DEVOLOPMENTAL DYSPLASIA OF HIP
DEVOLOPMENTAL DYSPLASIA OF HIPBYE.D.PRASANNA
DEFINITIONThe definition of developmental dysplasia of the hip (DDH) is not universally agreed upon. Typically, the term DDH is used when referring to patients who are born with dislocation or instability of the hipDevelopmental dysplasia of the hip is the condition in which the femoral head has an abnormal relationship to the acetabulum.DDH encompasses a spectrum of disorders
DYSPLASIAA shallow or underdeveloped acetabulumIt can either be stable or unstable
DISLOCATION reducible or non reducible
SUBLUXATION
This refers to antenatal dislocation of the hip.
TERATOLOGIC DISLOCATION
ETIOLOGY
FAMILIALIncidence is more in First Degree RelativesHereditary predisposition to joint laxity
FEMALE SEXMaternal hormone relaxin
Crosses the placenta
If foetus is female , it causes laxity of foetal joint
Dislocation
BREECH PRESENTATION
Reduced Uterine volumeFirst bornMultiple pregnancyoligohydramnios
Packaging Disorders LikePlagiocephaly , Torticollis , Foot Deformities
RACE AND CULTURESwaddling of the babyIncreased incidence in Native Americans
PATHOLOGICAL CHANGES
Elongated capsuleFemoral head displaced upwars and laterally
Hip jointfills w/ fibrofatty debris known as pulvinarAcetabular labrum - becomes enlarged along the superior, posterior, and inferior rim; - may infold into joint (inverted limbus); - limbus blocks reduction of femoral head;
CLINICAL FEATURES
FROM BIRTH TO 3 MONTHSMainstay for diagnosis are
Ortolani testBarlow testGaleazzis sign
BARLOWS TESTFacing childs perineumHold upper part of the childs thigh fingers behnd the greater trochanter thumbs in frontPosition knees fully flexed , hips flexed to right angleHip is now adductedsimultaneously pressure is exerted in proximal direction trying to push out the hipIf the hip is dislocatable abnormal posterior movement will be felt along with a distinct clunkNothing is noted then hip is either stable or it has already been dislocated
Hips are in 90 flexion and fully adductedThighs are gently abductedForward pressure is exerted on the greater trochanter while abductionIf the hip was dislocated , a clunk will be heard or felt as femur is reduced into acetabulumIf nothing is noted , there my be no dislocation or irreducible dislocation is present
ORTOLANIS TESTHips and knee of child held in flexed positionGradually abducted Clunk of entrance felt as dislocated femoral head slips back into acetabulumTest is negative if no dislocation or irreducible dislocation is present
ASYMMETRICAL GLUTEAL AND THIGH FOLDS
GALEAZZIS SIGN
Seen in Unilateral dislocation Limb length is shorter on affected side
AFTER 3 MONTHS Ortolani and barlow become negative due to development of adaptive shortening
LIMITATION OF ABDUCTION
ASYMMETRICAL GLUTEAL AND THIGH FOLDS
POSTIVE TELESCOPY
Hip to be tested in flexed postionPlace thenar eminence of one hand on ASIS and finger on trochanter Using other hand , hold knee and give a gentle push pull along long axis of femur Up and down movement of femur indicates positive telescopy
Place the middle finger over the greater trochanter, and the index finger on the anterior superior iliac spine
With a normal hip, an imaginary line drawn between the two fingers points to the umbilicusWhen the hip is dislocated, the trochanter is elevated and the line projects halfway between the umbilicus and the pubisKLISIC TEST
WALKING AGE OR > 1 YEAR
TRENDELENBERG TEST
LORDOSIS OF LUMBAR SPINE
GAIT Trendelenberg gaitWaddling gait
Waddling gait
IMAGING
X ray
Perkins line: This is a vertical line drawn at the outer border of the acetabulum Hilgenreiners line: This is a horizontal line drawn at the level of triradiate cartilage Shentons line: This is a smooth curve formed by the inferior border of the neck of the femur with the superior margin of the obturator foramenAcetabular index: The angle is formed by Hilgenreiner line and a line which extends along the acetabular roofs.Normal is < 30 degrees
IMAGING
the head lies in the upper and outer quadrantthe continuity of Shentons line is broken
ULTRASOUND
Femoral head
Abductors
Ilium
Alpha angle is formed by the acetabular roof to the vertical cortex of the ilium.
GRAFS CLASSIFICATION
COMPUTED TOMOGRAPHY
Document reduction postoperativelyPre operative planning
Done preoperativelyAssess the position of femoral head in relation to other structuresFind out any obstructions to reductionARTHOGRAPHY
TREATMENT
TREATMENT PRINCIPLES
TECHNIQUES OF REDUCTIONClosed reductionTraction followed by closed reductionOpen reduction
MAINTENANCE OF REDUCTIONPlaster cast
Von Rosen Splint
ACETABULAR RECONSTRUCTION PROCEDURESSatlers osteotomyChiaris OsteotomyPemberton Osteotomy
SALTERS OSTEOTOMYRoof of acetabulum is rotated so that it covers head of femurFulcrum through pubic symphysis
PEMBERTON OSTEOTOMYRoof of acetabulum is deflected downwards so that it covers head of femurFulcrum through triradiate cartilage
CHIARIS OSTEOTOMYUsed when no other osteotomy can be performedIliac bone is divided transversely above acetabulumLower portion is displaced medially Margin of upper portion provide depth to acetabulum
Closed reductionSuccessfulMaintain in a cast for 3 monthesBraceAcetabulum developsRemove the bracePhysiotherapy
Acetabulum does not developAcetabular reconstructionphysiotherapy
DISLOCATION DIAGNOSED AT BIRTH
Not successfulTraction Closed reductionsuccessfulTreat as before
Not successfulOpen reductionacetabular reconstructionDerotation osteotomy
DISLOCATION AT LATER AGES
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