A 14 month old boy presented with a limp noticed that morning. The differential diagnosis for a limping child includes painful conditions like infection, trauma, tumors and painless conditions such as developmental dysplasia of the hip and neuromuscular diseases. The history, physical exam including assessment of gait, and investigations help to determine the etiology. Common causes of painful limp in this age group are septic arthritis, osteomyelitis and transient synovitis of the hip. Synovial fluid analysis and imaging studies like ultrasound and x-rays are used to diagnose septic arthritis versus transient synovitis. Treatment involves antibiotics, splinting and rest for septic arthritis.

1. Approach to limping child

2. Case Scenario
• 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…

3. Pathophysiology
• 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

4. 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.

5. Differential Diagnosis
Age
1-3yr
Painful limp
1- Infection
Septic arthritis /
osteomyelitis/
cellulitis / transient
synovitis
2- Trauma
3- Primary or
metastatic neoplasm
Painless limp
1- Developmental
dyplasia of the hip
2- Neuromuscular
disease
-Cerebral palsy
-Muscular dystrophy
3- lower limb length
discrepancy

6. Differential Diagnosis
Age
Painful limp
4 - 10yr
1-Infection
2- inflammatory JRA, SLE
3- Trauma
4- Primary or metastatic
tumor
5- hematological disease
Hemophilia, leukemia
6-Legg-Calve-Perthes
Disease (AVN of femoral
head)
Painless limp
1-Developmental dyplasia
of the hip
2- Neuromuscular disease:
Cerebral palsy
Muscular dystrophy
3- Lower limb length
discrepancy

7. Differential Diagnosis
Age
Painful limp
11- 18yr
1-Infection
2- inflammatory :JRA, SLE
3- Trauma
4-Primary or metastatic tumor
5-hematological disease
Hemophilia, leukemia
6-Legg-Calve-Perthes Disease
(AVN of femoral head)
7-acute slipped upper femoral
epiphysis*
Painless limp
1- Developmental dyplasia of
the hip
2- Neuromuscular disease
Cerebral palsy
Muscular dystrophy
3- lower limb length
discrepancy
4- chronic slipped upper
femoral epiphysis
*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

8. Approach
•
•
•
•
History
Examination
Investigation
Management

9. History
•
•
•
•
•
•
•
Age
Sex
Onset
Painful or painless? ( analysis…)
Acute or chronic
History of trauma
Association : Night pain (ALL), arthralgia,
swelling, morning stiffness(JRA), backache
(malignancy or rheumatologic disease)

10. History
• Systemic review
– Recent illness : URTI
– Weight loss, anorexia
– Fever, chills
– Unexplained rash (SLE) or bruising (haematology
ds)
– Voiding problem (neuromuscular ds)

11. Examination
•
•
•
•
•
General inspection + Gait
Vital signs & anthropometric measurements
Musculoskeletal examination +Back exam
Neurological examination
Evaluate leg lengths- anterior iliac spine to
medial mallelous

12. Investigations
•
•
•
•
•
•
FBC
ESR, CRP
TRO Infection
Blood culture
Coagulation profile
TRO Haematological
Peripheral Blood Film
disorder
Immunological : RF, ANA TRO Rheumatological
disorder

13. Investigations
• Imaging studies
– Plain x ray
– U/S
– CT
– MRI
– Radionuclide studies
– Bone scan

14. Investigations
• Synovial
fluid
aspiration
normal
traumatic
JRA
Septic
Arthritis
appearance
Clear to
yellow
Bloody to
straw colored
Cloudy yellow
Purulent
WBC
<200
<5,000
5,000- 80,000
50,000200,000
Polymorphs
<25%
<25%
50-75%
75-100%
other
High RBC
count
Bacterial
culture
positive
Low glucose
High protien

15. CASE SCENARIO
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

16. PMH/PSHx: nil
FHx: no chronic illness running in
family
Developmental : able to walk at 1 y.o.
speak 2-3 words with
meaning

17. 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

18. Ix
• ESR not elevated
• CRP not elevated
• USG hip Joint:
- no psoas abscess seen bilaterally
- no hip effusion seen bilaterally

19. 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

20. Symptoms
- Unilateral hip or groin pain is the most common
symptom.
- Limp.
- Recent history of an upper respiratory tract
infection in 50% of patients.
- Usually afebrile or have a mildly elevated
temperature.
- Very young children with transient synovitis may
have no symptoms other than crying at night.

