Hip care

Pediatric hip care in Denver

The hip specialists at the Hip Center at Rocky Mountain Hospital for Children (RMHC) in Denver provide comprehensive orthopedic care for pediatric hip pain and disorders from infancy through adolescence. The hips are crucial to many movements that we often take for granted. When the hips are not working properly, whether from a genetic abnormality or sports-related injury, freedom and stability can be compromised.

For more information about our pediatric hip care program, please call (877) 752-2737.

Parents’ fears are often eased the moment they walk into the Hip Center. Our gentle, caring team provides comprehensive care from diagnosis and individualized treatment plans to follow-up and long-term care.

Physical therapy still remains an important element of treatment for pediatric hip pain, but specialty MRI arthrograms, coupled with better understanding of traditional radiographs, have redefined our understanding of the true pathology that lies deep within the hip.

As a part of the larger network of RMHC, patients of the Hip Center receive the benefit of coordinated care from all disciplines in pediatrics.

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Infant Hip Program

When we dream about the futures of our newborn children, we often see them filled with laughter as they jump, run and play—important to all these movements are the hips. Identifying and treating hip conditions early in life can help promote lives full of activity and freedom. The newborn period is a golden period to diagnose and take care of any hip concerns, such as hip dysplasia, before the condition interferes with activity.

After birth, your pediatrician will perform a physical examination of your baby. Part of that newborn exam focuses on your baby’s hips. If a concern is detected, your pediatrician will refer you to an orthopedic specialist. The specialists in our Hip Center’s Infant Hip Program combine state-of-the-art ultrasound exams with gentle physical examinations to detect subtle differences between a normal hip and a hip that may be at risk.

In a single visit to the Hip Center, all components of the initial screening can be accomplished: ultrasound, consultation and diagnosis. Any questions about your baby’s hips will be answered, and if treatment is required, it can be initiated during the visit. This comprehensive visit helps limit disruptions to your baby’s schedule and alleviates parent concerns as soon as possible.

Pediatric hip dysplasia

The hip is a ball-and-socket joint. In a normal hip, the ball fits well in the deep socket. In patients with hip dysplasia, also referred to as developmental dysplasia of the hip (DDH), the ball or socket may be abnormally shaped or unstable. Hip dysplasia can be diagnosed early after birth (congenital), or it can develop as a child grows.

In mild cases of hip dysplasia, the femoral head moves back and forth within the socket, causing a child to have an unstable hip. In more serious cases, the head slips completely out of the socket, becoming dislocated. The hip socket may be too shallow and the ligaments too loose to allow for normal development of the hip joint. This abnormal development causes the femoral head to put too much pressure on the rim of the hip socket. During childhood, this is usually painless. However, as time passes, cartilage within the hip will be damaged, resulting in degenerative osteoarthritis and disability.

Hip dislocations are relatively uncommon, affecting only one to two out of every 1,000 babies. Most commonly, hip dysplasia involves only a single side, but bilateral cases have been diagnosed. The left side is more often affected than the right because of intrauterine positioning that limits the motion in the left hip.

The causes of hip dysplasia are not completely understood, but experts think that many factors are involved. Higher risk of hip dysplasia occurs in infants with any situation that stretches hip ligaments, such as a positioning of the infant in utero causing the ball to slip out of the socket. The most common risk factors include:

• Breech positioning that may strain ligaments in the hip.
• Females tending to have more lax ligaments.
• First-born children being constrained by a tight uterine wall.
• Family history of increased laxity of the ligaments.

Symptoms of hip dysplasia

Most babies with hip dysplasia experience no pain. Infants often don’t show signs of hip dysplasia, and there may be no signs at all. Still, doctors look for these indicators:

• The leg on the side of the dislocated hip may appear shorter.
• The leg on the side of the dislocated hip may turn outward.
• The fat folds in the skin of the thigh may be uneven.
• In a frog position of the legs, there is asymmetry.
• “Clicks” or “clunks” may be felt during the exam.

Diagnosing hip dysplasia

With gentle hip manipulations, which include pushing and pulling on the child’s thighbones, the physician can assess range of motion and stability to determine whether the hips are loose in their sockets. Pain is not a reliable indicator of hip dysplasia in infancy because it is a pain-free condition. Because developmental hip dysplasia can be present as the child grows, the hip exam continues to be an important component of a well-child check-up.

