Clin. Radiol. (1977) 28, 187-191 T H E R A D I O L O G Y O F T H E HIP J O I N T S A N D P E L V I S IN C E R E B R A L P A L S Y G. J. GRIFFITHS, K. T. EVANS, G. M. ROBERTS and K. N. LLOYD
The Departments of Diagnostic Radiology and Rheumatology, Welsh National School of Medicine, Cardiff The radiological appearances found in the pelvis and hip joints in 79 patients with cerebral palsy, aged 5 - 1 6 years, have been studied. These findings have been recorded and correlated with the clinical severity and distribution of the disease. Subluxation of the hip joints was found in 14% and dislocation in a further 6%. Spasticity was the predominant neuromuscular handicap in 69 out of 79 cases (88%). The acetabular angle and femoral neck shaft angle were related to the degree of migration of the femoral head. The acetabular angle, iliac angle, iliac index and femoral neck shaft angle were all significantly increased in the deranged group. In the dislocated group, the mean neck-shaft angle was 154 °. When the degree of spasticity was asymmetrical, there was a striking relationship between the laterality of the spasticity and the laterality of the deranged hip, pelvic obliquity and increased acetabular angle. A typical teardrop-shaped femoral head was seen in 48%, spina bifida occulta of the lower lumbar and sacral spine in 32% and pseudoarthrosis in 3.8%. No ectopic calcification or ossification of soft tissue was noted. An awareness that these children are at risk from subluxation and dislocation of the hip and the importance of early diagnosis and treatment are emphasised. Cerebral palsy is a leading cause of physical and mental handicap in children. Phelps (1941) used the term to describe any paralysis, weakness, incoordination or functional abnormality of the motor system, resulting from an anomaly, injury or disease of the brain. The prevalence is estimated as 100-600 cases per 100000 population, most cases being identified in childhood usually in the first year of life. These children provide important economic, social, as well as medical problems. Numerous specialties are involved in the care, support and treatment of children with cerebral palsy. A number of papers in the orthopaedic literature have dealt with the management and treatment of hip derangements in cerebral palsy (Mathews et al., 1953; Tachdjian and Minear, 1956; Phelps, 1959; Lamb and Pollock, 1962; Samilson et al., 1972; Craig, 1973; Sharrard et al., 1975). However, despite the fact that radiographic examination plays an important role in the assessment of disability, particularly with regard to the hip joints, the subject has received scant attention in the radiological literature to date. Keats (1972) has emphasised the importance of prompt diagnosis in the success of early surgery, which is usually aimed at preventing dislocation of weight-bearing joints. The study was prompted by the observation that in this group of children no ectopic soft tissue calcification or ossification was noted in relation to the hip joints. This is unlike the observations of others in traumatic paraplegia and other neurological disorders (Hardy and Dickson, 1963; Lodge, 1963). In this paper we describe the radiological
appearances in the hip joints, pelvis, lower lumbar and sacral spine of patients with cerebral palsy and aim to determine their significance in relation to the clinical findings. MATERIALS AND METHODS A study was made of 79 patients with cerebral palsy who were attending residential schools for physically handicapped children. Thirty patients were female and 49 were male. The mean age was 11 years (range 5 - 1 6 years). Full clinical information regarding all of the patients was available. Antero-posterior radiographs of the pelvis and hip joints were taken with the hips, if possible, in the neutral position. The radiographs were obtained irrespective of any clinical involvement of the hips or their musculature. To avoid unnecessary irradiation to these young patients, horizontal beam lateral radiographs of the hip joints were not performed. In one case serial films were available, but in the remainder, single films only. The following observations and measurements were made from the radiographs. The hips were classified as normal, subluxed or dislocated. A hip was considered to be subluxed when contact with the acetabulum was maintained, but more than one-third of the femoral head was not covered. The hip was designated as dislocated when there was complete loss of acetabular contact (Putti, 1933; Wiberg, 1953; Sharrard et al., 1975). The presence of pseudoarthrosis was noted. The femoral neck-shaft angle, 187
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CLINICAL RADIOLOGY
acetabular angle, iliac angle and iliac index were measured, as described by previous authors (Caffey et al., 1956; Caffey and Ross, 1958; Keats et al., 1966). The number of patients showing spina bifida occulta o f the lower lumbar and sacral spine was recorded together w i t h the direction of any pelvic obliquity. It was noted whether the ischiopubic synchondrosis was open or closed. Particular attention was given to any abnormafity in the shape o f the femoral head. The severity of the neurological deficit and mental impairment was noted. In particular, the number of children showing spasticity and contracture o f the muscles around the hip joint and whether the involvement was symmetrical or n o t was recorded. The clinical state of the patient was then correlated with the radiological findings.
