Hip Problems in Children: When To See A Paediatric Orthopaedic Surgeon in Malaysia

Introduction to Paediatric Hip Problems

Hip problems in children are a concern, especially since early diagnosis and treatment could avoid long-term complications. Special hip conditions in children manifest in different ways, depending on the age and the underlying cause. From developmental hip dysplasia in neonates to conditions like Perthes Disease and SCFE (Slipped Capital Femoral Epiphysis) in older children and adolescents, recognising the symptoms and seeking timely medical help is key.

In addition to developmental issues, other factors affecting adults such as trauma, infections, inflammation and tumours can also cause hip symptoms in children. As an orthopaedic surgeon in Kuala Lumpur, Malaysia, I frequently encounter various hip conditions in children that, if treated early, can lead to excellent outcomes. In this article, we’ll explore some of the most common paediatric hip problems, their causes, and the treatment options available.

Special Hip Problems in Children

Developmental Dysplasia of the hip (DDH)

Developmental Dysplasia of the Hip (DDH) is a condition seen in 1:1000 healthy newborns. This occurs when the hip joint is not well aligned, leading to a dislocation of the hip joint. It can range from a mild dysplasia (loose hip joint) to a completely dislocated hip.

Symptoms: asymmetry in the posterior thigh creases, limited range of motion (abduction) in the affected leg or unequal leg lengths causing a painless limp. These may not be obvious if both hips are affected as both limbs would have symmetrical findings.

Risk Factors for Hip Dysplasia:

First born: the first born child is more likely to develop DDH, possibly because the uterus is tighter, limiting space for fetal movement.

Female: more common in girls than boys, possibly due to the effect of maternal hormones (such as relaxin) on the baby’s ligaments.

Breech Pregnancy: Babies born in the breech (buttocks or feet first) position are at a higher risk of hip dysplasia, particularly if the breech position persists in the third trimester.

Twin/Multiple Pregnancy: Limited space in the womb for multiple babies can affect the development of the hips.

Oligohydramnios: Insufficient amniotic fluid during pregnancy creates a cramped environment that restricts fetal movements and impacts the baby’s hip alignment.

Improper or Overtight Swaddling: Another important factor is swaddling practices which was shown to actually cause hip dislocation in a previously normal enlocated hip. It is important to educate carers/parents not to swaddle below the umbilicus; to leave the legs free.

Treatment for Hip Dysplasia:

Pavlik Harness: Pavlik Harness: Most cases of hip dysplasia under six months old can be treated non-surgically with a Pavlik harness, a special dynamic splint that positions the hip joint as it grows.

Surgery: In rare cases where non-surgical treatment is not successful, surgery may be needed. 

Hip Dysplasia at walking age:

Sometimes a dislocated DDH is discovered much later, usually during the walking age (12-18 months old).  This delay is because DDH is painless and the child is thriving well despite a dislocated hip or hips.  Common presentation would be a painless limp, uneven gait (funny walking pattern) which is only noticed once the child stands and walks.  As a result, these late presentations are treated surgically to reconstruct the hip joint; with procedures ranging from soft tissue procedures such as relocation of the hip joint, release of tight contractures to bony procedures such as reshaping of the socket (acetabulum) and occasionally bone cuts of the proximal femur to redirect the ball (femur head) into the socket. 

A dye is injected into the left hip joint under anaesthesia to assess the anatomy of the joint. Childrens’ bones are cartilaginous and do not show well with plain Xray, hence the need for the dye to mark the joint outlines during the procedure to relocate the joint. Following successful relocation of the hip joint, a hip spica is applied. 

Following successful relocation of the hip joint, a hip spica is applied. A hip spica is a type of plaster cast that covers one or both legs from the ankles up to the belly button. An area around the groin is cut out for toileting. This type of cast is used to prevent movement for hip dysplasia, after hip surgery or for fractures of the femur (thigh bone), allowing the area to heal. A child may be uncomfortable in a hip spica at first, but they will get used to it quickly.

