6 – Paediatric hip diseases (Perthes, epiphyseolysis)

13. Juvenile slipped upper femoral epiphysis

• Slipped capital femoral epiphysis = Juvenile slipped upper femoral epiphysis
• Epidemiology
  • Most common hip disorder in adolescents
  • Males > females
  • 6 – 16 years
• Etiology
  • Unknown cause
  • GH and sex hormone imbalance may be involved
  • Obesity and family history are risk factors
• Pathology
  • The femoral head (epiphysis) slips off the neck (metaphysis) in the line of the growth plate
  • Can be acute or chronic
• Clinical features
  • Often bilateral
  • Acute type
    • Sudden onset pain
  • Chronic type
    • Nagging groin/thigh/knee pain
    • Antalgic gait
  • Flexion, abduction, and internal rotation contracture
  • Features of sex hormone imbalance
    • Fat
    • No pubic hair
    • Delayed sexual development
• Diagnosis
  • X-ray
  • MRI
• Treatment
  • Always surgical – there is no conservative treatment
  • Urgent surgical internal fixation with screwing of the femoral head
    • Percutaneous procedure
    • Screw can be removed when child is done growing

26. Perthes’s Disease

• Legg-Calve-Perthes disease = Perthes disease = idiopathic avascular necrosis of the femoral head
• Epidemiology
  • 3 – 16 years
  • Boys > girls
• Etiology: Idiopathic by definition
• Pathomechanism
  • The femoral epiphysis grows quickly and is therefore highly dependent on adequate blood supply
  • Inadequate blood supply can be due to compression of the arteries (for example from transient coxitis)
• Clinical features
  • Usually unilateral
  • Antalgic gait
  • Pain in groin, thigh, or knee
  • Limited internal rotation and abduction
• Diagnosis
  • X-ray
    • Often shows nothing the first 3 – 6 months
    • Shows flat, collapsed femoral head
  • MRI
    • If x-ray is negative but clinical suspicion persists
• Treatment
  • The primary aim of treatment of Perthes disease is containment (= holding the femoral head in the acetabulum)
    • Can be achieved by conservative therapies or by surgery
  • Conservative
    • Non-weightbearing activities
      • To allow re-ossification
      • Swimming is excellent
    • Pain management
    • Physical therapy
  • Surgical
    • Generally only for children > 8 years
      • Younger children generally don’t benefit from surgery
    • Surgical containment by femoral or pelvic osteotomy
• Complications
  • The younger the patient, the better prognosis
  • Heals in 3 – 5 years
  • May lead to late osteoarthritis (Perthes is a prearthritic condition)

54. Transitory coxitis, coxa saltans

• Transitory coxitis = transitory synovitis of the hip = irritable hip
  • Epidemiology
    • Most common cause of acute hip pain in children 3 – 8 years
    • Boys > girls
  • Etiology
    • Occurs without precipitating cause in most cases
    • May follow upper respiratory tract infections or trauma
  • Pathology
    • Synovitis of the hip
  • Clinical features
    • Almost always unilateral
    • After upper respiratory tract infections
      • This may give transitory coxitis a season appearance
    • Often recurs
    • Antalgic limp
    • Thigh/knee pain
    • Flexion contracture
    • Limited internal rotation
    • No fever
  • Diagnosis
    • ESR, CRP, WBC slightly raised
    • US/MRI show hip joint effusion
    • X-ray shows nothing
  • Treatment
    • The condition is self-limiting after a few weeks in most cases
    • Rest
    • NSAIDs
    • Joint fluid aspiration
      • This can also exclude septic arthritis, which may cause similar symptoms
  • Complications
    • The pressure caused by the effusion can cause avascular necrosis of the femoral head

• Snapping hip syndrome = coxa saltans
• A condition characterised by a snapping sensation felt in the hip
• May or may not be audible, may or may not cause pain
• Three types
  • External snapping hip
    • Caused by iliotibial tract sliding over greater trochanter
    • Often visible
  • Internal snapping hip
    • Caused by iliopsoas tendon sliding over femoral head or other structures
    • Often not visible, but is audible
  • Intra-articular snapping hip
    • Caused by loose bodies in the hip joint
• Treatment
  • Internal and external types usually don’t require treatment
    • If painful, the anatomic structure which causes the snapping can be incised
  • Intra-articular type can be repaired by hip arthroscopy