Limp: Non-infectious Hip Michael Peyton, MD
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) 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 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 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 Klein Lines - line extended from lateral cortex that intersects femoral epiphysis 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 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
Legg-Calve-Perthes Pathology
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% 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) 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 Limited ABduction of left hip Limited internal rotation of left hip Limited internal rotation of left hip (prone) Legg-Calve-Perthes
Imaging Evaluation
● AP pelvic and bilateral frog-leg
● MRI - accurate for early dx Early signs - flattening of left femoral head and subchondral sclerosis Later signs - extrusion of femoral head laterally, not contained by acetabulum Legg-Calve-Perthes
Diagnosis of Exclusion
Consider other diseases causing osteonecrosis of femoral head
● Sickle cell disease ● Lupus ● Chemotherapy ● Long-term steroid use 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
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 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%
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
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
Evidence is used to support treating hip dislocation (Ortolani+) while observing milder instability (Barlow+) 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)