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HIP
DISORDERS IN CHILDREN
Each of the hip disorders that affect children has a different
etiology, but all cause damage to the proximal femoral epiphysis
and lead to impaired hip function by altering normal growth.
Developmental dysplasia, or congenital dislocation of the hip,
is caused by instability of the hip in the socket. The altered
pressure causes the socket to grow with a shallow rim (Figure
19.1). As the hip slides laterally out of the socket, the leg
shortens and the articular cartilage eventually degenerates.
Septic arthritis destroys the articular and growth cartilage
through bacterial enzyme release into the infected joint.
Impairment of the blood supply to the hip causes necrosis of
the bone with collapse of the round contour of the femoral
head. This impairs motion and leads to later degenerative arthritis.
Slipping of the femoral epiphysis changes the contour of the
femoral head in the socket, impairs motion and causes degenerative
arthritis (Figure 19.2).
Evaluation and diagnosis
Age is a useful indicator of the diagnosis. All of these disorders
are associated with decreased motion, but loss of internal
rotation is seen earliest. In the older child, knee pain and
limp are common presentations. Infection is associated with
the systemic signs of fever and malaise. X-rays are helpful
but not essential initially. If available, they help to determine
the long term prognosis during the follow-up period.
Age at presentation |
| Developmental
dysplasia |
Present
at birth |
| Septic
arthritis |
Throughout
childhood |
| Avascular
necrosis |
4–8
years |
| Slipped
epiphysis |
7–15
years |
| |
|
| Presenting
findings |
•
Developmental dysplasia
– First born child
– Breech delivery
– Unstable hip at birth
– Short leg
– Asymmetric thigh skin folds |
• Septic
arthritis
– Systemic signs
– Pain with any hip motion
– Hip held in flexed and abducted position |
• Avascular
necrosis
– Limp without known injury
– Knee pain with normal knee examination
– Loss of internal rotation |
• Slipped
epiphysis
– Limp
– Knee pain with normal knee examination
– Loss of internal rotation. |
Treatment
| :: |
Treat
patients with developmental dysplasia at birth with gentle
closed reduction and application of a Pavlick harness
(if available) or a double hip spica cast with the hips
in abduction and flexion. Position the hips so that the
reduction feels stable, but do not flex them greater
than 90 degrees. |
| :: |
Septic
arthritis requires immediate surgical drainage (see pages
19–5 to 19–6). Aspiration will confirm infection
by finding a cloudy or purulent joint fluid. In this
case, perform surgical drainage immediately without waiting
for culture results. |
| :: |
If
Perthe’s disease is suspected, place the child
at bed rest with straight leg skin traction and a few
kilos of weight. As the pain subsides, begin active and
active assisted motion. When full painless motion is
regained, begin ambulation, partial weight bearing with
crutches, and progress to full weight bearing as tolerated.
Check the child frequently to be certain that a painless
range of motion persists. If not, repeat the above process.
The course of revascularization of the epiphysis takes
1–2 years. |
| :: |
Slipping
of the proximal femoral epiphysis requires pin fixation
to prevent further displacement. This is a complex procedure
requiring special pins and X-ray equipment. While arranging
for this treatment, place the child in straight leg traction.
If the child must travel for surgical treatment, keep
him/her non-weight bearing with crutches or apply a hip
spica cast. |
TALPES EQUINOVARUS (CLUB FOOT)
This condition is present at birth and is distinguished by
rigid inversion of the heel and forefoot and a plantar flexed
ankle (Figure 19.3). Other less severe deformities are correctable
with gentle stretching and involve either the forefoot or the
ankle but not both. Other causes of deformity with a similar
appearance, include arthrogryposis, poliomyelitis and myelo-meningocele.
These are associated with multiple abnormalities and are treated
differently.
Treatment
Begin treatment as soon as possible with gentle manipulation
and cast application. Change the cast weekly until correction
is achieved.
Technique
| 1 |
Place
the child in a comfortable supine position on an examination
table or in the mother’s lap. |
| 2 |
Gently
manipulate the foot by pushing the forefoot from the
varus to a valgus position. Place your thumb on the base
of the fifth metatarsal to serve as a fulcrum while pushing
the forefoot laterally (Figure 19.4). |
|
| 3 |
Next,
evert the inverted heel, gently stretching the tight
medial structures. Grasp the heel in your hand and rotate
the whole foot outward. |
| 4 |
When
these deformities correct to ‘normal’, begin
to bring the foot upward out of the plantar flexed position.
Place your hand around the heel and rotate the foot upward
pushing on the midfoot. Do not push up on the metatarsal
heads as this will cause the foot to bend in the middle,
creating a curved or rocker bottom. |
| 5 |
Hold
the corrected position in a padded long leg plaster cast,
with the knee flexed or use an elastic or plaster splint
(Figure 19.5). |
|
| 6 |
Change
the cast or splint weekly, slowly bringing the foot to
a normal plantigrade position. Once corrected, hold the
position with a cast or brace until the child is of walking
age. Severely deformed feet may not correct completely
with cast or splint treatment and surgery may be required. |
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There are four major hip disorders
in children; each occurs within a specific age range
and may cause severe hip deformity if not treated early
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They
include:
– Developmental dysplasia of the hip
– Septic arthritis
– Avascular necrosis (Legg-Calve-Perthe’s Disease)
– Slipped capital femoral epiphysis
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Diagnosis
is made by clinical examination. X-rays are useful
for follow-up care, but are not essential.
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