RESULTS Deranged Hips. - Of the 79 children studied 11 (14%) had subluxed hips and six ( 8 % ) h a d dislocated
hips. Thus, 17 children (22%) fell into the deranged group (either subluxed or dislocated). Ten had unilateral subluxation, one bilateral subluxation (Fig. 1), three unilateral dislocation and three bilateral dislocations. The total number of affected hips was 21. In the unilaterally deranged hips, nine were affected on the right side and four on the left. Clinical Assessment. - Spasticity was the predominant neuromuscular handicap in 69 of the 79 children (88%). The remainder were mainly athetoid. 35 (44%) had a quadriplegia, 25 (32%) a diplegia, and five (7%) a hemiplegia. In 28 children the spasticity was n o t symmetrical, the right side being predominantly involved in 19 children and the left side in nine. In the remaining 41 cases both lower limbs showed spasticity. Thirty-seven per cent o f the patients were confined to bed or a wheelchair. Axial Relationship of the Hip Joints. - It can be seen from Table 1 that both the acetabular angle and the femoral neck shaft are related to the degree of migration o f the femoral head. There is an increase in
Fig. 1 - Radiograph of the pelvis and hips of a spastic quadriplegic child aged 7 years. Bilateral subluxations. Both acetabular angles are increased. There is a marked valgus deformity of both femoral necks. Spina bifida occulta at S-1. No pelvic obliquity. Fig. 2 - Radiograph of the pelvis and hips of a spastic diplegic child aged 12 years. Adductor spasm and flexion deformity affecting the left hip. Note dislocation and increased acetabular angle on the left. There is a marked valgus deformity of the left femoral neck. There is pelvic obliquity with the left side elevated. Fig. 3 - Radiograph of the pelvis and hips of a spastic tetraplegic patient aged 15 years with marked bilateral adductor spasm and contracture. There are bilateral dislocations with a right pseudo-arthrosi~ Note bilateral sloping acetabular roofs and bilateral coxa valga. Both femoral heads show a typical teardrop shape. No pelvic obliquity.
THE RADIOLOGY
O F T H E HIP J O I N T S A N D P E L V I S IN C E R E B R A L
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Fig. 4 - Radiograph of the pelvis and hips Of a spastic diplegic child taken when he was aged 10 years. He had marked adductor spasm and hip flexion deformity which was worse on the right. The left hip is normal, the right subluxed. Note spina bifida occulta at L-5. There is pelvic obliquity with the right side elevated,
Fig. 5 - Same patient as in Fig. 4 taken when he was aged 15 years. The right hip is n o w dislocated and a pseudoarthrosis has developed. Note the increased acetabular angle and destructive changes compared with the normal left side. The radiographs suggest that the acetabular changes are secondary to the dislocation. The right femoral head shows an early and mild teardrop shape.
the acetabular angle in the deranged group (mean 36 °) when compared with the unaffected group (mean 14 ° P
The Departments of Diagnostic Radiology and Rheumatology, Welsh National School of Medicine, Cardiff The radiological appearances found in the pelvis and hip joints in 79 patients with cerebral palsy, aged 5 - 1 6 years, have been studied. These findings have been recorded and correlated with the clinical severity and distribution of the disease. Subluxation of the hip joints was found in 14% and dislocation in a further 6%. Spasticity was the predominant neuromuscular handicap in 69 out of 79 cases (88%). The acetabular angle and femoral neck shaft angle were related to the degree of migration of the femoral head. The acetabular angle, iliac angle, iliac index and femoral neck shaft angle were all significantly increased in the deranged group. In the dislocated group, the mean neck-shaft angle was 154 °. When the degree of spasticity was asymmetrical, there was a striking relationship between the laterality of the spasticity and the laterality of the deranged hip, pelvic obliquity and increased acetabular angle. A typical teardrop-shaped femoral head was seen in 48%, spina bifida occulta of the lower lumbar and sacral spine in 32% and pseudoarthrosis in 3.8%. No ectopic calcification or ossification of soft tissue was noted. An awareness that these children are at risk from subluxation and dislocation of the hip and the importance of early diagnosis and treatment are emphasised. Cerebral palsy is a leading cause of physical and mental handicap in children. Phelps (1941) used the term to describe any paralysis, weakness, incoordination or functional abnormality of the motor system, resulting from an anomaly, injury or disease of the brain. The prevalence is estimated as 100-600 cases per 100000 population, most cases being identified in childhood usually in the first year of life. These children provide important economic, social, as well as medical problems. Numerous specialties are involved in the care, support and treatment of children with cerebral palsy. A number of papers in the orthopaedic literature have dealt with the management and treatment of hip derangements in cerebral palsy (Mathews et al., 1953; Tachdjian and Minear, 1956; Phelps, 1959; Lamb and Pollock, 1962; Samilson et al., 1972; Craig, 1973; Sharrard et al., 1975). However, despite the fact that radiographic examination plays an important role in the assessment of disability, particularly with regard to the hip joints, the subject has received scant attention in the radiological literature to date. Keats (1972) has emphasised the importance of prompt diagnosis in the success of early surgery, which is usually aimed at preventing dislocation of weight-bearing joints. The study was prompted by the observation that in this group of children no ectopic soft tissue calcification or ossification was noted in relation to the hip joints. This is unlike the observations of others in traumatic paraplegia and other neurological disorders (Hardy and Dickson, 1963; Lodge, 1963). In this paper we describe the radiological
