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Hip, leg and knee disorders

Hip, leg and knee disorders

Hip, leg and knee disorders

Developmental dysplasia of the hip

Developmental dysplasia of the hip (DDH) is a defect in the joint of the hip that can occur before, during or after a baby is born. The hip is a ball-and-socket joint. The rounded section of the thighbone, or femoral head, rests in the cup-like hipbone socket. In some cases of DDH the thighbone moves within the socket, causing an unstable hip. In more serious cases, the femoral head becomes dislocated and moves completely out of the socket. In other cases, the femoral head may not reach the socket.

Treatment options

  • Nonsurgical
    • Pavlik harness: If an unstable hip is diagnosed in a newborn, the child's doctor may prescribe positioning the hip properly with a Pavlik harness. This harness keeps the femoral head in its socket by holding the affected knee toward the child's head. A shoulder harness attaches to foot stirrups to keep the leg elevated. This treatment can last from six to 12 weeks, or until ultrasounds confirm that the hip location is normal.
  • Surgical
    • Closed reduction: For infants younger than 18 months, the affected bone can be manually set into place while the child is under anesthesia and held in place with a cast.
    • Open reduction: Surgery to realign the hip and place the thighbone back into the hip socket is recommended for children that fail Pavlik harness and closed reduction. During this surgery any tight muscles and tissues surrounding the hip joint are loosened and then tightened once the hip is in the proper position. This also involves placement into a Spica cast.

Children older than 18 months may need surgery on their pelvis to deepen their hip socket or realign or shorten their thighbone. Following surgery, they are placed in a body cast while they are recovering.

Slipped capital femoral epiphysis

Slipped capital femoral epiphysis (SCFE) occurs when the top of the thighbone shifts out of place. SCFE usually affects children approaching adolescence. The top section of the thighbone is ball-shaped (femoral head) and fits into the hip socket. The ball connects to the straight section of the thighbone by the growth plate, which, in children, is still developing.

Treatment options

  • Surgery: Recommended to prevent further slippage of the ball from the bone. The doctor will perform surgery to reposition the slip in their hip through a small incision near the affected hip. A metal screw will be placed through the bone, the growth plate and the femoral head's cap, which will stabilize the bone.

Leg length discrepancy

Some limb length discrepancies are congenital or present at birth. Other discrepancies can develop after a fracture, infection, tumor or other injury that results in loss of bone or damage to the growth plate. As the child continues to grow, the limb length discrepancy may slowly increase.

Treatment options

  • Growth modulation (or epiphysiodesis): This is a surgical procedure that arrests the growth of one or more of the growth plates of the leg. When done at the right time, this procedure allows the short leg to catch up and reach equality just at maturity. It is the most simple and least risky of all treatments, but requires precise timing to avoid over or under correction.
  • Lengthening: Leg lengthening can be performed by an external fixation device, which are rings or rods, that surgically connect to the bone using pins or wires that go from outside the leg, through the skin and into the bone. Options also exist in which an internal lengthening rod will be surgically implanted into the femur bone. Once the rod is implanted the lengthening occurs when a handheld unit is activated directly over the implant to gradually lengthen the inserted rod and the bone. The implant holds the bone ends in alignment and stabilizes the femur being lengthened until the body makes new bone to fill in the gap.
  • Femoral shortening: In this procedure, a part of the femur is surgically removed and internal fixation is used to stabilize the femoral segments. It is used when there is enough growth remaining to allow epiphysiodesis to be effective.
  • Nonsurgical modalities: These include lifts, braces and orthotics to equalize the child's legs.

Leg-Calve-Perthes disease

Legg-Calvé-Perthes disease is a temporary childhood condition where the ball-shaped head (femoral head) of the thighbone loses its blood supply, causing the femoral head to collapse. The body absorbs the dead bone cells and replaces them with new cells. These new bone cells eventually reshape the femoral head of the thighbone. Legg-Calvé-Perthes disease causes the hip joint to become stiff and painful.

Treatment options for Legg-Calvé-Perthes disease are centered around protecting the hip from further injury and stress, and keeping the thighbone's ball in the hip socket.

