Date post: | 24-Dec-2014 |
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ADOLESCENT HIPADOLESCENT HIPADOLESCENT HIPADOLESCENT HIP
What does the parents complain of ?
What does the parents complain of ?
LimpingPain in hipKnee pain
What could it be due to ?What could it be due to ?
Transient synovitis Perthes disease Slipped capital femoral epiphysis Idiopathic Chondrolysis Septic arthritis Tuberculous arthritis Trauma Tumours
TRANSIENT SYNOVITIS TRANSIENT SYNOVITIS HIPHIPTRANSIENT SYNOVITIS TRANSIENT SYNOVITIS HIPHIP
Benign self limitingMost common cause of hip
pain in children
AETIOLOGYAETIOLOGYAETIOLOGYAETIOLOGY
Unknown Trauma Allergic manifestation infection
SYNOVITIS HIPSYNOVITIS HIPSYNOVITIS HIPSYNOVITIS HIP
Unilateral hip pain 3 – 18 years Limb and antalgic gait ROM restricted
DIAGNOSIS IS BY
EXCLUSION
DIAGNOSIS IS BY
EXCLUSION
INVESTIGATIONSINVESTIGATIONSINVESTIGATIONSINVESTIGATIONS
Usually within normal limitsUSG – joint effusion
Complete resolution Complete resolution is the rule usually is the rule usually within 3-4 weekswithin 3-4 weeks
Complete resolution Complete resolution is the rule usually is the rule usually within 3-4 weekswithin 3-4 weeks
TREATMENTTREATMENTTREATMENTTREATMENT
Strict bed rest and non-weight bearing
Skin traction – recurrent symptoms
SEPTIC ARTHRITISSEPTIC ARTHRITISSEPTIC ARTHRITISSEPTIC ARTHRITIS
True orthopaedic emergencyAny age – common in infants
and children
Clinical featuresClinical features
Febrile and toxicSwollen and painful jointPseudoparalysis
The key to treatment is early diagnosis with a high index of suspicion and early removal of pus from the joint.
Investigations Investigations
Raised total countRaised ESRRaised CRP
TREATMENTTREATMENT
Early diagnosisArthrotomyAntibioticsSplintage – rest -- traction
ComplicationsComplications
OsteomyelitisDislocationAvascular necrosisLate osteoarthritis
SLIPPED CAPITAL SLIPPED CAPITAL FEMORAL FEMORAL EPIPHYSISEPIPHYSIS
SLIPPED CAPITAL SLIPPED CAPITAL FEMORAL FEMORAL EPIPHYSISEPIPHYSIS
A true adolescent problem
Gradual or acute slip through the capital femoral physis
Gradual or acute slip through the capital femoral physis
SLIPPING
SLIPPED CAPITAL SLIPPED CAPITAL FEMORAL EPIPHYSISFEMORAL EPIPHYSISclinical profile pictureclinical profile picture
SLIPPED CAPITAL SLIPPED CAPITAL FEMORAL EPIPHYSISFEMORAL EPIPHYSISclinical profile pictureclinical profile picture
SCFESCFE
Boys more than girlsLeft more than rightBilateral – 20 %
Etiology Etiology
Exact cause – unknownHormonalTraumaMechanical factors
Classification Classification
PreslipAcuteChronicAcute on chronic
Preslip Preslip
Weakness or pain in the thigh or knee
Limitation of internal rotationX-ray – widening of the physis
Acute Acute
Less than 3 weeks duration Trauma – may be insignificant Bedridden – antalgic gait Shortening External rotation deformity Axis deviation
Acute on chronicAcute on chronic
Mild trauma results in increase in the prodromal pain present for more than 3 weeks
Chronic Chronic
Intermittent pain present for more than 3 weeks.