Sometimes a doctor will recommend an X-ray or ultrasound to get a better view of an at-risk hip. X-rays are helpful for babies who are at least six months old or older, but ultrasounds are preferred for babies under six months. Ultrasounds can be more helpful in younger babies because their hip structures are cartilage, and cartilage does not show up on X-rays.

Treating hip dysplasia

Treatment for hip dysplasia depends on the age of the child and the severity of the condition. Mild cases may correct themselves in the first few weeks of life, but close monitoring is necessary to ensure that the hip is growing and improving normally.

The good news for parents is that the vast majority of hips with dysplasia will respond to treatment very well. The goal of these treatment methods is to align the ball and socket so that they begin to influence each other to create a normal hip. Treatment options may include:

• Pavlik harness: This flexible, soft harness uses straps to maintain a leg position that encourages the hip to develop a deeper socket, thus providing better coverage and stability for the femoral head. This is the least risky form of treatment for hip dysplasia with success rates approaching 95 percent in children with a single hip involved.
• Rigid brace: If the Pavlik harness is not effective, a rigid hip orthosis will provide additional support to maintain the desired position that is necessary to treat hip dysplasia.
• Casting: The next step in treatment for dysplastic and unstable hips that do not respond to the Pavlik harness or rigid orthosis is casting. Usually, the cast application is combined with an exam and arthrogram under anesthesia.
  • The spica cast covers both legs and extends up to the baby’s trunk to provide firm support, maintaining the desired relationship between the femoral head and the socket.
  • Arthrograms are X-ray studies that involve injecting “dye” into the hip to visualize the cartilage structures of the ball and socket that otherwise do not show up on X-rays.
• Surgery: For infants, surgery is used to correct the hip that remains persistently dislocated. The procedure balances the tight and loose tissues around the hip to keep the ball centered within the existing shallow socket. The baby is then protected with a hip spica cast so that the dysplastic hip structures can grow into a more normal shape. Children who are one year old and older and are diagnosed with hip dislocations usually require surgery as the first line of treatment.

For nearly all of these options, the length of treatment is an average of 12 weeks. The goal for each patient is a stable hip. For some patients, this happens faster than it does for others. The length of treatment is personalized, so each child has the best possible outcome.

Adolescent Hip Program

As parents, we often find ourselves trapped between genuine concern for our adolescent’s health and the instinct to dismiss their aches and pains. At the Rocky Mountain Adolescent Hip Preservation Institute, partnered with our sports medicine team, we can help diagnose and treat hip issues from the most simple to the most complex. We are pioneers in hip arthroscopy and complex hip reconstruction in adolescents, allowing us to treat even the most complicated hip disorders.

Hip pain in adolescents can present a difficult diagnostic problem. Injuries range from fractures to labral tears, while other issues, such as hernias, can confuse the picture. A combination of a medical history evaluation, physical exam and imaging procedures can make all the difference.

Parents and patients are usually very anxious about hip injuries because they affect the athlete’s ability to participate in a beloved sport now and in the future. We take all the time necessary to discover and explain the diagnosis and treatment plan to each patient and family. Whether it is a prima ballerina or a star running back, we have the ability to walk him or her through every step of the process, from surgery to rehabilitation and returning to competition. We know that the best result is achieved when your adolescent is fully informed and engaged about treatment choices.

Adolescent hip deformity can be a devastating problem. Although pain may be the main concern now, extremely early degenerative joint disease may be an even bigger issue in the near future. The understanding and surgical treatment of these deformities are important to prolong the life of the hips, avoiding the need of a hip replacement. With proper surgical treatment, teens can look forward to decades of activity with their own hips.

Snapping hip

Like it indicates in its name, snapping hip refers to an orthopedic condition where a snapping sensation or audible pop is felt or heard when the hip is being extended or flexed. To determine the source of your child’s symptoms, a specialist at RMHC will perform a physical exam that can cause the iliotibial (IT) band, the fibrous tissue that extends from your pelvis to your knee on the outside of your leg, to move back and forth across the greater trochanter (the largest part of the bone at the top of the thigh) reproducing the snapping sensation.

