import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # Child Hip Examination (SUFE/Perthes) The child with a painful limp requires careful hip examination. Examiners expect you to recognize the classic findings of SUFE (obligate external rotation with flexion - Drehmann sign) and Perthes disease (limited abduction and internal rotation), and understand the importance of always examining both hips. ## Quick Reference One-Pager ## Clinical Presentation **Slipped Upper Femoral Epiphysis:** **Demographics:** - Age: 10-15 years (growth spurt) - Male:Female = 2.5:1 - Often obese (90% overweight) - Bilateral in 25% (examine both!) **Presentation:** - Limp (antalgic, externally rotated gait) - Groin, thigh, or KNEE pain (referred) - Limited internal rotation - Duration: acute (less than 3 weeks) vs chronic **Risk Factors:** - Obesity - Hypothyroidism, growth hormone therapy - Renal osteodystrophy - Previous SUFE (contralateral) **Legg-Calvé-Perthes Disease:** **Demographics:** - Age: 4-8 years (peak 5-7 years) - Male:Female = 4:1 - Bilateral in 10-15% - Often small, delayed bone age **Presentation:** - Painless limp initially - Groin or thigh pain - Limited abduction and internal rotation - Trendelenburg gait - Thigh atrophy **Stages (Waldenstrom):** - Initial (necrosis) - Fragmentation - Reossification - Healed (remodeling) **Critical Point - Knee Pain:** Hip pathology (especially SUFE) commonly presents with KNEE pain. Always examine the hip in any child with knee pain! **Clinical Rule:** "A limping child with normal knee = hip problem until proven otherwise" ## Physical Examination ### Observation and Gait **SUFE Gait:** - Antalgic (short stance on affected side) - Externally rotated leg - Reluctant to fully weight bear (if acute/unstable) **Perthes Gait:** - Antalgic limp - Trendelenburg (abductor weakness from pain inhibition) - May circumduct leg (if LLD or stiffness) **Observation (Supine):** - Leg position at rest (external rotation in SUFE) - Muscle wasting (thigh, buttock) - Apparent leg length discrepancy ### Range of Motion **Key Points:** - Compare with opposite side - Note pain and any guarding - NEVER force ROM (risk of further slip in SUFE) **Normal Paediatric Hip ROM:** - Flexion: 120-135° - Extension: 10-20° - Abduction: 45-50° - Internal rotation: 40-50° - External rotation: 40-50° **Pattern in SUFE:** - Internal rotation markedly reduced (often less than 10°) - Obligate external rotation with flexion (Drehmann sign) - Flexion may be limited **Pattern in Perthes:** - Abduction and internal rotation most limited - Flexion relatively preserved - Hip irritability (pain with log roll) ### Specific Tests **Understanding Drehmann Sign:** In SUFE, the femoral epiphysis slips posteroinferior relative to the neck. When you flex the hip: - The neck moves anteriorly - The fixed (slipped) head forces external rotation - Patient CANNOT internally rotate while hip is flexed - This is PATHOGNOMONIC for SUFE ## SUFE Classification **Critical for Prognosis:** | Classification | Definition | AVN Risk | |----------------|------------|----------| | **Stable** | Able to weight bear (with or without crutches) | 0-10% | | **Unstable** | Unable to weight bear (acute, severe pain) | 20-50% | **Unstable SUFE = Urgent Surgical Treatment** **Severity (Southwick Angle):** - Mild: less than 30° - Moderate: 30-60° - Severe: greater than 60° ## Perthes Classification and Prognosis **Poor Prognosis (Head at Risk Signs):** - Age greater than 8 years at onset - Lateral subluxation (Reimer's index) - Gage sign (radiolucency in lateral epiphysis/metaphysis) - Calcification lateral to epiphysis - Horizontal physis - Greater than 50% head involvement (Herring lateral pillar C) **Herring Lateral Pillar Classification:** | Group | Lateral Pillar Height | Prognosis | |-------|----------------------|-----------| | A | 100% (normal) | Good | | B | Greater than 50% preserved | Intermediate | | B/C border | 50% preserved | Guarded | | C | Less than 50% preserved | Poor | ## Differential Diagnosis **Kocher Criteria (Septic vs Transient Synovitis):** - Fever greater than 38.5°C - Non-weight bearing - WBC greater than 12,000 - ESR greater than 40 mm/hr 0 criteria = less than 0.2% chance septic 4 criteria = 99% chance septic If in doubt, aspirate the hip! ## Summary Presentation ## Examiner Tips