dr. abdulmonem alsiddiky, md, ssco. assistant professor & consultant pediatric ortho.&...
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Dr. ABDULMONEM ALSIDDIKY , MD , SSCO.
Assistant Professor & Consultant
pediatric Ortho.& Spinal Deformities
KSU,KKUH
Riyadh , Saudi Arabia
Nomenclature
CDH : Congenital Dislocation of the Hip DDH : Developmental Dysplasia of the Hip
NORMAL PELVIS
Normal hip Dislocated hip
Patterns of disease
Dislocated Dislocatable Sublaxated Acetabular dysplasia
Radiology
After 6 months: reliable
Causes (multi factorial)
Hormonal Relaxin, oxytocin
Familial Lig.laxity diseases
Genetics Female 4 X male --- twins 40%
Mechanical Pre natal Post natal
Mechanical causes
Pre natal Breach , oligohydrominus , primigravida , twins
(torticollis , metatarsus adductus )
Post natal Swaddling , strapping
Infants at risk
Positive family history: 10X A baby girl: 4-6 X Breach presentation: 5-10 X Torticollis: CDH in 10-20% of cases Foot deformities:
Calcaneo-valgus and metatarsus adductus
Knee deformities: hyperextension and dislocation
Infants at risk
When risk factors are present
The infant should be reviewed Clinically radiologically
Clinical examination
The infant should be quiet comfortable
Look: External rotation Lateralized contour Shortening Asymmetrical skin folds
Anterior – posterior
Move Limited abduction
Special test Galiazzi Ortolani , Barlow test Trendelenburgh sign Limping ( waddling gait if bilateral)
Special test
Galiazzi test
Special test
Ortolani test
Special test
Barlow test
Special test
Trendelenburgh sign
Screening programs
Clinical screening proven to be effective
Performed by trained personnel Must be dynamic
Repeated with periodic examination
U/S screening is controversial
Investigations
0-3 months U/S
> 3months X-ray pelvis AP + abduction
U/S Screening
Incidence of hip stability declines rapidly to 50% within the first week of neonatal life.
Better to delay U/S screening
U/S - Problems
Too sensitive:Detects a lot of hip abnormalities, most of which
would develop normally if left alone
Operator-dependant
Radiology Early infancy: not reliable
Radiology After 2-3 months: more reliable
Radiology After 2-3 months: more reliable
27o 39o
Radiology
After 2-3 months: more reliable
in out
in out
Von Rosen view
in out
Radiology After 2-3 months: more reliable
in out
Radiology After 6 months: reliable
Radiology After 6 months: reliable
Treatment - Aims
Obtain concentric reduction Maintain concentric reduction In a non-traumatic fashion Without disrupting the blood supply to femoral
head
Treatment
Method depends on age The earlier started, the easier it is The earlier started, the better the results are
Should be detected EARLY
Treatment Birth – 6m
Pavlik harness or hip spica
6-12 m: Closed reduction under GA and hip spica
12 - 18 m: Open reduction
18 – 24 m: Open reduction and Acetabuloplasty
2-8 years: Open reduction, Acetabuloplasty, and femoral shortening
Above 8 years: Open reduction, Acetabuloplasty cutting all three pelvic bones, and
femoral shortening
Treatment: Neonatal hip instability
Most resolve spontaneouslyCan initially wait
Avoid adduction swaddleApply double diapers – to bring back!!See at 2weeks of age
Treatment: Neonatal hip instability
Unstable at 2 weeks: Double / Triple diapers: inadequate
Gives illusion that patient is “in treatment” while wasting valuable time
Treatment: Neonatal hip instability
Unstable at 2 weeks: Pavlik Harness
Dynamic, effective, safe
Treatment: 6-12 m Initially non-operative closed reduction UGA and
immobilization in hip spica cast
Position: Avoid sever abduction Avoid frog position
Must obtain stable concentric reduction, otherwise needs surgery
Treatment: 6-12 m Possibly closed reduction
Stable and concentric reduction
Possibly open reduction Unstable or un-concentric reduction
Arthrography-guided
Treatment: 6-12 m Arthrography-guided Closed Reduction
Treatment: 6-12 m
Arthrography-guided Closed Reduction
Too lateralized Acceptable
Treatment: 18-24 m
Open reduction – surgery
Possibly: Acetabuloplasty
Treatment: Above 2 years
Open reduction, and Acetabuloplasty, and Femoral shortening
Acetabuloplasties
Many types
Treatment Birth – 6m
Pavlik harness or hip spica
6-12 m: Closed reduction under GA and hip spica
12 - 18 m: Open reduction
18 – 24 m: Open reduction and Acetabuloplasty
2-8 years: Open reduction, Acetabuloplasty, and femoral shortening
Above 8 years: Open reduction, Acetabuloplasty cutting all three pelvic bones, and
femoral shortening
CDH - Summary Complex multi-factorial, endemic disease Health education and Drs. awareness Screening programs are needed Learning proper examination methods Identify at risk groups Efficient referral system Proper management by specialized Drs
Examples