Childhood Hip Problems
Developmental dysplasia of the hip (DDH) is a common disorder that is seen in infants and young children. It may be present at birth or may occur during the first year of life of the infant. As the name suggests, it occurs due to improper development of the hip joint either while the foetus is in the uterus or during the growth phase in the first year of life.
In a normal hip, the head of the femur (thighbone) fits well into the socket (acetabulum); whereas in hip dysplasia, the socket and femoral head are not congruent because of their abnormal development. The exact cause of DDH is not clear. However, there are factors that may contribute to the development of DDH, and may include:
- Abnormal position of the femoral head
- Too shallow or sloping acetabulum rather than normal cup shape
- Laxity or looseness of the ligaments around the joint
- Breech position of the foetus, leading to abnormal stress on the hip joint
- Swaddling or wrapping of the infant with both legs tied together and extended out straight
DDH can be mild or severe, and can affect one or both hips. It is more common in girls and usually affects the left hip. DDH does not cause any pain and so the condition may not be noticed until the child starts to walk. A child with DDH may walk with a limp (if one hip joint is affected) or waddle (if both hip joints are affected). If both hips are dislocated, the child’s abnormal walk (gait) is difficult to detect.
Appropriate screening should be performed for all newborns and infants for the early detection of DDH. This is especially important if the baby is born by breech or has a family history of DDH. Usually, Ortolani’s maneuver or Barlow’s test are used to detect any hip instability in infants. For infants older than three months, an additional Galeazzi’s test may also be performed. In this test, any difference in knee height is examined while the child is made to lie on their back with the legs folded at the knee. If any one of these tests is positive, your child will be closely observed or treated with a brace. During hip examination, the doctor may also look for the difference in range of motion of the hip, presence of uneven skin folds around the thigh and difference in leg length from side to side. In infants less than 6 months, an ultrasound may be advised to confirm the diagnosis.
The treatment for DDH depends on both the age of the child and severity of the condition. The aim of treatment is to keep the femoral head in good contact with the acetabulum so that the hip can develop normally. If detected in the first six weeks, double and triple diapering may be required. If the problem continues to exist, use of a pelvic harness to keep the hip in flexion and abduction may be advised. Only when conventional treatment is not effective, surgery to put the hip back into place, may be advised.
Legg-Calve-Perthes Disease (LCPD) or Perthes disease is a disorder of the hip that affects children, usually between the ages of 4 and 10. It usually involves one hip, although it can occur on both sides in some children. It occurs more commonly in boys than girls.
The cause of Legg-Calve-Perthes Disease is not clearly known. It may occur due to inadequate blood supply to the ball of the hip joint (the femoral head), which leads to death of the bone. Over the course of several months, the blood supply returns back to the bone tissue and new bone cells gradually replace the dead bone over 2 – 3 years.
Some signs and symptoms of Perthes disease include:
- Walking with a limp (painless limp)
- Pain or stiffness in the hip, groin, thigh or knee
- Shortening of the leg or unequal leg length
- Wasting of thigh muscles
Your doctor will make a diagnosis based on your child’s signs and symptoms, a thorough physical examination, imaging studies such as X-ray of the hip, and magnetic resonance imaging (MRI) scan.
The goal of treatment for Perthes disease is to keep the femoral head snug in the socket portion of the joint. Nonsurgical treatment options may include rest, activity restrictions, anti-inflammatory medications, casting or bracing, and physical therapy. If nonsurgical treatments don’t work, your child may need surgery. Surgery involves lengthening a groin muscle or reshaping the pelvis (osteotomy), depending on the severity of the condition and the shape of the femoral head.
Slipped capital femoral epiphysis (SCFE) is a common hip disorder in adolescents, causing slippage or separation of the femoral head (ball at the upper end of the femur bone) from the weakened epiphyseal growth plate (growing end of the bone). This condition often develops during the rapid growth period, after the onset of puberty, and may affect one or both legs at a time. The separation may be caused by an injury or other factors such as obesity and hormonal imbalances. SCFE commonly occurs in children between 11 and 15 years, and boys are more likely to develop the condition than girls.
The exact cause of SCFE remains unclear; however, the presence of certain factors may increase the risk of your child developing this condition. These include:
- SCFE is more common in children who are obese and have rapid growth. This may be attributed to excess pressure on the growth plate.
- Endocrine disorders such as diabetes, thyroid disease and growth hormone abnormalities (acromegaly)
- Kidney diseases
- Radiation therapy or chemotherapy for childhood leukaemia
- Steroid medications
- Family history of the disorder
Types of SCFE
SCFE is classified into two types, stable and unstable SCFE, based on the severity of pain and damage.
- Stable SCFE (mild slip): The condition is considered mild or stable if the child is having pain or stiffness in the knee or groin area, but can manage to walk and may limp. Symptoms worsen with activity and subside with rest. In stable SCFE, the child is able to walk with or without the help of crutches.