appearances in the hip joints, pelvis, lower lumbar and sacral spine of patients with cerebral palsy and aim to determine their significance in relation to the clinical findings. MATERIALS AND METHODS A study was made of 79 patients with cerebral palsy who were attending residential schools for physically handicapped children. Thirty patients were female and 49 were male. The mean age was 11 years (range 5 - 1 6 years). Full clinical information regarding all of the patients was available. Antero-posterior radiographs of the pelvis and hip joints were taken with the hips, if possible, in the neutral position. The radiographs were obtained irrespective of any clinical involvement of the hips or their musculature. To avoid unnecessary irradiation to these young patients, horizontal beam lateral radiographs of the hip joints were not performed. In one case serial films were available, but in the remainder, single films only. The following observations and measurements were made from the radiographs. The hips were classified as normal, subluxed or dislocated. A hip was considered to be subluxed when contact with the acetabulum was maintained, but more than one-third of the femoral head was not covered. The hip was designated as dislocated when there was complete loss of acetabular contact (Putti, 1933; Wiberg, 1953; Sharrard et al., 1975). The presence of pseudoarthrosis was noted. The femoral neck-shaft angle, 187
188
CLINICAL RADIOLOGY
acetabular angle, iliac angle and iliac index were measured, as described by previous authors (Caffey et al., 1956; Caffey and Ross, 1958; Keats et al., 1966). The number of patients showing spina bifida occulta o f the lower lumbar and sacral spine was recorded together w i t h the direction of any pelvic obliquity. It was noted whether the ischiopubic synchondrosis was open or closed. Particular attention was given to any abnormafity in the shape o f the femoral head. The severity of the neurological deficit and mental impairment was noted. In particular, the number of children showing spasticity and contracture o f the muscles around the hip joint and whether the involvement was symmetrical or n o t was recorded. The clinical state of the patient was then correlated with the radiological findings.
RESULTS Deranged Hips. - Of the 79 children studied 11 (14%) had subluxed hips and six ( 8 % ) h a d dislocated
hips. Thus, 17 children (22%) fell into the deranged group (either subluxed or dislocated). Ten had unilateral subluxation, one bilateral subluxation (Fig. 1), three unilateral dislocation and three bilateral dislocations. The total number of affected hips was 21. In the unilaterally deranged hips, nine were affected on the right side and four on the left. Clinical Assessment. - Spasticity was the predominant neuromuscular handicap in 69 of the 79 children (88%). The remainder were mainly athetoid. 35 (44%) had a quadriplegia, 25 (32%) a diplegia, and five (7%) a hemiplegia. In 28 children the spasticity was n o t symmetrical, the right side being predominantly involved in 19 children and the left side in nine. In the remaining 41 cases both lower limbs showed spasticity. Thirty-seven per cent o f the patients were confined to bed or a wheelchair. Axial Relationship of the Hip Joints. - It can be seen from Table 1 that both the acetabular angle and the femoral neck shaft are related to the degree of migration o f the femoral head. There is an increase in
Fig. 1 - Radiograph of the pelvis and hips of a spastic quadriplegic child aged 7 years. Bilateral subluxations. Both acetabular angles are increased. There is a marked valgus deformity of both femoral necks. Spina bifida occulta at S-1. No pelvic obliquity. Fig. 2 - Radiograph of the pelvis and hips of a spastic diplegic child aged 12 years. Adductor spasm and flexion deformity affecting the left hip. Note dislocation and increased acetabular angle on the left. There is a marked valgus deformity of the left femoral neck. There is pelvic obliquity with the left side elevated. Fig. 3 - Radiograph of the pelvis and hips of a spastic tetraplegic patient aged 15 years with marked bilateral adductor spasm and contracture. There are bilateral dislocations with a right pseudo-arthrosi~ Note bilateral sloping acetabular roofs and bilateral coxa valga. Both femoral heads show a typical teardrop shape. No pelvic obliquity.
THE RADIOLOGY
O F T H E HIP J O I N T S A N D P E L V I S IN C E R E B R A L
PALSY
189
Fig. 4 - Radiograph of the pelvis and hips Of a spastic diplegic child taken when he was aged 10 years. He had marked adductor spasm and hip flexion deformity which was worse on the right. The left hip is normal, the right subluxed. Note spina bifida occulta at L-5. There is pelvic obliquity with the right side elevated,
Fig. 5 - Same patient as in Fig. 4 taken when he was aged 15 years. The right hip is n o w dislocated and a pseudoarthrosis has developed. Note the increased acetabular angle and destructive changes compared with the normal left side. The radiographs suggest that the acetabular changes are secondary to the dislocation. The right femoral head shows an early and mild teardrop shape.
the acetabular angle in the deranged group (mean 36 °) when compared with the unaffected group (mean 14 ° P
![[Triple osteotomy of the pelvis in dysplastic hip joints in children and adults].](/assets/img/hold.png)