Occasionally, mild DDH (shallow acetabulum cup / socket) persists into teenage or adulthood and these are the ones that may only be incidentally discovered during Xrays for other conditions.  In these much older age group of adolescents/teenagers, usually a salvage procedure instead of a reconstructive hip procedure is done.

Perthes Disease in School-Age Children

Perthes Disease typically affects children between the ages of 6 and 10. This is a rare condition where the blood supply to the femoral head (the ball part of the hip joint) is temporarily disrupted, leading to bone death and eventual regeneration.

Without adequate blood flow, the femoral head can lose its round shape, leading to pain and reduced range of motion in the hip.

Symptoms of Perthes Disease:

Limping, pain in the hip, thigh, or knee, stiffness and limited range of motion in the hip.

(NOTE: Pain may radiate from the hip to the knee area, hence the child may complain of knee pain rather than the hip. (Parents are often surprised when the doctor is more interested in the hips when their child complains of knee pain)

Treatment for Perthes Disesase:

Rest, physical therapy, bracing, or surgery to reshape the hip joint.

SCFE (Slipped Capital Femoral Epiphysis) in Adolescents

SCFE is a condition that affects older children and adolescents, typically between the ages of 10 and 16. The head of the femur slips off the neck of the bone at the growth plate, causing pain and instability in the hip joint.

This condition occurs when the ball at the head of the femur slips off the neck of the bone at the growth plate.

Symptoms of SCFE:

Hip pain, referred knee pain, a limp, and limited hip motion (stiff hip).

Risk Factors for SCFE:

Obesity: Excess weight places additional stress on the hip joint.

Early Puberty: Rapid growth during early puberty increases the risk of SCFE.

Treatment:

Surgical Intervention: Surgery to stabilise the femoral head using screws or pins is necessary to prevent further slippage.

Other Causes of Hip Problems in Children

Trauma and Hip Injuries

Trauma to the hip can occur due to falls, sports injuries, or accidents. Children are particularly vulnerable to hip injuries because their bones and growth plates are still developing.

Symptoms of Hip Trauma:

Sudden Pain: Sudden onset of pain in the hip or groin area.

Difficulty Walking: Trouble putting weight on the affected leg.

Swelling: Swelling or bruising around the hip joint.

Treatment for Hip Trauma:

Rest: Minor injuries like bruises or sprains often require rest and pain relief.

Surgery: Severe injuries, such as fractures or dislocations, may require surgical intervention.

Transient Synovitis of the hip

The irritable hip or transient synovitis of the hip is a temporary inflammation of the synovial membrane in the hip joint, commonly seen in children between the ages of 3 and 10. It is a common cause of hip pain in children and is often self-limiting, typically resolving within 1 to 2 weeks. While the exact cause is unknown, it is often associated with a viral infection or a recent upper respiratory illness.

Symptoms of Transient Synovitis:

Sudden onset of hip pain or limp. Refusal to bear weight on the affected leg. Pain may radiate to the thigh or knee. Low-grade fever (if present). Limited range of motion, especially internal rotation of the hip.

Diagnosis:

History and physical examination: A detailed history of symptoms and physical exam will usually raise suspicion of transient synovitis.

Ultrasound: May show fluid (effusion) in the hip joint.

X-ray: Typically normal, but may be used to rule out other conditions like fractures or Perthes disease.

Lab tests: Blood tests (like CRP and ESR) may show mild inflammation but are usually normal or mildly elevated.

Differential Diagnosis: Septic arthritis (a more serious infection of the joint). Legg-Calvé-Perthes disease (avascular necrosis of the femoral head). Slipped Capital Femoral Epiphysis (SCFE). Septic arthritis must be ruled out, as it requires urgent treatment and can have severe complications.

Treatment of Transient Synovitis:

Rest: Limiting activity is key for recovery.

Pain management: Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are typically effective.

