limp: non-infectious hip · slipped capital femoral epiphysis (scfe) treatment stabilize physis...
TRANSCRIPT
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Limp: Non-infectious HipMichael Peyton, MD
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Slipped Capital Femoral Epiphysis (SCFE)
Pathology
Femoral head (epiphysis) of the
proximal femur displaces on the
femoral neck due to weakness in the
hypertrophic zone of the growth plate
(physis)
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Slipped Capital Femoral Epiphysis (SCFE)
Contributing Factors
● Obesity / Puberty
○ Inc stress across physis
○ Inc prevalence younger
● Metabolic derangement
○ Inherently weakening physis
Epidemiology
● Pre- / Adolescent (Puberty)
● 1.5 Male > F
● Greater in black, Hispanic,
Polynesian, Native Americans
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Slipped Capital Femoral Epiphysis (SCFE)
Presentation
● Groin/hip or knee pain
○ Acute vs Chronic (>3wk)
● Painless limp with external rotation
of the affected leg
● Limited hip ROM - decreased
internal rotation, flexion,
abduction
● Obligatory external rotation with
passive hip flexion
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Slipped Capital Femoral Epiphysis (SCFE)
Unstable SCFE
● Unable to bear weight
● High risk for osteonecrosis
● Risk of early osteoarthrosis
Imaging Evaluation
● AP and frog-leg lateral XR
● MRI - only if not seen on XR with
high suspicion or risk of
contralateral slip
● CT - only for presurgical planning
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Klein Lines - line extended from lateral cortex that intersects femoral epiphysis
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Slipped Capital Femoral Epiphysis (SCFE)
Lab Evaluation
Consider for:
● < 10 years old
● Weight < 50%ile
● Suspected endocrine
○ Hypothyroidism - thyroid function
○ Osteodystrophy of chronic renal failure - BUN and Cr
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Slipped Capital Femoral Epiphysis (SCFE)
Treatment
● Stabilize physis with
percutaneous in situ fixation
● Contralateral tx for high risk pt
Prognosis
● Leg length discrepancy
● Osteonecrosis
● Osteoarthritis
● Impingement
● 45% require total hip
replacement by 50 yo
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Legg-Calve-PerthesPathology
Idiopathic osteonecrosis of the
femoral capital (head) epiphysis
Disruption of Blood Supply -> Bone
Resorption -> Femoral Head
Weakening and Flattening ->
Reossification -> Growth Resumption
Epidemiology
● School aged (4-8 yo)
● 3:1 M:F
● Bilateral in 10-15%
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Legg-Calve-Perthes
Possible Risk Factors
● Collagen type II mutations
● Coagulation abnormalities
● Microtrauma from repetitive hip
loading and extreme hip flexion
(gymnast and dancers)
● Venous congestion
● Hyperactive behavior (ADHD)
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Legg-Calve-Perthes
Presentation
● Painless limp
● Referred pain to knee (femoral n.),
medial thigh (obturator n.), buttock
(sciatic n.)
● Limited hip abduction and internal
rotation
● Weak quadriceps and hip
abductions from atrophy
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Limited ABduction of left hip
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Limited internal rotation of left hip
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Limited internal rotation of left hip (prone)
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Legg-Calve-Perthes
Imaging Evaluation
● AP pelvic and bilateral frog-leg
● MRI - accurate for early dx
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Early signs - flattening of left femoral head and subchondral sclerosis
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Later signs - extrusion of femoral head laterally, not contained by acetabulum
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Legg-Calve-Perthes
Diagnosis of Exclusion
Consider other diseases causing osteonecrosis of femoral head
● Sickle cell disease
● Lupus
● Chemotherapy
● Long-term steroid use
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Legg-Calve-Perthes
Treatment and Prognosis
● Early referral to peds ortho
● Tx varies, but no cure
● Goal: maintain shape to prevent
degenerative changes and loss
of hip ROM
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Developmental Dysplasia of the Hip (DDH)
● Ranges from mild acetabular
dysplasia to frank hip dislocation
● RF: breech, female, firstborn, family
hx, oligohydramnios; prolonged
swaddle
● Tx goal: maintain concentric
reduction of the femoral head in the
acetabulum to allow continued
normal development of the hip
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Developmental Dysplasia of the Hip (DDH)
Hip Exam: Newborn
● Barlow: adduct hip midline and apply posterior force
○ → + clunk from subluxation
○ +Barlow = femoral head rests in acetabulum, but pathologic instability
● Ortolani: after Barlow maneuver, abduct the hips while applying anterior-
directed pressure at the greater trochanters
○ → + if femoral head relocates (clunk)
○ +Ortolani = femoral head is dislocated at rest
● Sensitivity 54%
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Developmental Dysplasia of the Hip (DDH)
Hip Exam: older infant or walking child
● Leg length discrepancy
● Thigh-fold asymmetry
● Limited hip abduction
● Galeazzi sign
● Trendelenburg gait or Waddling Gait
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US is useful in neonate with little
ossification of the acetabulum and
no ossification center of the
femoral head (<3 mo)
Screening US for < 6 mo with 1 or
more significant risk factors
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Evidence is used to support treating hip dislocation (Ortolani+)
while observing milder instability (Barlow+)
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Hip Trauma
Traumatic Hip Dislocation (usually posterior)
● < 10 yo = due to low injury sports, trip, or fall
● > 10yo = high energy MVA
● Urgent closed reduction → open if intraarticular fragment following reduction
Fractures to consider in high energy mechanism
● Femoral head, neck
● Proximal femur physis
● Pelvic ring
● Acetabular (lower incidence compared to adults due to cartilaginous
acetabulum and ligamentous laxity)