Hip - Pediatric and Adolescent Hip Conditions

The more proximal we are...

the more systemic issues can refer to the hip

What are the Viscerogenic sources of Hip Pain?

Kidney, Ureter, Urinary tract, Ileitis, and Crohn's Disease

What systemic symptoms may accompany visceral hip pain?

Abdominal spasms, urinary frequency/urgency, decreased urine output, fever, chills, headache, hypertension, nausea, and vomiting

If someone has a lot of systemic symptoms, what should we be thinking?

It is most likely not musculoskeletal or maybe there is something additional going on and maybe we should refer (septic arthritis)

What are the somatic sources of hip pain?

Nerve root compression,

L/S Facet Joint, and

Sacroiliac joint

What are the main sources of pain within the hip region?

Bone, musculotendinous, capsuloligamentous, intra-articular, and extra-articular

Why is it important to differentiate between dermatomal and peripheral nerve pain patterns?

Dermatomal pain may indicate a lumbar spine or nerve root issue, while peripheral nerve pain may be caused by the lumbar spine or nerve impingement/trapping closer to the hip. Identifying the pattern helps determine the source of the symptoms and guides treatment, as the interventions may be very different

Which piece of information MOST assists in establishing a musculoskeletal hip diagnosis in a child?

Age

What is the typical age of onset for Developmental Dysplasia of the Hip (DDH)?

0-2 years

What is the gender ratio for DDH (M:F)?

1:4

What percentage of DDH cases are bilateral?

20%

What is the typical age of onset for Legg-Calvé-Perthes disease?

3-10 years but can occur as young as 18 months

What is the gender ratio for Legg-Calvé-Perthes disease (M:F)?

5:1

What percentage of Legg-Calvé-Perthes cases are bilateral?

10%

What is the typical age of onset for SCFE?

13-15 years in males; 11-15 years in females

What is the gender ratio for SCFE (M:F)?

2:1

What percentage of SCFE cases are bilateral?

30%

What is the typical age of onset for transient synovitis?

3-8 years

What is the gender ratio for transient synovitis (M:F)?

2:1

How often is transient synovitis bilateral?

Rare

What is Developmental Dysplasia of the Hip (DDH)?

Instability of the femoral head within the acetabulum- a shallow acetabulum

What is the range of severity of DDH?

Wide range, from mild abnormalities to complete dislocation

What is a subluxable hip?

A hip that can partially move out of the acetabulum

What is a dislocated hip?

The femoral head is already completely displaced from the acetabulum

What is a dysplastic hip?

A hip with abnormal development, such as a shallow or underdeveloped acetabulum

What is the incidence of DDH?

1.3 per 1,000 births

What is the cause of DDH?

Unknown

What percentage of DDH cases occur in females?

80-85%

What percentage of DDH cases are first-born children?

60%

What percentage of DDH cases are associated with breech position?

>40%

What are some risk factors for DDH?

Female sex, first-born child, breech position, and family history

Will there be normal or abnormal gait with DDH?

Abnormal

What can happen when a child with DDH begins weight bearing?

Chronic hip dislocation leading to abnormal gait

What is a common physical finding in DDH?

Asymmetrical leg creases

What may cause apparent shortening of the femur in DDH?

Hip dislocation

How is DDH treated at birth?

Pavlik harness

What does a Pavlik harness do?

Helps position the femoral head within the acetabulum. An infant's bones are still largely cartilaginous and developing, proper positioning encourages the hip joint to develop and remodel into a more normal shape

How is DDH treated after 6 weeks?

Hip spica and/or Pavlik harness

How is DDH treated after 1 year?

Open reduction

What is Legg-Calvé-Perthes disease (LCPD)?

Idiopathic avascular necrosis (AVN) of the femoral head which can lead to a flattened femoral head

What is the cause of LCPD?

Unknown/idiopathic

What is one theory for the cause of LCPD?

The artery in the ligamentum teres may close too early, before the medial circumflex artery is ready to provide adequate blood supply

What is the incidence of LCPD?

5.5 per 100,000.

What population has a higher incidence of LCPD?

Caucasian children

What nerve is the anterior hip joint innervated by?

Femoral Nerve (L1-L3) and the Obturator Nerve (could give groin pain)

What nerve is the posterior hip joint innervated by?

Sacral Plexus (Sciatic Branch and could give butt pain)

How does Legg-Calvé-Perthes Disease typically present?

Hip and/or knee pain, ROM limitations, muscle atrophy, leg length discrepancy, and gait abnormalities (Can present with only knee pain)

What ROM limitations are commonly seen with Legg-Calvé-Perthes Disease?

hip internal rotation (IR), abduction (ABD), and adduction (ADD), often with muscle spasm limiting abduction

What muscle changes can occur with Legg-Calvé-Perthes Disease?