Treatment options

  • Anti-inflammatory medications: Medicines containing ibuprofen can help relieve pain associated with this disease and help reduce swelling. The doctor will prescribe the appropriate dose based on the severity of the disease.
  • Physical therapy: Range-of-motion exercises can help with joint mobility and may be part of a home physical therapy treatment.
  • Bracing, casting, traction: In some cases, the doctor may recommend temporary immobilization of the bone as part of their treatment. This can be done through braces, casts and traction, where a pulling force is applied to the bone.
  • Surgery: In older children with more severe Perthes, some may require surgery to reposition the ball portion of the hip within the socket. Additionally, tendon surgery may be required for any stiffness that has developed. In the older adolescent, a procedure to resculpt the hip may also be required to correct for deformity and prevent the possible need for a hip replacement as a young adult.

Blount's disease

Blount's disease is a growth disorder that affects the two parallel bones, the fibula and tibia, which make up the lower leg and cause them to curve inward or bow.

Although the cause is not known, many doctors believe that the weight of the growth plate causes the curvature, or uneven bone growth, and the shinbone, or tibia, does not develop normally causing the bone to become angled. Blount's disease is progressive and worsens with growth and should be treated aggressively.

Treatment options

  • Bracing: Braces may be used to treat children under three years of age who develop severe bowing.
  • Surgery: Surgery may be needed if the bowing is not diagnosed until the child is older. Or, if braces do not work to correct the bowing. Surgical procedures can be done to place the shin in the proper position and in some cases, lengthen the shin. In other cases, the growth of the outer half of the shinbone can be restricted and surgery can correct this limitation, which allows the child's natural growth to correct or reverse the bowing.

Bowlegs

Bowed legs before the age of 2 are very common. This is also known as genu varum. When a child with bowed legs stands with his or her feet together, there is a distinct space between the lower legs and knees. This may be a result of either one or both of the legs curving outward. Walking often exaggerates this bowed appearance. For most children this is a normal variant of bone growth and development.

Treatment options

  • Observation: In children with physiologic genu varum, the bowing begins to slowly improve at approximately 18 months of age and continues as the child grows. By ages 3–4, the bowing has corrected and the legs typically have a normal appearance.

Knock knees

Children's legs grow in a predictable manner. In the first 12 months of life, bowed legs are normal. By age 4, it is common to see the child become knock kneed, and then between ages 7–10, the legs again become straight. A family history of knock-knees is common and this type of knock-knees requires no treatment.

Pathologic knock-knees do not straighten with growth, but may become worse over time and will require treatment.

Treatment options

  • Observation: For most children the treatment is observation, allowing time and growth to correct the legs. Parents/guardians may want to take a picture of of the child standing and several months later, take another photo to compare the straightening process.
  • Surgery: Only in rare cases is an operation needed to correct the legs. Surgery is done to improve the way the child walks, to prevent arthritis or for cosmetic reasons. Usually, surgery is not done until adolescence and involves manipulation of the growth centers to correct the deformity.

Osgood-Schlatter disease

Osgood-Schlatter disease is an overuse condition of the knee causing pain and swelling below the knee area over the shinbone where the tendon from the kneecap attaches. The disease is caused by the constant pulling of this tendon.

Osgood-Schlatter disease is common in adolescents, especially those who are active in sports. During adolescence, a child's bones are usually growing at a faster rate than the muscles and tendons. Because of this, the muscles and tendons tend to become tight, causing swelling and pain in the knee area. Osgood-Schlatter disease is most often diagnosed in boys 10–15 years old and girls ages 11–12, who are involved in sports requiring running, jumping and swift changes of direction — such as soccer, basketball, figure skating and ballet.

Treatment options

  • RICE: Rest, ice, compression and elevation
  • Anti-inflammatory medication: Medication containing ibuprofen will reduce pain and swelling.
  • Elastic wrap: This will offer further support to the knee, especially during activities.
  • Restricted activities: The child's doctor may have the patient limit or temporarily stop sports or other activities that aggravate the condition.
  • Physical therapy: Exercises to strengthen and stretch the thigh and leg muscles will help the healing process.
   
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