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• Jungle Orthopaedics

Jungle Orthopaedics

ORTHOPAEDIC PROBLEMS IN A PRIMITIVE SETTING

Monograph NO. 7

Some Hip Problems

TRANSIENT SYNOVITIS of the hip is the most common cause of hip pain and limp in children under ten years of age. It frequently follows an upper respiratory infection. Males are more often affected than females.

• Sometimes no pain -- only limp
• Physical examination: Patient has guarded rotation of the hip, plus pain at extremes of abduction and medial rotation. May or may not have elevated temperature.
• X-ray: Widened medial joint space, due to femoral head being forced laterally by synovial fluid pressure.
• Bone density normal
• Laboratory: ESR normal or mildly elevated WBC and differential normal
• Differential:
• Septic hip - pain, fever, ESR elevated,WBC elevated.
• Rheumatic fever - history of antecedent strep infection, polyarthralgia, other signs of rheumatic fever
• Legg Calve Perthes Disease - x-ray changes; bone scan in early stages will show decreased uptake
• Slipped capital femoral epiphysis - characteristic x-ray changes
• Tumors - osteoid osteoma - night pain, relief by ASA
• Course:
Self-limiting - 3-7 days but sometimes prolonged weeks or months I -39% may develop Legg-Calve Perthes -- observe carefully
• Treatment:
• Rest
• Maybe traction
• Maybe anti-inflammatory medication
• Observation

LEGG-CALVE PERTHES SYNDROME

In this condition the femoral head becomes softened, due to avascular necrosis. The age group affected is approximately 4-10 years, but can occur as early as age 2 and as late as the late teens. Boys are more affected than girls. It is a self-limited condition, with revascularization and reconstitution of the head occurring with time, usually about 18 months.

The prognosis depends on the extent of involvement of the necrotic process in the head, Involvement of the anterior 1/4 of the head is Catterell Class I.

Class II involves approximately one-half of the anterior portion of the head.

Class III involves approximately three-fourths of the head, with some rarefaction of the metaphysis adjacent to the epiphyseal line. Class IV involves the entire head or ephiphysis. Prognosis is best in Class I and worst in Class IV

The patient presents with a limp that may or may not be accompanied by pain. Pain, if present, may be referred to the thigh or knee. Every child that presents with "knee pain" should be examined for possible Legg-Calve Perthes syndrome. The patient may also have some restriction of motion in the involved hip, especially in abduction and extension.

There are four stages:

Stage one is synovitis: During this stage the capsule is distended with fluid and the femoral head may be displaced somewhat laterally. Synovitis of the hip is the most common cause of pain and limp in children under ten years of age. Only I -3% of cases of synovitis progress to LCP Syndrome, but this must be kept in mind and the patient followed.

Stage two is the stage of fragmentation: X-rays show fragmentation of the osseous nucleus and areas of increased radiodensity and radiolucency.

Stage three is the reparative stage during which there is restoration of vascularisation of the head, with return to normal densities.

Stage four is the healed stage: The head is completely reossifled and has its final shape.

X-ray examination should include anteroposterior views of both hips, and frogleg lateral views of both hips. On the lateral view the extent of involvement of the anterior portion of the head can be ascertained.

The object of treatment is to prevent the head from becoming flattened during the stage of softening. There is considerable controversy in the literature as to how best to accomplish this. Most people feel that if the entire head can be contained within the acetabulum, the acetabulum will act as a molding force, causing the head to retain a round shape. Often this "containment", can be accomplished by simply maintaining the hip in an abducted position, and a commonly used way of doing this is by the use of an abduction orthosis:

Before treatment with the abduction brace can be started, my contractures must be overcome. If the patient can be admitted, abduction Buck's traction can be used. If admission is not feasible, broomstick plaster casts can be used, with the abduction gradually increased until x-rays show the head to be contained in the acetabulum:

Several types of devices are available for accomplishing this. The Pavlick harness is probably the most effective:

DOUBLE DIAPERS DO NOT MAINTAIN THE EFFECTIVE POSITION VERYWELLAND SHOULD NOT BE DEPENDED UPON TO ACCOMPLISH THIS.

The Pavlick harness holds the hips flexed at 100 degrees, and prevents adduction but does not prevent further flexion.

GENERAL TREATMENT GUIDELINES:

• Age 0-6 mos. - Pavlik harness for 6-12 weeks
• Age over 6 months - Pavlik harness not effective
• 6 mos to 2 years - skin traction, and then closed reduction, cast in hip flexion a bit over 90 degrees and 50 degrees abduction. CAUTION:TOO MUCH FLEXION CAN CAUSE AVASCULAR NECROSIS.
• Over 2 years of age - no traction - open reduction with femoral shortening to relax pressure on located head to avoid avascular necrosis.

INSTRUCTIONS FOR APPLICATION AND USE OF PAVLICK HARNESS:

Use in newborn to 6 months of age, only.

1. Fasten chest strap first with child lying on his back. Strap must be loose enough to allow a hand to be passed beneath the strap.
2. Adjust shoulder strap to keep chest strap at nipple level.
3. With feet in stirrups and hips flexed 90-120 degrees, tighten anterior strap to hold in this position.
4. Posterior strap loosely fastened to limit adduction. Knees should be 3-5 cm. apart at full adduction.
5. Do Barlow test -- pressure on long axis of femur to try to dislocate hip.
6. X-ray to confirm reduction -- adjust harness as necessary.
7. If not reduced in 6-8 weeks, abandon this form of treatment and go to traction, closed reduction, and cast.
8. If successful, wear full time until stable on exam (negative Barlow test).

PSOAS ABSCESS (TROPICAL HIP):

A strange malady that is frequently seen in tropical countries is psoas abscess. This is an abscess that develops along or within the psoas muscle. It may point above or below the inguinal ligament.

Most commonly the child presents with fever and pain, and with the involved hip held in flexion and internal rotation. Palpation reveals a mass above the inguinal ligament.

X-rays of the spine should be obtained, because some of these cases areTB of the spine with an abscess extending down the psoas sheath.

Treatment is by incision above the inguinal ligament, with extra-peritoneal dissection down to the psoas muscle as it passes over the brim of the pelvis. Usually the abscess is encountered at this time, but if it is not you should introduce a hemostat into the fusiforrn swelling of the psoas muscle, and often you will find pus. Insert a drain.