Investigations Investigations
X-ray – APFrog leg lateral view ( contraindicated when
suspecting acute slip)
Eyes
do not see what mind does not knowIt is true about reading x-rays also
Goal of treatmentGoal of treatment Promote early physeal closure Prevent additional slipping Relieve pain Correct deformity Restore function of hip Prevent complications
Conservative managementConservative management
RestAnalgesics
Surgical treatment is the standardSurgical treatment is the standard
Surgical options Surgical options
Insitu pinning Reduction and fixationCorrective osteotomies
Insitu pinningInsitu pinning
Image intensifier controlCannulated screw fixation
C-ARMC-ARM
Complications Complications
ChondrolysisAvascular necrosisSecondary osteoarthritis
PERTHES DISEASEPERTHES DISEASE
Common problem4 – 12 years of ageMale > female (4:1)Low socioeconomic status
Late onset Perthes after the age of 9 years.
Late onset Perthes after the age of 9 years.
Etiology Etiology
Exact etiology – unknownCurrent theory – vascular
embarrassmentIncreased intra-osseous
pressure
This results in avascular necrosis of the capital femoral epiphysis.
This results in avascular necrosis of the capital femoral epiphysis.
Clinical featuresClinical features
Painless limping
CLINICAL PROFILECLINICAL PROFILE
Abduction-Internal rotation limited Flexion variably limitedAdduction deformity Limb-length discrepancy
INVESTIGATIONSINVESTIGATIONS
X-ray --- AP & FROG LEG LATERAL
Sclerosis of the epiphysisCollapse of the epiphysisSubchondral fracture
MRI – to know the shape of the cartilage
ARTHROGRAM
ARTHROGRAMARTHROGRAM
Subchondral fracture heralds the onset of clinical Perthes.
Subchondral fracture heralds the onset of clinical Perthes.
MANAGEMENTMANAGEMENT
Depends on stage of diseaseShape of the headManagement of complications
CATERALL CATERALL CLASSIFICATIONCLASSIFICATIONCATERALL CATERALL 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
Guiding principle in the treatment is the containment of the femoral head in the acetabulum.
Guiding principle in the treatment is the containment of the femoral head in the acetabulum.
Treatment optionsTreatment options
ConservativeSurgicalSupervised neglect
In the initial synovitis stage treatment is by skin traction
In the initial synovitis stage treatment is by skin traction
Conservative treatmentConservative treatment
Time consumingDifficult for parents and childPsychological problems
Surgical treatmentSurgical treatment
Contain head by osteotomiesFemoral or acetabularVarus derotation osteotomy of
femur commonly done
VARUS DEROTATION OSTEOTOMYVARUS 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
Complications Complications
Hinged abductionChondrolysis Secondary osteoarthritis
TB HIPTB HIPTB HIPTB HIP
Not so uncommon in our practice
Family history of TB
TB HIPTB HIPTB HIPTB HIPLimp – commonest presentationNight criesStiffnessWastingFever Weight loss
TB HIPTB HIPTB HIPTB HIPRaised ESRMantoux testX-rayPCRIgM antibody assayBiopsy
TB HIP- X-RAYTB HIP- X-RAYTB HIP- X-RAYTB HIP- X-RAY Osteoporosis Travelling acetabulum Dislocated hip Mortar and pestle appearance Perthes type Protrusio acetabuli Destruction of head
TB HIPTB HIPTB HIPTB HIP
ATT Traction Splintage Surgery – last resort
IDIOPATHIC CHONDROLYSISIDIOPATHIC CHONDROLYSIS
Progressive destruction of articular cartilage with effusion and joint space narrowing.
Progressive destruction of articular cartilage with effusion and joint space narrowing.
Girls -- 9 – 18 yearsInsidious onsetPainLimping Stiffness
Investigations Investigations
X-ray -- joint space narrowing
Blood – within normal limitsMRI
TREATMENTTREATMENTNSAID’sAggressive physical therapy
(CPM)Periodic tractionBed restProlonged non - weight bearing
Questions & CommentsQuestions & Comments