Quadriceps and gluteal muscle atrophy

What gait abnormalities can occur with Legg-Calvé-Perthes Disease?

An antalgic gait or a painless limp

How is Legg-Calvé-Perthes Disease evaluated with imaging?

X-rays, including a frog-leg position/view

What are the main treatment goals for Legg-Calvé-Perthes Disease?

Preserve femoral head sphericity, maintain function, and keep the femoral head contained within the acetabulum

What is treatment for early-stage Legg-Calvé-Perthes Disease?

ROM and strengthening exercises and possibly an abduction brace for 6-12 months.

What treatment may be indicated in later stages of Legg-Calvé-Perthes Disease?

Surgery may be indicated (hip replacement)

What is Slipped Capital Femoral Epiphysis (SCFE)?

A condition where the femoral head epiphysis slips off the femoral neck, usually in a posterior direction.

What is a serious complication of SCFE?

Femoral head necrosis

Who is most commonly affected by SCFE?

Adolescents during puberty, with boys affected more often than girls

What is the typical age range for SCFE?

Boys: 13-15 years old; Girls: 11-13 years old

What body type is associated with an increased risk of SCFE?

Being obese and underdeveloped, or very tall and/or athletic

What medical conditions can increase the risk of SCFE?

Endocrine problems, including hypothyroidism and growth hormone abnormalities

What is the most common hip disorder among adolescents?

SCFE - 10.8 per 100,000 children in the US

What population has an increased risk of SCFE?

African American children have an approximately 3.94× greater risk.

What are common chief complaints with SCFE?

Pain and stiffness where pain is most commonly felt on the Anterior thigh, groin, or medial knee

What typically increases SCFE pain?

Weight bearing

What may acute SCFE present with?

Significant groin pain

What may gradual-onset SCFE present with?

Mild pain, muscle guarding, and limited motion

What may happen to weight bearing with SCFE?

Weight bearing may be limited

What gait abnormalities or asymmetry may be present with SCFE?

Antalgic gait and/or Trendelenburg sign and possible leg length discrepancy and the foot may turn outward

What are the main ROM limitations in SCFE?

Decreased hip flexion and decreased internal rotation

What hip ROM is excessive in SCFE?

External rotation

What happens to the hip during flexion in SCFE?

The hip rotates laterally (externally).

What tissue characteristics are associated with SCFE?

Muscle spasm and guarding (maybe adductors or glutes)

What special tests/imaging are used to evaluate SCFE?

X-ray, bone scan, and MRI

What is the primary treatment for SCFE?

Surgery, typically percutaneous pinning

What is the weight-bearing status after SCFE surgery?

Partial weight bearing (PWB) for 4-6 weeks

When can full weight bearing (FWB) begin after SCFE surgery?

After evidence of callus formation.

What muscles are targeted for strengthening after SCFE?

Hip abductors and hip extensors

What ROM should be addressed after SCFE?

Internal rotation and hip flexion

What is a nonsurgical treatment option for SCFE?

Bilateral hip spica cast or brace

What is the most common cause of hip pain in children?

Transient synovitis (when theres no anatomical issues going on)

What is transient synovitis?

Inflammation of the synovium of the hip

How does transient synovitis typically present?

Acute, insidious, unilateral hip pain

Where can pain from transient synovitis be felt?

Hip, thigh, or knee

How is the hip typically positioned with transient synovitis?

Flexed and externally rotated (open packed position)

What would the level of C-Reactive Protein be if someone had Transient Synovitis?

What is the most important condition to rule out with transient synovitis?

Septic arthritis (C- Reactive Protein >20)

How is transient synovitis treated?

Symptom management, Avoid weight bearing, and Anti-inflammatory medications

Is transient synovitis self-limiting?

Yes

What is the difference between transient synovitis and septic arthritis?

Septic Arthritis can kill someone

What is an apophysis?

A normal bony outgrowth from an ossification center where a tendon or ligament attaches

Who commonly experiences apophyseal injuries?

Athletes, especially adolescents

Why are adolescent bones more susceptible to apophyseal injuries?

Rapid growth makes the bone more vulnerable to injury

What is the typical age range for apophyseal injuries?

14-17 years old

What is apophysitis?

Inflammation of an apophysis

What athletes commonly develop apophysitis?

Track and cross-country runners because they commonly occur during sprinting or explosive movements

What are the common regions for apophyseal injuries around the hip?

ASIS, AIIS, and less common are the ischial tuberosities

What is the chief complaint with an apophyseal injury?

Pain at the apophysis, possibly with an audible pop

What type of activity history is common with apophyseal injuries?

Increased activity and explosive movements

What happens to ROM with an apophyseal injury?

Decreased AROM and/or PROM because of pain

What tissue characteristics are associated with apophyseal injuries?

Decreased flexibility and increased tone, guarding, or muscle spasm