DAMASCUS HOSPITAL

Dr.MHD BASHAR ALBOSHI

Definition:

Developemental?!! DDH is a disorder that evolves over time.

The left hip> right hip.

bilateral hips> right hip alone.

Etiology:

تداخل عدة عوامل مشتركة

الرخاوة الرباطية (1)

الرحم ) (2) داخل المقعدية .(الوضعية

Generalized familial

hyperlaxity

Etiology:

(3).وضعية البسط التام للوركين بعد الوالدة(4):العرق

أعلى لدى القوقاز واألمريكان المحليين. أقل عند السود واألسيويين

Associated Conditions

Torticollis (15% have DDH) Metatarsus Adductus(1.5-10%have DDH)

PATHOPHYSIOLOGY( NORMAL HIP DEVELOPMENT):

The hyaline cartilage

( triradiate cartilages)

Pathophysiology (secondary obstacles):

الشحمية (.pulvinar thickens)النسج

) ومتطاول ) متسمك المدور الرباط) ( متضخم المعترض الرباط

) الرملية) الساعة شكل المحفظة

Iliopsoas

Fatty tissue(pulvinar thickens).

Teres ligament (elongated and thickened)

Docking the head

•Labrum: Cartilaginous acetabular lip.

•Neolimbus:a ridge of thickened articular cartilage

dislocatedsubluxated

Transverse ligament )hypertrophic(

Hourglass shape of the capsule by the iliopsoas

tendon

Pathophysiology (secondary obstacles):

Shortened of pelvifemoral muscles

progressive

Figure 15-17

CLINICAL PRESENTATION(THE NEONATE):

Ortolani,s or Barlow,s sign

Sonographic morphology.

CLINICAL PRESENTATION(THE NEONATE):

CLINICAL PRESENTATION(THE NEONATE):

Barlow Ortolani

clunk

CLINICAL PRESENTATION(THE INFANT):

Limited Abduction Galeazzi Sign

Hips 90degrees

CLINICAL PRESENTATION(THE INFANT):

Asymmetric Folds

CLINICAL PRESENTATION(THE INFANT):

Klisic Test

recognize a bilateral dislocation.

Greater trochanter

Anterior superior iliac spine

Normal Dislocation

CLINICAL PRESENTATION(THE WALKING CHILD):

FIG15-24

CLINICAL PRESENTATION

(THE WALKING CHILD)

Femoral Neck Anteversion

IMAGING STUDIES(ULTRASOUND)

identify a silent hip

IMAGING STUDIES(ULTRASOUND)

15-28

IMAGING STUDIES(ULTRASOUND)

15-29

BASELINE: line of ilium which intersects the bony and the cartilaginous portions of the acetabulum.

As the femoral head subluxates:

ALPHA angle

BETA angle

IMAGING STUDIES(ULTRASOUND)

The Ultrasound ( before 3 mo. )

Abductor M.Ilium

IMAGING STUDIES(ULTRASOUND)

TABLE15-2

IMAGING STUDIES(RADIOGRAPHY)

IMAGING STUDIES(RADIOGRAPHY)

لديه الذي الوليد على DDHعند طبيعي يظهر قد. البسيطة الصورة

لعمر يصل .6-3عندما شعاعيا الخلع يظهر أشهر

IMAGING STUDIES(RADIOGRAPHY)

Acetabulum

) ميالنا) أكثر السقف) مسطح) التقعر

) ( متسمك االنسي الجدارشديد أمامي إنقالب

IMAGING STUDIES(RADIOGRAPHY)

IMAGING STUDIES(RADIOGRAPHY)

lateralbroken

IMAGING STUDIES(RADIOGRAPHY)

figure15-33

•Useful in newborns.

•Decrease with age.

IMAGING STUDIES(RADIOGRAPHY)

figure15-34

IMAGING STUDIES(RADIOGRAPHY)

Figure15-35

teardrop body:

Losees its convexity

Wider.

The presence of a teardrop at 6 months after reduction predicted a satisfactory outcome in 93% of hips.