21. Signs
- Hip kept in flexion with slight abduction and
external rotation.
- 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.

22. Causes
• 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.

23. Differential diagnoses
Common
• Septic arthritis.
• Juvenile idiopathic arthritis.
• Juvenile rheumatoid
arthritis.
• Osteomyelitis.
Less common
• Avascular necrosis (Perthe’s
disease).
• Fracture.
• Gonococcal arthritis.
• Lyme’s arthritis.
• Soft tissue injuries.
• Tumor or malignancy.

24. Investigations
• Usually to rule out other diagnoses.
• WBC, ESR and CRP are usually elevated in
septic arthritis.
• XRAYS: can exclude bony lesions.
• Ultrasound guided aspiration of the effusion.

25. Sign of effusion :
Widening of the
joint space. Note
that the space is
wider on the left
side. Discrepancies
greater than 1 mm
indicate the
presence of fluid.

26. Management
• 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).

27. Prognosis
• Usually marked improvement within 24-48
hours.
• 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.

28. Complications
• 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
subluxation.
• 1-3 % develop perthe’s disease.

29. SEPTIC ARTHRITIS
IN CHILDREN
• 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
children.

30. • 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)

31. • 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.

32. Septic arthritis - Definition
• Hematogenous bacterial infection of the
hip, usually
• in infants or toddlers, with or without
involvement of
• the proximal femoral metaphysis.
• Synonym: Septic coxitis

33. • 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

34. Any OM changes, widening
of joint space

35. • Kocher criteria: (for child with painful hip)
- includes:
1) non-weight-bearing on affected side
2) ESR greater than 40 mm/hr
3)Fever
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

36. Organisms

37. • epiphyseal plate prevents infection from
entering joint space in older children
• but apparently does not act as a barrier
in infants
• synovial membrane inserting distally to
epiphysis,
• allowing bacteria to spread directly from
the metaphysis to joint space;

38. • metaphysis of shoulder, hip, radial head, and
ankle remain intracapsular during early
childhood
• the hip joint seems especially prone to sepsis
from adjacent osteomyelitis
• synovial reflections over the metaphyseal bone
decrease with age;

39. Examination
• Limp
• 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
normal hip
- patient resists all attempts to move hip;
- palpate the SI joint for local tenderness;

40. Differential diagnosis
• Acute osteomyelitis - tenderness and swelling
over the metaphysis
• Transient synovitis
• Tuberculosis
• Acute rheumatic fever
• Haemarthrosis

41. Investigations
• Joint fluid aspiration analysis: AFB, Gram
stain, C&S, protein, glucose, wcc and crystal.
• FBC : leukocytosis
• Blood C&S
• C-reactive protein
• ESR
• X-ray
• Ultrasound

42. Investigations
Investigations
Explaination
Full blood count
Elevated white blood cell count
ESR
> 40 mm/hr
CRP
> 20 mg/dL
Blood culture
May be positive

43. 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
and treatment.

44. Suspected
condition
Appearanc
e
Viscosity White
cells
Crystals
Biochemistry
Normal
Clear
yellow
High
Septic
arthritis
Purulent
Tuberculous
arthritis
Few
-
As for plasma
-
Low
+
-
Glucose low
+
Turbid
Low
+
-
Glucose low
+
Rheumatoid
arthritis
Cloudy
Low
++
-
-
-
Gout
Cloudy
Normal
++
Urate
-
-
Pseudogout
Cloudy
Normal
+
Pyropho
sphate
-
-
Osteoarthrit
is
Clear
yellow
High
Often +
-
-
few
Bacteriology

45. Imaging
X ray
 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
formation).

46. Narrowing of joint space and irregularity of
subchondral bone.
Joint space loss
subchondral erosions and
sclerosis of the femoral
head
osteonecrosis and
complete collapse of
the femoral head

