Diagnostic calendar of childhood hip disorders
| Age (years) |
Probable diagnoses |
| Birth |
Congenital dislocation |
| 0 - 5 |
Perthe's disease |
|
Late presentation of CDH |
|
Irritable hip |
| 5 - 10 |
Perthe's disease |
|
Irritable hip |
| 10 - 15 |
Slipped upper femoral epiphysis |
|
Septic arthritis |
|
Rheumatoid arthritis |
Causes of an 'irritable hip'
- Perthe's disease
- Slipped upper femoral epiphysis
- Juvenile chronic arthritis
- Septic arthritis
- Osteomyelitis
- Rheumatic fever
Perthe's disease
- A childhood osteochondrosis of the hip
- Occurs secondary to avascular necrosis of the capital femoral epiphysis
- It is a self-limiting disorder with revascularisation occurring within 2 - 4 years
- The femoral head may remain deformed resulting in osteoarthritis
- Four stages of the disease are recognised
- Stage 1 - Avascular necrosis
- Stage 2 - Fragmentation of the femoral epiphysis
- Stage 3 - Regeneration and revascularisation
- Stage 4 - Healing
Clinical features
- Median age of onset is 6 years
- Male : female ratio is 4:1
- Presents with hip pain and a limp
- Examination shows reduced movement - especially abduction & internal rotation
- 10% have fixed deformity
Radiology
- X-ray shows capital femoral epiphysis to be smaller, denser and flattened
- Medial joint space is increased and ossific nucleus is fragmented
- Bone scan will show a 'cold' femoral epiphysis
Treatment
- Aims of treatment are to prevent deformation if femoral head and prevent osteoarthritis
- Can be achieved by:
- Period of bed rest & reduced weight bearing
- Surgical containment achieved by a subtrochanteric or innominate osteotomy
Slipped upper femoral epiphysis
- Commonest significant hip disorder of adolescence
- Femoral head 'slips' posteriorly and into varus
- Occurs in the obese and skeletally immature child
- A progressive disorder and therefore early diagnosis is essential
- Male : female ratio 3:1
- 20% of cases are bilateral
- 5% of patients have family history
Clinical features
- Usually presents with gradual onset of hip or knee pain
- Clinical features are initial minimal and diagnosis is often missed
- Occasionally presents with sudden onset of pain after exercise
- Examination shows an antalgic gait
- Initially hip may have full range of movement
- A severe slip results in fixed external rotation
Radiology
- A radiological diagnosis can be difficult
- A 'frog lateral' radiograph is possibly best at demonstrating the slipped epiphysis
Picture provided by Dr Paul Rowe, Gloucester Royal Infirmary, United Kingdom
Treatment
- The aims of treatment are to
- Preserve blood supply to femoral head
- Stabilise the physis
- Prevent avascular necrosis and chondrolysis
- Usually achieved by in-situ pinning of the epiphysis
- Occasionally reconstructive subtrochanteric osteotomy is required
Bibliography
Maroo S. Diagnosis of hip pain in children. Hosp Med 1999; 60: 788-793.
Spence G, Tsiridis E, Hashemi-Najed A. Diagnosing slipped upper femoral epiphysis. Hosp Med
2001; 62: 338-342.
Weinstein S L. Natural history and treatment outcomes of childhood hip disorders. Clin Orthop 1997;
344: 227-247.
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