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Paediatric Hip Problem

  1. Limping Child
  1. Differential Diagnosis of Limping Child
    1. Painless Limp
      1. 1-3 years age group
        • CDH (congenital dysplasia of hip)
        • Cerebral palsy
        • Muscular dystrophy
      2. 4-10 years age
        • Limb length discrepancy
        • Poliomyelitis may cause muscular dystrophy & imb length discrepancy.  
    2. Painful Limp
      1. Toddler (1-3 years age)
        • Toddler’s fracture      
        • Diskitis                      
        • Pauciarticular juvenile arthritis
      2. Child (4-10 years age)
        • Legg calves—Perthes disease                       
        • Discoid meniscus (knee)
      3. Adolescent (11-15 years)
        • Slipped capital femoral epiphysis                       
        • Osteochondritis dissecans (mostly of knee)
        • Chondrolysis                                     
        • Hip dysplasia
      4. For all age groups
        • Septic arthritis                                               
        • Tubercular arthritis
        • Transient synovitis                            
        • Osteomyelitis

An antalgic gait, is caused by pain in lower extremity or occasionally in the back, is generally most common type of gait disturbance in the limping child. In an attempt to avoid the pain the child will take quick, soft steps on affected leg (short stepping), which reduces the amount of time the affected extremity is in stance phase of gait.



It is reduced angle between neck & shaft of femur due to some growth anomaly at upper femoral epiphysis (infantile type) or secondary to various other pathologies (acquired). An angle of < 1200 is called coxa vara.


  1. Clinical
    1. Painless limp in a child who has just started walking            
    2. Shortening
    3. Limitation of abduction & internal rotation  
  2. Radiological
    1. Reduced neck shaft angle
    2. Vertical epiphysis plate
    3. Separate triangle of bone in infero-medial part of metaphysis called Fair Bank’s triangle
    4. Because of distorted anatomy it may be difficult to measure the neck shaft angle.
    5. A helpful alternative is to measure Hilgenreiners epiphyseal angle — angle between horizontal line joining center (triradiate cartilage) of each hip (Hilgenreiner’s line) and line parallel to physis; the normal angle is about 300.


Classification (Causes) of Coxa Vara

  1. Congenital Coxa Vara
    1. Congenital femoral deficiency with coxa vara
    2. Developmental coxa vara
      • Isolated
      • Associated with a skeletal dysplasia eg. Cleidocranial dysostosis, metaphyseal dysostosis 
  2. Aquired Coxa Vara
    1. SCFE (slipped capital feoral epiphysis)
    2. Sequelae of avascular necrosis of femoral epiphysis
      • Legg-Calve Perthe’s disease              
      • Femoral neck fracture
      • Traumatic hip of CDH                                   
      • Septic necrosis
    3. Associated with pathological bone disorders
      • Osteogenesis imperfecta                    
      • Fibrous dysplasia                   
      • Osteopetrosis 
  1. Treatment (based on HE Angle)
    1. 40° but < 60° Observation
    2. >60° or if shortening is progressive
    3. Subtrochanteric valgus osteotomy  

Legg Calve - Perthe’s Disease / Osteochondritis Deformans Juvenilis / Coxa Plana


It can be defined as osteonecrosis of the proximal femoral epiphysis in a growing child caused by poorly understood (non genetic) factors. 



  1. The precipitating cause is unknown but the cardinal step in the pathogenesis is ischemia of femoral head. Between 4 & 8 years of age femoral head depends for its blood supply and venous drainage almost entirely on the lateral epiphyseal vessels whose situation in retinacula makes them susceptible to stretching and to pressure from an effusion.
  2. A “Predisposed Child” may have
    1. Coagulation abnormalities eg sickle cell disease, thalessemia, protein C and protein s deficiency
    2. Abnormal growth and development (delay in bone age relative to patient’s chronological age, and growth hormone abnormalities)
    3. Trauma, particularly in predisposed child
    4. As sequela of synovitis (may be first manifestation but is rarely, if ever, the cause of the disorder).
    5. Environmental (nutritional eg low manganese) influences.
    6. Heriditary (genetic) influence 


  1. It is a syndrome in which an avascular necrosis affects the capital epiphysis (head) of the femur. Following the avascular event, growth of the ossification nucleus stops and the bone becomes dense.
  2. The dense bone is subsequently resorbed & replaced by new bone (which is soft) during which process the mechanical properties of the femoral head are altered such that the head tends to flatten and enlarge (coxa plana).
  3. So it is self limiting non inflammatory condition, affecting the capital femoral epiphysis with stages of degeneration and regeneration, leading to restoration of the bone nucleus.

Description: images-6

Clinical Presentation

  1. Male sex prevalence: boys 4-5 times more likely to develops the disease than girls.
  2. Bilateral in 10-12% cases and familial in 10%
  3. Most frequent symptom is limp that is exacerbated by activity and alleviated with rest.
  4. 2nd most frequent complaint is pain which may be located in the groin, anterior hip region, or laterally around greater trocharter and referred to knee.
  5. There may be h/o antecedent trauma (often a fall or twisting) several months earlier.
  6. The classical portrait of child is – small often thin, extremely active, constantly running and jumping, and limping after strenuous physical activities.
  7. After a few days, these initial symptoms normally resove completely. The patient often goes through periods of exacerbation and alleviation, with symptoms waxing & waning.
  8. Abductor limp, a combination of antalgic & Trendelenburg gait and positive Trendelenburg test on the involved side.
  9. During the very early phase, joint is irritable so extremes of all movements are diminished & painful.
  10. Later on most movements are full, but abduction (especially in flexion) is nearly always limited and usually internal rotation also. When the hip is flexed it may go into obligatory external rotation (Catterall’s sign)
  11. The range of flexion and extension, though is seldom affected 

Course of Disease

  1. Most consistent factor affecting course is patient’s age at onset of disease. Those with early onset (before 6 years) have mild disease,  those with onset between 6 and 9 years have moderate symptoms, and those with onset at 9 years or later have most severe course and worst out come.
  2. Out come is also affected by duration from onset to complete resolution; the shorter the duration the better the final results.  


  1. The main aim of treatment is containment of femoral head in acetabulum.
  2. Non surgical containment is achieved by orthotic braces All braces abduct the affected hip, most allow for hip flexion, and some control rotation of the limb.
  3. Surgical containment is through femoral varus derotation osteotomy, innominate osteotomy, valgus osteotomy, self arthroplasty, chiari osteotomy and chielectomy (surgically removing protuding fragments of femoral head usually antero lateral). 

Slipped Capital Femoral Epiphysis / Epiphysiolysis


During a period of rapid growth, due to weakening of upper femoral physis & shearing stress from excessive body weight, there is upward & anterior movement of femoral neck on the capital epiphysis. So the epiphysis displaces primarily posteriorly and medially relative to the femoral neck.

  1. Aetiology
    1. The cause is unknown in vast majority of patients.
    2. Many of the patients are either fat and sexually immature or excessively thin and tall.
    3. Endocrinopathies such as
      1. Hypothyroidism (most common) treated or not
      2. Growth hormone excess caused by growth hormone deficiency conditions treated by growth hormone administration
      3. Chronic renal failure ( 2nd degree hyperparathyroidism)
      4. Primary hyperparathyroidism
      5. Panhypopituitism associated with intracranial tumors
      6. Craniopharyngioma
      7. Hypogonadism
      8. MEN 2 B
      9. Turner’s syndrome
      10. Klinfelters syndrome
      11. Rubinstein- Taybi syndrome
      12. Prior pelvic irradiation

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