In some instances, an X-ray will be ordered when there is concern for bone abnormality. If the patient’s medical history and physical exam indicate a problem within the joint itself, an MRI may be necessary to look closely at the cartilage and labrum of the hip.

Treating snapping hip

Stretching exercises are frequently used to gain better mobility of the muscles and soft tissues, which can lessen snapping frequency and discomfort. A short course of anti-inflammatory medication, such as ibuprofen, may be helpful.

In most cases, snapping hip is a benign condition with no long-term complications. Most children can continue their activities without restrictions. Stretching and awareness of the cause will most often get your child through these episodes without further concern. When rapid growth is a contributing factor, this syndrome can resolve once that phase passes. Especially for high-demand athletes, a routine program of stretching the IT band will help prevent recurrences.

Femoroacetabular impingement (FAI)

Femoroacetabular impingement, commonly referred to as FAI, is essentially a mismatch between the shape of the ball and socket of the hip joint, causing the two to make contact when they should not. The abnormal contact, called impingement, causes damage and pain within the hip joint.

FAI is common in high-level athletes, but it can also occur in active individuals. It is more frequently diagnosed in females than males. Sports, like ice hockey, bike riding, horseback riding, deep squatting activities, dancing and yoga tend to increase the risk of developing FAI.

Young, very competitive athletes work their joints more vigorously than other people of the same age. The months and years of pushing the hip joint to its limit can result in an overuse injury. Painful symptoms of FAI occur when there are underlying abnormalities in the ball or socket (or both).

Types of femoroacetabular impingement (FAI)

Pincer lesions

A misshapen socket is called a “pincer lesion.” The socket must cover the ball in just the right area to provide stability and allow enough motion. If the socket is too deep, points in the wrong direction or covers too much of the ball, the ball will collide with the edge of the socket, even within a normal range of motion.

Cam lesion

A misshapen ball is called a “cam lesion.” In order for the ball to move through a large range of motion, it must be a sphere and have a large diameter, which then narrows quickly into a skinny shaft (neck) so that it won’t impinge on the edge of the socket. This difference in diameter allows the ball to move freely. If the neck is too broad, and the difference between the diameter of the head and neck is too small, they will impinge on the edge of the socket.

Combined FAI

A hip joint experiencing both a cam lesion and a pincer lesion.

Labral tear

The labrum is a rubber-like ring of cartilage attached to the circular edge of the hip socket. It creates a fluid-tight seal around the edge of the socket, maintaining a frictionless environment between the ball and socket and providing some stability to the joint. When the ball and socket impinge, the labrum gets crushed and torn. Sometimes the labrum tears in the center of its own tissue, but it is more common for it to tear away from the bony edge of the socket. Either type of tear causes pain and loss of labral function. This endangers the cartilage within the joint, leading to early onset arthritis.

Symptoms of FAI

FAI usually feels like a sharp pain deep in the groin area or in the front of the hip. It worsens with athletic activities, or with prolonged sitting. As symptoms progress, the muscles surrounding the hip will fatigue and become very sore. This can feel sharp or dull and can be located at the side of the hip, the lower back or the buttocks. Popping is a symptom which may or may not be painful. Sometimes, the pain will even happen with normal activities, like walking or going up and down the stairs.

Diagnosing FAI

FAI is best-diagnosed by a pediatric orthopedist who sub-specializes in the treatment of FAI. The specialist will first take a thorough patient history to begin the process of defining the pain pattern. Next, an examination of the hip, knees and back will be performed to determine the source of the pain. A range of motion exam will also help indicate the source of the pain. The impingement test is a way to maneuver the hip that will clarify if FAI is a likely cause of the pain.

If FAI is expected, X-rays of the hip and pelvis will be reviewed. This is the best way to evaluate the shape of the ball and socket. If your history, physical examination and X-ray all indicate an FAI diagnosis, an MRI of the hip may be ordered to further assess the extent of the damage.

The MRI requires an injection of medications into the hip, which helps in two ways. One of the medications helps to show the damage to the labrum. The second medication (a numbing medication) may relieve pain for an hour or two. If the pain significantly improves during that time, it can be concluded that the pain is indeed coming from the hip joint.

