– with respect to SCFE, the chronicity of symptoms does not seem to have a huge bearing on treatment outcome anymore – it is really based on how stable the hip is rather than how long the hip has been bothersome. There are a few things that are true – there is a narrow window just before skeletal maturity in which is occurs, it is bilateral in only 10-25% of idiopathics, up to 70% in those with endocrinopathies, and osteonecrosis remains the most common reason for a bad result (not sure if it is the most common complication though)
– transient pin penetration is NOT felt to cause chondrolysis. If left in, however, it is the main reason for chondrolysis
– prophylactic pinning of SCFE is done in endocrinopathies only (many of these are not prophylactic, because they already have it on the other side!)
– a patient returning after a Salter innominate osteotomy that has an abduction contracture should probably just have physio.
– for a CDH a 2.5 years, the treatment plan should include a shortening osteotomy of the femur.
– best treatment for CDH at 6 months is a closed reduction with adductor tenotomy (this age is right at the upper limit of usefulness for a Pavlik)
– in a 4 day old with a dislocated hip, you would expect the Ortolani and Barlow to be positive (or achievable) and you would expect that the hip would be relocatable at this stage; and you would expect decreased abduction. It is too early for the capsule to really be “hourglass”.
– for a 5 year old with a newly diagnosed dislocation, best treatment is an open reduction, femoral shortening, and innominate osteotomy. In children over 3, simultaneous open reduction, femoral shortening, and redirectional osteotomy of the innominate bone usually are required to achieve concentric reduction, avoid AVN, and address the secondary acetabular pathology. Note that the innominate osteotomy is controversial. Some would do it, others would let the acetabulum remodel once the hip is in.
– for a 12 month old with undiagnosed DDH – traction, adductor release, closed reduction, spica cast
– for a 3 month old with undiagnosed DDH – Pavlik (up to the age of 6 months)
– 6 year old with intertrochanteric hip fracture – can be treated in traction (the intertroch’s can be treated in traction) followed by spica cast, but probably better to do closed reduction and internal fixation with multiple screws, then spica.. I think in contemporary pediatric trauma, although this can be treated in a cast, go with internal fixation.
– subtrochanteric fractures are difficult to manage because of the flexion, abduction, external rotation deformity of the proximal fragment; 90-90 traction is safe, reliable, and the most popular method of management of these injuries. It is not uncommon to use ORIF when a reduction is not obtainable or with head/polytrauma. Again, sort of a stupid question, because unless very young I think I’d treat with ORIF.
– in a severely displaced femoral neck fracture, the remaining blood supply comes from probably the obturator artery. The main supply to the head is the posterosuperior and posteroinferior retinacular vessels, but in a displaced neck fracture, these are most likely torn.
– in a 3.5 year old kid with Perthes, completely asymptomatic but with limp – observe. ROM, exercises, weight reduction, avoidance of weight bearing, x-ray followup. This is likely Meyer’s dysplasia and will probably resolve. The patient should be followed closely and management should follow his symptoms.
– indications for Chiari – coxa magna with subluxation out laterally (extrusion); basically, this is a salvage osteotomy when a congruous reduction of the femoral head is impossible.
– for Legg Perthes, loss of containment is a bad sign. Also, whole head involvement, the presence of metaphyseal cysts, Gage’s sign, a horizontal growth plate, and lateral epiphyseal calcification is bad. Girls tend to have lateral pillar involvement and therefore may have a less favorable long term prognosis.
– a 6 year old