dr. abdulmonem alsiddiky, md, ssco. assistant professor & consultant pediatric ortho.&...

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