Adolescent hip

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Adolescent hip

  1. 1. ADOLESCENT HIPADOLESCENT HIPADOLESCENT HIPADOLESCENT HIP
  2. 2. What does the parents complain of ? Limping Pain in hip Knee pain
  3. 3. What could it be due to ?  Transient synovitis  Perthes disease  Slipped capital femoral epiphysis  Idiopathic Chondrolysis  Septic arthritis  Tuberculous arthritis  Trauma  Tumours
  4. 4. TRANSIENT SYNOVITIS HIPTRANSIENT SYNOVITIS HIP Benign self limiting Most common cause of hip pain in children
  5. 5. AETIOLOGYAETIOLOGY  Unknown  Trauma  Allergic manifestation  infection
  6. 6. SYNOVITIS HIPSYNOVITIS HIP  Unilateral hip pain  3 – 18 years  Limb and antalgic gait  ROM restricted
  7. 7. DIAGNOSIS IS BY EXCLUSION
  8. 8. INVESTIGATIONSINVESTIGATIONS Usually within normal limits USG – joint effusion
  9. 9. Complete resolution is theComplete resolution is the rule usually within 3-4rule usually within 3-4 weeksweeks
  10. 10. TREATMENTTREATMENT  Strict bed rest and non-weight bearing  Skin traction – recurrent symptoms
  11. 11. SEPTIC ARTHRITISSEPTIC ARTHRITIS True orthopaedic emergency Any age – common in infants and children
  12. 12. Clinical features Febrile and toxic Swollen and painful joint Pseudoparalysis
  13. 13. The key to treatment is early diagnosis with a high index of suspicion and early removal of pus from the joint.
  14. 14. Investigations Raised total count Raised ESR Raised CRP
  15. 15. TREATMENT Early diagnosis Arthrotomy Antibiotics Splintage – rest -- traction
  16. 16. Complications Osteomyelitis Dislocation Avascular necrosis Late osteoarthritis
  17. 17. SLIPPED CAPITALSLIPPED CAPITAL FEMORAL EPIPHYSISFEMORAL EPIPHYSIS A true adolescent problem
  18. 18. Gradual or acute slip through the capital femoral physis
  19. 19. SLIPPING
  20. 20. SLIPPED CAPITAL FEMORALSLIPPED CAPITAL FEMORAL EPIPHYSISEPIPHYSIS clinical profile pictureclinical profile picture
  21. 21. SCFE Boys more than girls Left more than right Bilateral – 20 %
  22. 22. Etiology Exact cause – unknown Hormonal Trauma Mechanical factors
  23. 23. Classification Preslip Acute Chronic Acute on chronic
  24. 24. Preslip Weakness or pain in the thigh or knee Limitation of internal rotation X-ray – widening of the physis
  25. 25. Acute  Less than 3 weeks duration  Trauma – may be insignificant  Bedridden – antalgic gait  Shortening  External rotation deformity  Axis deviation
  26. 26. Acute on chronic Mild trauma results in increase in the prodromal pain present for more than 3 weeks
  27. 27. Chronic Intermittent pain present for more than 3 weeks.
  28. 28. Investigations X-ray – AP Frog leg lateral view ( contraindicated when suspecting acute slip)
  29. 29. Eyes do not see what mind does not know It is true about reading x-rays also
  30. 30. Goal of treatment  Promote early physeal closure  Prevent additional slipping  Relieve pain  Correct deformity  Restore function of hip  Prevent complications
  31. 31. Conservative management Rest Analgesics
  32. 32. Surgical treatment is the standard
  33. 33. Surgical options Insitu pinning Reduction and fixation Corrective osteotomies
  34. 34. Insitu pinning Image intensifier control Cannulated screw fixation
  35. 35. C-ARMC-ARM
  36. 36. Complications Chondrolysis Avascular necrosis Secondary osteoarthritis
  37. 37. PERTHES DISEASE Common problem 4 – 12 years of age Male > female (4:1) Low socioeconomic status
  38. 38. Late onset Perthes after the age of 9 years.
  39. 39. Etiology Exact etiology – unknown Current theory – vascular embarrassment Increased intra-osseous pressure
  40. 40. This results in avascular necrosis of the capital femoral epiphysis.
  41. 41. Clinical features Painless limping
  42. 42. CLINICAL PROFILE Abduction-Internal rotation limited Flexion variably limited Adduction deformity Limb-length discrepancy
  43. 43. INVESTIGATIONS X-ray --- AP & FROG LEG LATERAL Sclerosis of the epiphysis Collapse of the epiphysis Subchondral fracture
  44. 44. MRI – to know the shape of the cartilage ARTHROGRAM
  45. 45. ARTHROGRAM
  46. 46. Subchondral fracture heralds the onset of clinical Perthes.
  47. 47. MANAGEMENT Depends on stage of disease Shape of the head Management of complications
  48. 48. 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
  49. 49. Guiding principle in the treatment is the containment of the femoral head in the acetabulum.
  50. 50. Treatment options Conservative Surgical Supervised neglect
  51. 51. In the initial synovitis stage treatment is by skin traction
  52. 52. Conservative treatment Time consuming Difficult for parents and child Psychological problems
  53. 53. Surgical treatment Contain head by osteotomies Femoral or acetabular Varus derotation osteotomy of femur commonly done
  54. 54. 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
  55. 55. Complications Hinged abduction Chondrolysis Secondary osteoarthritis
  56. 56. TB HIPTB HIP Not so uncommon in our practice Family history of TB
  57. 57. TB HIPTB HIP Limp – commonest presentation Night cries Stiffness Wasting Fever Weight loss
  58. 58. TB HIPTB HIP Raised ESR Mantoux test X-ray PCR IgM antibody assay Biopsy
  59. 59. TB HIP- X-RAYTB HIP- X-RAY  Osteoporosis  Travelling acetabulum  Dislocated hip  Mortar and pestle appearance  Perthes type  Protrusio acetabuli  Destruction of head
  60. 60. TB HIPTB HIP  ATT  Traction  Splintage  Surgery – last resort
  61. 61. IDIOPATHIC CHONDROLYSIS
  62. 62. Progressive destruction of articular cartilage with effusion and joint space narrowing.
  63. 63. Girls -- 9 – 18 years Insidious onset Pain Limping Stiffness
  64. 64. Investigations X-ray -- joint space narrowing Blood – within normal limits MRI
  65. 65. TREATMENT NSAID’s Aggressive physical therapy (CPM) Periodic traction Bed rest Prolonged non - weight bearing
  66. 66. Questions & Comments

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