adolescent hip

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