica is applied (6wks) and
hip is splinted
Closed reduction is less likely to succeed.
Traction: help to loosen the tissue and bring the femoral head down opposite the
Arthrography: clarify anatomy of hip shows whether there is an inturned limbus or
any marked degree of acetabular dysplasia.
remove redundant capsule
Usually require derotation femoral osteotomy held by a plate and screw
1cm segment removed from proximal femur to reduce pressure on hip
If there is marked acetabular dysplasia, may require acetabuloplasty
After operation, hip is held in a plaster spica for 3 months
Keep under clinical and radiological surveillance
Children >4 years
Up to 8 y/o; reduction and stabilization as above, risk of
AVN and hip stiffness (>25%)
Over 8 y/o;
– unilateral [mobile hip, little pain, abnormal gait.]
• no intervention @ open reduction + acetabular
– bilateral [deformity + waddling gait not so noticeable]
• non-intervention unless painful/severe deformity.
(fail leads to asymmetrical deformity.)