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He walks funny.

Peter, who is 3 years of age, is seen for his well-child visit, and his mother says that while he has done well this year, she is concerned because he continues to have a "funny" gait when walking. His mother is frustrated because the pediatrician keeps telling her it would go away, but it hasn't.

HPI: Peter began walking at age 10 months of age, but his mother said she noticed almost at once that his gait was just "different." She thought it would go away and he would become more steady on his feet as he got older, but that hasn't happened. In fact, she thinks it is worse. She denies any other symptoms, such as fever or swelling of the extremities. She says he doesn't complain of pain or stiffness.

History: Peter weighed 8 lbs. 8 ounces, and was 22 inches long at birth. His mother was gravida 4 para 4, received prenatal care from 6 weeks, and had an uneventful pregnancy. He was a footling breech birth, but was normal upon examination, fed well, and discharged from the nursery after 24 hours. Peter had one ear infection at 6 months, successfully treated with amoxicillin (Amoxil[R]). He received an influenza vaccination last fall and is up to date on other immunizations.

Physical Examination

VS: T 99, R 24, HR 85, BP 100/60.

Weight: 45 lbs.(> 95%); Height 38 inches (95%) BMI 22.

General: Pleasant and talkative, able to converse, answers questions readily, appropriate development for age. Has a 6-week-old sister, who is healthy.

HEENT: Normocephalic, scalp clean without lesions, no lymphadenopathy, Eyes: Sclera white, no discharge, red reflex symmetrical both eyes. Ears: TMs dark red, mobile, landmarks visible, light reflex present. Mouth: mucosa deep pink, palate intact, no dental caries, tonsils 2+, no exudate, uvula mobile, positive gag reflex.

Cardiovascular: Heart rate and rhythm regular, no murmurs, pulses symmetrical and full.

Respiratory: Bilateral breath sounds clear to auscultation, respiratory excursion symmetrical.

Musculoskeletal: Full range of motion of upper extremities, muscle tone firm, equal strength. Left hip has full range of motion (ROM), no pain, joint non-tender, moves upper and lower leg without limitation but with a Trendelenberg gait. Right hip has limited abduction but no pain over the femoral head. Stands on both feet, no scoliosis or lordosis. Positive Galeazzi sign. Full range of motion bilaterally in knees and ankles, no pain or tenderness. Muscle strength and tone in lower extremities seems unimpaired.

Neurological: DTRs 2+, symmetrical, Cranial nerves I-XII intact. Alert, responds appropriately. Rhomberg negative. Visual tracking seems normal for age. Sensation and discrimination appropriate.

Diagnostic tests: WBC with differential and sedimentation rates, A-P and frog leg lateral X-ray of pelvis. An MRI was deferred to the orthopedist, but this could have contributed to the diagnostic workup.

Differentials

Trauma: A screening X-ray will reveal a fracture that was previously undetected. However, there is no history of trauma or falls in this case.

Developmental dysplasia of the hip: This problem is more frequent in children of a breech delivery. There is a genetic cause for some forms of hip dysplasia, but he has no family history that would suggest that is the case. It is usually detected at an earlier age.

Skeletal dysplasia: A screening X-ray will also detect bony abnormalities, such as coax vera.

Septic arthritis: If an infectious process is the cause of hip pain and limp, the expected course would include a history of moderate to high fever, redness, warmth, malaise, and irritability. None of these symptoms were present.

Osteomyelitis would present with point tenderness, redness, warmth, swelling, and refusal to walk or move.

Tumor: This diagnosis should be considered because of the slow onset of symptoms. X-rays might reveal/rule out this diagnosis, or a CAT scan or MRI may be required if no other cause is found.

Legg-Calve-Perthes disease: This disorder is frequently found in children 6 to 10 years of age. A radiology study to measure the acetabular head index (AHI), the slope of the acetabular roof (SAR), and the articulo-trochanteric distance (ATD) can determine the degree of limitation of movement (abduction). Treatment may be conservative, with crutches used and NSAIDs taken for a few months. There are several surgical procedures that may be chosen.

Slipped capital femoral epiphysis: This disorder is usually seen in overweight adolescents. The degree of disability can range from a limp to the inability to walk without crutches. A frog-leg lateral X-ray can detect the problem.

