Paediatric Orthopaedic

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  • Ortolani- Baby thigh held with thumbs medially and finger resting on greater trochanter , flexed 90dgree and abducted the hipIf abduction stop halfway, no jerk of entry irreducible dislocationBarlow- thumb in the groin, gasping upper thigh , make the femoral head in n out of acetabulum during abduct and adduct
  • Xray usually dificult to evaluate bcoz the acetabulum and femoral head are largely cartilaginous, therefore not visible on Xray before
  • Hip that unstable at birth 80-90% will stabilized spontaneously in 2-3w
  • Paediatric Orthopaedic

    1. 1. Farah Adibah Kasmin 2008402312
    2. 2.  Formerly known as congenital dislocation of the hip Comprise a spectrum of disorder: 1. Dislocation during neonatal period 2. Subluxation or partial displacement 3. Shallow acetabulum without actual displacement 5-20 per 1000 live births Re-examination 3 weeks after birth , the incidence : 1-2 per 1000 infants Girls>boys, 7:1 Left hip> right hip 1:5 cases - bilateral
    3. 3. • Generalized joint laxity Genetic • Shallow acetabula • High level of maternal estrogen,Hormonal progesterone and relaxin in the last few changes weeks of pregnancy aggravate ligamentous laxity in infantIntrauterine • esp. breech position with extended legs ->malposition dislocation • Who swaddle their babies & carry them Postnatal with fully extended hips n knees > factors compare to person who carry babies astride their backs with hips abducted
    4. 4. In the neonate: Every newborn child should be examine for sign of hip instability esp: - FHx of congenital hip instability, breech presentationSpecial tests: Ortolani’s test Barlow’s test
    5. 5.  Late features:  Asymmetry, a clicking hip or difficulty in applying napkin  Unilateral dislocation- skin creases look asymmetrical, short leg, internally rotated  Bilateral dislocation- wide perineal gap, abduction is limited  Walking is delayed  Gait: limp or Trendelanburg gait
    6. 6.  hip dislocation  Hilgenreiners line  horizontal line through right and left triradiate cartilage  femoral head ossification should be inferior to this line  Perkins line  line perpendicular line to Hilgenreiners through point at lateral margin of acetabulum  femoral head ossification should be medial to this line  Shentons line  arc along inferior border of femoral neck and inferior edge of superior pubic ramus  arc line should be continuous
    7. 7.  hip dyplasia  acetabular index - angle formed by a line drawn from point on triradiate cartilage to point on lateral margin of acetabulum (normal is < 30 deg.) Von Rosen’s lines- the hip abducted 45degree.The femoral shaft should pointed into acetabula
    8. 8.  Plain X rays Normal Dislocated hip
    9. 9.  The first 3-6 month of age  Double napkin or an abduction pillow for 1st 6weeks  Re-examined  Persistent instability  abduction splintage until hip is stable  Follow up- until the child walking Splintage: - hold the hip 100 degree flexed and abducted - allow some movement in the splint
    10. 10. Persistent dislocation: 6month to 6 years Closed reduction Splintage Open reductionAfter the age 6 yearsUnilateral dislocation- operative reductionBilateral dislocation- Symmetrical, less notifiable - Greater risk for surgical intervention - avoid operation unless pain and deformity is unusually severe
    11. 11.  Displacement of the proximal femoral epiphysis aka epiphysiolysis Most common hip pain in adolescence M > F->3:2 M: 12 - 16 y/o, F: 10 - 15 y/o Bilateral: 17 – 50% of cases
    12. 12.  Risk factors include:  Obesity  Hx of radiation therapy to femoral head region  Endocrine disorders (e.g. hypothyroidism and osteodystrophy of chronic renal failure)  Positive family history of SUFE/SCFE (autosomal dominant)  African American
    13. 13. 1. History:  Pain - Hip or groin pain (most common) - Reffered pain: ant part of thigh and knee  Limp 2. Physical examination  Trendelenburg gait  Leg is externally rotated  1-2cm short  Limitation of abduction and internal rotation
    14. 14. SUFE Grading
    15. 15. ManagementNon weight bearing and restSurgical: Percutaneous in-situstabilization/fixationComplications Avascular necrosis of femoral head (10-15%) Acute cartilage necrosis/chondrolysis (7-10%) Deformity Secondary osteoarthritis (~90%) Slip progression (1-2% of single screw fixation) Hip stiffness
    16. 16.  Painful hip disorder of childhood characterized by necrosis of the femoral head Incidence: 1 in 10 000 Boys>girls , 4x as often as girls Usually 4-8 years old Femoral head supplied by: •Mataphyseal vessels •Lateral epiphyseal vessels •Scanty vessels
    17. 17. •Bone death •Part of the bony femoral head dies, stop enlargeStage 1 •Revascularization and repair •New blood vessel enter the necrotic area and new bone is laid down on theStage 2 dead trabeculae •Distortion and remodelling •Epiphysis is damaged and the growth at the head and neck will be distorted •Epiphysis ends up flattened (‘coxa plana’) but enlarged (‘coxa magna’)Stage 3 •The femoral head is incompletely covered by the acetabulum.
    18. 18.  Complaint of pain and start to limp Little wasting of muscles in the upper thigh Joint is irritable  All movements are diminished  Extremely painful The child is not seen till later  Limited abduction and internal rotation
    19. 19.  X- ray  Earliest changes – increased density of the bony epiphysis and apparent widening of the joint space  Followed by - flattening, fragmentation and lateral displacement of the epiphysis, with rarefaction and broadening of the metaphysis.
    20. 20.  Symptomatic tx:  Pain control  Gentle exercise to maintain movement Containment Operative reconstruction
    21. 21. Transient synovitis is the most common cause ofacute hip painaged 3-10 years.Boys >> GirlsThe disease causes arthralgia and arthritissecondary to a transient inflammation of thesynovium of the hip.Usually it is a diagnoses of exclusion, oncetrauma and infection are ruled out
    22. 22. Symptoms Signs-- Most commonly: -Hold the hip in flexion Unilateral hip or with slight abduction groin pain and external rotation.- Limp. - mild restriction of abduction and internal- 50% patient has rotation, but 1/3 recent history of an demonstrate no URTI limitation of motion.- Usually afebrile or - The hip may be tender have a mildly and painful even with elevated passive movement. temperature. - The most sensitive test :the log roll- Very young children -> crying at night.
    23. 23. Investigatios Usually to rule out other diagnoses. WBC, ESR and CRP are usually elevated in septic arthritis. XRay: can exclude bony lesions. Ultrasound- may show a joint effusionManagement Apply heat and massage .Non-steroidal anti-inflammatory drugs (NSAIDs). Advise bedrest until pain dissapear and the effusion resolves

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