Follow-up: To ensure symptoms resolve and to rule out other causes if symptoms persist.

Prognosis:

The condition usually resolves on its own within 1-2 weeks, although some children may have recurrent episodes.

Infections (Septic Arthritis)

Septic arthritis is a serious infection of the hip joint, typically caused by bacteria. It is more common in younger children and can cause joint damage if not treated immediately.

Symptoms of Septic Arthritis:

Severe Pain: Intense pain in the hip, especially with movement.

Fever: Accompanied by a high fever.

Swelling: Swelling and redness around the joint.

Treatment for Septic Arthritis:

Antibiotics: Immediate antibiotic treatment is essential to clear the infection.

Surgery: In some cases, surgery is required to drain infected fluid from the joint.

Joint Inflammation (Juvenile Idiopathic Arthritis)

Juvenile idiopathic arthritis (JIA) is an autoimmune condition that causes chronic inflammation in the joints, including the hip.

Symptoms of JIA:

Persistent Pain: Chronic pain and stiffness in the hip joint.

Swelling: Swelling and warmth around the affected area.

Limping: Difficulty walking due to joint inflammation.

Treatment for JIA:

Medication: Anti-inflammatory medications are used to reduce joint swelling and pain.

Physical Therapy: Therapy helps maintain joint mobility and flexibility.

Tendonitis

Tendonitis occurs when the tendons around the hip become inflamed, usually due to overuse or repetitive movements, and is common in active children.

Symptoms of Tendonitis:

Pain: Pain in the hip, especially during physical activity.

Tenderness: Tenderness and swelling around the hip joint.

Treatment for Tendonitis:

Rest: Resting and reducing physical activity can relieve symptoms.

Physical Therapy: Therapy can help strengthen the muscles and prevent recurrence.

Risk Factors and Causes of Hip Problems in Children

Risk factors that contribute to paediatric hip problems vary depending on the condition:

Breech Pregnancy: Increases the risk of hip dysplasia.

Obesity: Adds stress to the hip joint, increasing the risk of SCFE.

Injury: Falls or accidents can lead to fractures or dislocations.

Infection: Bacterial infections such as septic arthritis affect the hip joint.

Treatment for Paediatric Hip Problems

Non-Surgical Treatments

Pavlik Harness: Used for hip dysplasia in neonates to correct joint alignment.

Physical Therapy: Prescribed for conditions like Perthes Disease and tendonitis to improve hip mobility.

Antibiotics: Essential for treating infections like septic arthritis.

Surgical Interventions

SCFE Surgery: Stabilises the slipped femoral head using screws or pins.

Septic Arthritis Drainage: In severe cases, surgery is required to drain infected fluid.

Perthes Disease Surgery: Involves reshaping the femoral head in severe cases.

Importance of Early Diagnosis

Early diagnosis is crucial for successfully treating paediatric hip problems. Conditions like hip dysplasia, Perthes Disease, SCFE, and septic arthritis can lead to long-term complications, such as arthritis or hip deformities, if not treated promptly. By seeking medical help from a paediatric orthopaedic surgeon, parents can ensure their children receive the appropriate care and avoid future issues.

Conclusion on Hip Problems in Children in Malaysia

Paediatric hip problems vary from mild to severe, but early intervention and treatment can significantly improve a child’s quality of life. Whether your child has hip dysplasia, Perthes Disease, SCFE, or hip trauma, timely care can prevent long-term complications and ensure they grow up healthy and active.

If you have concerns about your child’s hip health or notice signs such as pain, limping, or limited mobility, seek medical advice. As a paediatric orthopaedic surgeon in Kuala Lumpur, Malaysia, I specialise in diagnosing and treating a wide range of hip conditions in children. For more information or to schedule an appointment, please visit drmariawong.com and take the first step toward ensuring your child’s orthopaedic health.

For more information or to schedule an appointment with Dr. Maria Wong, please visit drmariawong.com and take the first step towards improving your child’s musculoskeletal health.