Juvenile arthritis (JRA): JRA may start with a refusal to ambulate or problems with only one joint. Younger children frequently have a low-grade fever and a transient rash. An elevated sedimentation rate is often the only diagnostic test that is positive, and that is non-specific. A rheumatologist would need to evaluate the child if this diagnosis is suspected.

Assessment: CBC, Differential and sedimentation rates were normal. Xrays of Peter's hips supported the diagnosis of developmental dysplasia of the hip, Group II (unilateral, no necrosis of the femoral head).

Plan: Peter will have a femoral osteotomy with open reduction and soft tissue lengthening of the involved hip. He will be in a cast for 4 to 6 weeks. Infants under 3 months of age may be successfully treated with a Pavlik[TM] harness, which maintains the hip in abduction. After 3 months, this method is less successful. At that point, the infant would have soft tissue lengthening and a body cast for 3 months, followed by a splint until the femoral head ossifies.

Regardless of the manner of treatment, parents must have appropriate teaching and preparation for the care of the child. They may have to change their child care arrangements, work schedule, and activities while the child is in a cast or harness. Peter's mother was able to bring his grandmother into the home to care for him while his parents were at work. Other families might need additional resources and support. Transporting the child home or anywhere else requires modification of the car seat or use of an Easy On[TM] harness. The care and maintenance of children wearing spica casts have been simplified; waterproof casts that allow easy diapering and cleaning to prevent skin breakdown are now available. Children who are immobile may experience other problems that require planning, including decreased appetite and the tendency to develop constipation. Older children may require homebound schooling. Primary care providers can assist the family by staying in close contact and helping them prevent problems during the treatment and follow up care.

Additional Readings

American Academy of Family Physicians. (2006). Developmental dysplasia of the hip. Retrieved November 12, 2008, from http://www.aafp.org/afp/20061015/1310. html

Hart, E.S., AIbright, MB., Rebello, G.N., & Grottkau, B.E. (2006). Developmental dysplasia of the hip: Nursing implications and anticipatory guidance for parents. Orthopedic Nursing 25(2), 100-109.

Loder, R.T., Starnes, T., & Dikos, G. (2006). Atypical and typical (idiopathic) slipped capital femoral epiphysis. Reconfirmation of the age-weight test and description of the height and ageheight tests. Journal of Bone and Joint Surgery in America, 88(7), 1574-81.

Medline Plus. (2007). Developmental dysplasia of the hip. Retrieved November 12, 2008, from http://www.nlm.nih.gov/ medlineplus/ency/article/000971.htm

Rafique, A., Set, R, & Berman, L. (2007). Late presentation of developmental dysplasia of the hip following normal ultrasound examination. Clinical Radiology, 62, 181-184.

Subasi, M., Arslan, H., Cebesoy, O., Buyukbebeci, O., & Kapukaya, A. (2008). Outcome in unilateral or bilateral DDH treated with one-stage combined procedure. Clinical Orthopedic Related Research. Retrieved March 11, 2008, from http://www.springerlink.com/content/34jv32768p2j1603

WebMD. (2007). Developmental dysplasia of the hip--Topic overview. Retrieved November 12, 2008, from http://children. webmd.com/tc/developmentaldysplasia-of-the-hip-topic-overview

Jean Ivey, DSN, CRNP, is an Associate Professor and Facilitator, Pediatric Graduate Options, University of Alabama, Birmingham, AL, and a member of Pediatric Nursing's Editorial Board.

Linda Wilkinson, MSN, RN, CRNP, is a Nurse Practitioner, Pediatric Orthopedics, Orthopedics for Kids, P.C., Birmingham, AL

John Killian, MD, AAOS, is a Pediatric Orthopedic Surgeon, Pediatric Orthopedics, Orthopedics for Kids P.C., Birmingham, AL.
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Title Annotation:PEDIATRIC MANAGEMENT PROBLEMS; diagnosis of congenital hip dysplasia
Author:Ivey, Jean; Wilkinson, Linda; Killian, John; Simpson, Tina
Publication:Pediatric Nursing
Article Type:Case study
Geographic Code:1USA
Date:Nov 1, 2008
Words:1340
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