- Unstable SCFE (severe slip): Any major blow, such as a fall or sports injury, may cause unstable SCFE. The child may have severe pain and stiffness that may limit movement. The child may not be able to walk or even put weight on the affected side.
Signs and symptoms
Children with SCFE will exhibit certain characteristic symptoms that may even help the physician in assessing the type of SCFE. The signs and symptoms of stable SCFE include:
- Stiffness in the hip
- Pain in the groin, the thigh or the knee that lasts from several weeks to months
- Limping while walking
- Restricted movements of the hip
- Outward twisting of the leg
The signs and symptoms of unstable SCFE include:
- Severe pain similar to that felt during bone fracture.
- Inability to move the affected leg
Your doctor will diagnose the condition based on a careful medical history and physical examination, where the walking pattern and hip movements will be monitored. X-rays of the hip confirm the diagnosis. Other imaging tests that may be ordered include:
- Bone scanning: Bone scans help in the early detection of children at risk of avascular necrosis and chondrolysis, common complications of SCFE.
- Computed tomography scan: CT scans reveal the degree of slippage.
- Ultrasonography: Ultrasound scans help to distinguish between stable and unstable slip.
- Magnetic resonance imaging scan: MRI scans may suggest possible complications such as avascular necrosis.
The goal of treatment in SCFE is to prevent progression or worsening of the slippage and is accomplished through surgery. Surgery is usually performed within 24-48 hours of diagnosis.
The surgical procedures available for correcting stable slipped capital femoral epiphysis include
- Internal fixation (pinning): This surgery is performed in a hospital-setting under general anaesthesia. The patient may be positioned on their back during the procedure. The surgeon will make a small incision near the hip. With the use of fluoroscope (X-ray machine that captures continuous real-time images, which are displayed on the TV monitor) as a guide, the surgeon will insert a metal screw or pin through the thighbone and the growth plate so that they are held in place. The surgeon may use either a single central pin or multiple pins.
- Bone-graft epiphyseodesis: In bone graft epiphyseodesis, the surgeon exposes the hip through the iliofemoral approach. A rectangular-shaped piece of bone is removed from the front part of the femoral neck. A tunnel is created through the growth plate and several corticocancellous strips taken from the iliac crest bone are pushed into the tunnel across the femoral physis so that growth plate closure can be achieved.
- Corrective osteotomy: The surgeon exposes the hip by the anterior Smith-Petersen or anterolateral approach. A piece of bone is removed from the metaphysis of the femoral neck. This allows the epiphysis to be repositioned on the metaphysis without affecting the epiphyseal blood supply. When the femoral neck gets shortened, the epiphysis is reduced and internally fixed with the help of 3 pins. Although, this procedure is anatomically sound, it is more invasive and may pose serious complications, such as avascular necrosis and chondrolysis.
Surgical correction of unstable slipped capital femoral epiphysis can be done with internal fixation method where your surgeon makes a small incision near the hip, and under the guidance of fluoroscope, may advance the screw through the metaphysis, growth plate and epiphysis, such that the screw holds all three structures in place.
Irritable hip, also known as acute transient synovitis is a common disorder of childhood characterised by the onset of hip pain and limping. The term transient means that it does not usually last long. It usually occurs before puberty and affects only one hip. Boys aged between 4 to 10 years are most often affected 2 to 4 times more than girls.
A child with irritable hip will experience the following symptoms:
- Hip pain
- Pain that can spread to the groin, thigh and knee
- Abnormal crawling
- Abnormal crying
- A slight fever
The exact cause of irritable hip is unknown, but in some cases, the condition can occur as a result of viral infection (upper respiratory tract), or a fall or injury. Irritable hip can also occur as a result of Perthes disease, a condition where the head of the thighbone deteriorates because of poor blood supply.
The diagnosis of irritable hip is made based on your child’s symptoms and physical examination. To rule out other possible causes of your child’s symptoms, the following diagnostic tests may be ordered:
- X-rays: To detect any problem with your child’s bone
- Blood tests: To determine a bone or joint infection
- Ultrasound scan: To create an image of the affected hip joint and detect any fluid in the joint
The treatment of irritable hip includes medications and bed rest. Painkillers or anti-inflammatory drugs (NSAIDs) are prescribed to help relieve pain and reduce inflammation. Your doctor may prescribe some specific medications depending on the type of infection detected in the child. Applying heat and massaging the affected hip may also help in reducing hip pain.
Swimming is a great exercise to strengthen and regain the movement of the hip joint.
- Femoroacetabular Impingement
- Cam Impingement
- Pincer Impingement
- Labral Tears
- Ligamentum Teres Tear
- Trochanteric Bursitis
- Psoas Tendinopathy
- Muscle Strain
- Hip Bursitis
- Hip Avascular Necrosis
- Hip Fracture
- Hip Dislocation
- Gluteus Medius Tear
- Hip Labral Tear
- Chondral Lesions
- Hip Instability
- Loose Bodies
- Hip Osteoarthritis
- Inflammatory Arthritis of the Hip
- Childhood Hip Problems