Treating FAI

Non-surgical treatment

Over the counter medications, such as ibuprofen and naproxen, along with ice, heat and massage may help the symptoms. None of these treat the underlying cause, but they can relieve pain temporarily. Physical therapy may also be prescribed to help strengthen the large muscles around the hip. This may relieve some of the stress on the injured labrum and cartilage, resulting in decreased pain.

Surgical treatment

If the history, physical exam, X-rays and MRI all support the diagnosis of FAI, and non-surgical management fails, surgery may be recommended. The goal of surgery is to correct the deformity and to repair the labrum. The initial benefit is pain relief and a return to sports. There is some evidence that surgery can prolong the long-term function of the hip.

The recommended surgery will depend on the exact type of FAI. The three main surgical options include:

• Hip arthroscopy treats cam, pincer and combined lesions, along with labral tears. During the surgery, small incisions are made around the hip. Through these incisions, the ball and socket are reshaped and the labrum can be repaired.
• Surgical dislocation of the hip may be used to treat cases of severe deformity on the ball side of the joint. This procedure is a safer way to expose and correct larger cam and pincer lesions, as well as labral deformities.
• Periacetabular osteotomy (PAO) is recommended in cases of severe deformity on the socket side of the joint. When the socket is shallow or poorly shaped, the femoral head may move excessively within the hip joint. This excessive motion can lead to accelerated wear and tear of the hip. A PAO moves the socket so that the joint, including the femoral head, is in a more stable position. This may delay development of arthritis in the hip joint.

Olivia’s story

Olivia began dancing when she was four years old. Although her dedication waxed and waned through the years, she has become increasingly involved during the last three years. Now at 15 years old, she has noticed a painful pop across the front of her hip joint. At first, she was almost amused by the sensations, but now it has progressed to an almost constant discomfort that bothers her even with prolonged sitting. She began physical therapy with some mild improvements, but her therapist noted some abnormal flexion and extension movements through the hip joint that were associated with femoroacetabular impingement (FAI). The therapist recommended an evaluation by an adolescent hip specialist at Rocky Mountain Hospital for Children.

After Olivia’s evaluation, an MRI revealed a pincer lesion and a labral tear that required arthroscopic correction. Even the day after surgery, Olivia told her mom that the deep hip pain she had experienced before surgery was now completely gone. After she completed her physical therapy course, she returned to the dance studio in time to prepare for her solo performance in the annual Christmas recital.

Slipped capital femoral epiphysis (SCFE)

To understand SCFE, you first have to know a little about the hip joint. The hip is a ball-and-socket joint. The ball is at the top end of the thighbone (femur) and the socket is in the pelvis. Ball-and-socket joints offer the greatest range of movement of all types of joints, which explains why we can move our legs forward, backward and around.

In kids and teens who are still growing, there is a growth plate (physis) at the base of the ball (femoral head). This growth plate is made of cartilage, which is softer than bone. The growth of the top part of the thighbone depends on this physis.

When a child has SCFE, the femoral head of the thighbone slips at the physis, almost the way a scoop of ice cream might slip off a cone. Sometimes this happens suddenly—after a fall or sports injury, for example—but often it is a slow process with vague pain that is easily dismissed.

Types of SCFE

SCFE can be classified into two types:

• Stable SCFE—This is referred to as a "mild slip," which causes a child to experience some stiffness or pain in the knee or groin area and possibly develop a limp. The pain and the limp usually tend to come and go, worsening with activity and getting better with rest. With stable SCFE, your child is still able to walk, although crutches may be necessary.
• Unstable SCFE—This is a more severe slip that is usually much more painful. Your child will not be able to bear weight on the affected side, and range of motion tends to be severely limited. An unstable SCFE is also more serious because it can restrict blood flow to the hip joint, leading to a condition called avascular necrosis of the femoral head.

What causes SCFE?

No one knows for sure what causes SCFE. However, it is known that it mostly occurs in kids between 11 and 16 years old who are going through a growth spurt. It is more common in boys, though girls can be affected too.

SCFE is also more likely to occur in kids who have the following risk factors, all of which can have an effect on bone health:

• Obesity (carrying extra weight puts increased pressure on the growth plate)
• Endocrine disorders, such as diabetes, thyroid disease or growth hormone problems
• Kidney disease
• Cancer treatments, like radiation and chemotherapy
• Certain medications, such as steroids
• A family history of SCFE