47. Ultrasonography
• More reliable in revealing a joint effusion in early cases.
• Widening of space between capsule and bone of > 2mm
indicates effusion.
• Echo-free  transient synovitis
• Positively echogenic  septic arthritis

48. Treatment
General supportive care
-Analgesics
-IV fluids
Splintage
- The joint must be rested either on a splint or in a widely split
plaster
-In neonates and infants, with hip infection the joint is held
abducted and 30 degree flexed, on traction to prevent dislocation.
Antibiotics
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

49. Surgical Management
 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

50. Complications
• Bone destruction and dislocation of the joint (esp
Hip)
•Cartilage destruction
-may lead to either fibrosis or bony ankylosis
- secondary osteoarthritis
•Growth disturbance
- presenting as either localised deformity or shortening
of the bone

51. 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
Boys:Girls= 4-5:1
Bilateral 10-12%
No evidence of inheritance

52. Pathogenesis
• 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
epiphysael vessels.
• 7 years old
Vessels of ligamentum teres has developed

53. *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:
Etiology
1)idiopathic
2) slipped capital femoral epiphysis
3) Trauma
4)steroid use
5)sickle-cell crisis
6)Synovitis
7) congenital dislocation of the hip.

55. Pathology
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
stops enlarging.
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.

56. Clinical features
• Male
• 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
atrophy
• 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
abduction.
• Children can have a Trendelenburg gait resulting from pain in the
gluteus medius muscle.

57. Investigation
1)Plain radiograph
• hip radiographs, anteroposterior and frog-leg
lateral views of the pelvis to establish the
diagnosis.
• 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 metaphysis.

58. Herring classification
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
change.
• B: there is a lucency and less than 50% loss of
lateral height.
• C: there is a more than 50% loss of lateral
height.

59. Herring classification
Coxa magna
Coxa plana

60. Lateral Pillar Classification
• 3 groups:
– A) no lateral pillar
involvment
– B) >50% lat height
intact
– C) <50% lat height
intact

61. • CT scan: allow early diagnosis of bone collapse
and also demonstrate subtle changes in the bone
trabecular pattern.
• 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
femoral head.

62. Treatment
• Skin traction as long as the hip is
painful(usually takes 3 weeks)
• Further treatment is taken by assessment of
the prognostic value:
Good prognosis
1)Onset under age 6
2)Partial involvement of
femoral head
3)Absence of metaphyseal
involvement
4)Normal femoral head shape
No active Tx needed
Poor prognosis
1)Age over 6 years old
2)Involve the whole femoral
head
3)Severe metaphyseal
rarefraction
4)Lateral displacement of
femoral head
containment

63. • 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.

64. Osteotomies

65. Slipped capital femoral
epiphysis (SCFE)

66. INTRODUCTION
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.)

67. 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

68. 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).
 Etiology:
1. Local trauma
2. obesity
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.

69. CLASSIFICATION
• Based on onset of symptoms-acute
-chronic
-acute on chronic
FUNCTIONAL CLASSIFICATION-stable
-Unstable
MORPHOLOGICAL CLASSIFICATION-mild
-moderate
-severe

70. BASED ON SYMPTOMS -
SYMPTOMS
X-RAY
<2WKS
displaced epiphyses
>2WKS grdual
remodelling and
no remodelling
healing noted
ACUTE ON CHRONIC SLIPS-Symptoms lasting longer than 1mth and
recent sudden exacerbation pain after trivial trauma

71. 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
AVN.

72. MORPHOLOGICAL CLASSIFICATION-Grading
Severity of SCFE according to AP and Lateral Xray views
PRESLIP-irregularity,widening,and indistinctness
of physes
Grade-1
Grade-II
Grade-III

73. 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
of flexion.
• 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.