IMAGING STUDIES(Arthrography )

الخفيف ( 1) التصنع عسر

الخلع (2) وتحت الخلعالرد ( 3)الرخوة ( 4) النسج إندخال

labrum (5)

العالج (6) أثناء المراقبة

Screening Criteria

all babies with the risk factors

ultrasound + clinical examination

Neonate: Pavlic harness ))6 weeks((.

1 to 6 months: Pavlic harness)) 6 weeks(( after hip reduces.

6 to18 months: traction?

)1( Closed reduction) cast 3 months(

)2(Open reduction) unsuccessful closed reduction(

< 12 months )Medial approach(

> 12 months )anterolateral approach(

18 to 24 months: Trial of closed reduction?

Or primary open reduction )anterolateral approach(

)+/-A salter osteotomy (

24 months to 6 years: primary open reduction )anterolateral approach( + femoral shortening . ))+/-A salter osteotomy ((

TREATMENT

TREATMENT( NEONATE-6 MONTHS)

PAVLIK harness for 6 weeks after hip reduction

•Hip flexion)120degrees(.

TREATMENT( NEONATE-6 MONTHS)

----- + بعد إيكو اإليكو على شذوذ وليد عند طبيعي سريري فحص6--- --- عالج شذوذ أسابيع

بعد خلع حدث .4-3إذا ------- مفتوح أو مغلق رد أسابيع

TREATMENT( 6-18 MONTHS)

Skin traction for 2 – 3 weeks

90D

TREATMENT( 6-18 MONTHS)

open reduction if closed reduction is unsuccessful !

Closed reduction

(spica cast for 3 mo). >90D flextion

abduction30-40D

Internal rotation 10-15D

TREATMENT(AFTER 18 MONTHS)

Primary open reduction

OPEN REDUCTION

Medial Approach:

. , : مباشرة الرد مواجهة صغير شق محاسنه , , المحفظة: رأب إنجاز يمكن ال ضيقة رؤية ساحة مساوئه

األنسي الفخذي المنعطف الشريان .أذية

Anterior approach:

, المحفظة رأب إنجاز أفضل رؤية ساحة

•Prefer>1 yrs.

•5-7 cm

•1cm distal and parellel to the inguinal crease.

•Centered over the anterior margin of the adductor longus

•If necessary can ligate and section saphenous vein.

•The adductor longus is sectioned at its origin and reflected distally.

•At the anterior margin of the adductor longus the pectineus are identified.

•)A( the hip is approached anterior to the pectineus, between the muscle and the femoral sheath.

•Expose the iliopsoas tendon at its insertion to the lesser trochanter.

•The femoral circumflex vessels retracted laterally.

•)B(the hip approach posterior and medial to the pectineus .

•Flexion:100 degrees.

•Abduction:30 degrees

•Cast: 3 months.

•Skin incision is oblique)bikini incision).((excellent exposure and cosmesis))

•Begin 2/3 the distance from greater trochanter to the iliac crest,crosses the inferior spine,and extends 1-2 cm beyond the inferior spine.

OPEN REDUCTION(Anterior Approach Smith-Petersen):

Begin the incision at the middle of the iliac crest or, for a larger exposure, as far posteriorly on the crest as desired.

•Must determine:

)1( Depth of acetabulum and inclination of its roof.

)2( Shape of femoral head ,and smoothness ,cartilage.

)3( Degree of antetorsion of femoral neck.

)4( Stability of hip after reduction.

•Suture:

iliac apophsis.

rectus femoris,sartorius to their origins

•Cast: 60-70 flexion

45 D abduction

20-30 medial rotation

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من • تقديمها و إعدادها تم محاضرات سلسلة من هي المحاضرة هذه , دمشق مشفى في العظمية الجراحة شعبة في المقيمين األطباء قبل

. . ميرعلي بشار د إشراف تحت• . المحاضرة هذه في الواردة األخطاء عن مسؤول غير الموقع

•This lecture is one of a series of lectures were prepared and presented by residents in the department of orthopedics in Damascus hospital, under the supervision of Dr. Bashar Mirali.

•This site is not responsible of any mistake may exist in this lecture.

كاظم. مؤيد Dr. Muayad Kadhimد