74. SYMPTOMS
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
external rotation

76. INVESTIGATIONS
•
•
•
•
•
•
•
•
•
X-RAYS-AP VIEW-thretowan’s sign[kleins line]
-steel metaphysel blanch sign
-sham’s sign
-capner’s sign
-widening of growth plate
-decrease of epiphyseal height
X-RAY -frog-leg [lowenstein]lateral view
CT-SCAN
MRI SCAN

77. A.P. VIEWinferior,
And medial translation of
epiphyses
LATERAL VIIEW-to
measure lateral
epiphyseal shaft
angle, anterior or
posterior translation

78. TRETHOWAN’S SIGN-
• 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
doesn’t intersect.

79. METAPHYSEAL BLANCH SIGN• In AP VIEW-crescent-shaped area of increased
density overlying the
metaphysis adjacent to
the physis
• This increased density is
due to the overlapping of
the femoral neck and the
posteriorly displaced
capital epiphysis

80. SHAM’S SIGN In the normal hip the inferiomedial femoral neck overlaps
the posterior wall of the acetabulum producing triangular
radiographic density
• With displacement of capital epiphysis this dense triangle
is lost because this portion of the femoral neck is located
lateral to the acetabulum.

81. CAPENERS SIGN-
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
acetabular margin

82. LATERAL VIEW
• 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
appearance[hordons hump]

84. 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
slipped epiphysis.
• 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
considered.
• MRI-useful to assess AVN

85. COMPLICATIONS
1. Avascular necrosis.
2. Chondrolysis.
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

86. IDEAL TREATMENT
•Prevent further slippage
•Stimulate early physeal closure
•Reduction of epiphyseal displacement
•Avoid complications like osteonecrosis , chondrolysis and
osteoarthritis
•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
deformity

87. MANAGEMENT-
• 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
hypothyroidism
• 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
hip

88. Operative management
- 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
methods
- 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
joint disease

89. Developmental Dysplasia of
Hip
A spectrum of disorder including :
Acetabular dysplasia without displacement
Subluxation
Dislocation

90. Epidermiology
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.

91. Aetiology
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
early development)

92. Pathology
Femoral head dislocate posteriorly and later
lies superolateral to acetabulum
Cartilagenous socket is shallow and
anterverted
Capsule is stretched
Ligamentum teres is elongated
and hypertrophied

94. Clinical Features
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)

95. Ortolani’s Test
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
irreducible dislocation

96. 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.

97. Barlow’s Test
• 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.

98. Clinical Features
The infant
Limitation of abduction - < 50-60°
Shortening of the femur by Galeazzi
sign
placing both hip in 90° of flexion and
comparing the height of knee and look
for asymmetry

99. Clinical Features
Increase thigh folds on the
affected side than the normal
side
because of the foreshortened the
thigh.

100. Clinical Features
Walking children
Abnormal gait – due to shortened of the affected
leg
Trendelenburg gait
Waddling gait - if bilateral hip affected
(walk with short steps and a clumsy swaying
motion)
Excessive lordosis – secondary to hip flexion
contracture

101. Investigation
1. Ultrasonography
Neonate’s hip is composed primarily of cartilage –
difficult by using radiographic techniques
Shows the shape of cartilaginous socket
Position of femoral head

102. Investigation
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.

103. X- Ray
(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
acetabulum
Hilgenreiner’ line = Horizontal line through the
triradiate cartilages.
Normally the head is medial to vertical
and below the horizontal

104. (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

105. A
B
C

106. Management
0-6 months
+ve Ortolani
+ve Barlow
+ve US
Double napkins OR Abduction pillow for 6 weeks
Stable hip = follow-up for 6 months
Persistent instability = Splint for 3-6 months (Pavlic harness)
Splintage
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
Types:
Von Rosen’s Splint (easy to apply)
Pavlik Harness (difficult to apply but more freedom to move)

107. Management
Von Rosen’s Splint

108. Management
Persistent dislocation: 6-18months
Failed early treatment or missed dislocation
Hip must be reduced by closed method or operation
Closed reduction
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

109. Management
Operation
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

110. Management
18months-4 years
Closed reduction is less likely to succeed.
Traction: help to loosen the tissue and bring the femoral head down opposite the
acetabulum
Arthrography: clarify anatomy of hip shows whether there is an inturned limbus or
any marked degree of acetabular dysplasia.
Operation
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

111. Management
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
reconstruction.
– bilateral [deformity + waddling gait not so noticeable]
• non-intervention unless painful/severe deformity.
(fail leads to asymmetrical deformity.)

112. -THANK YOU-