ppt aboout congenital hip dysplasia.pptx

ppt aboout congenital hip dysplasia

1. Congenital Hip Dysplasia Pramodhiya Sanduni Perera , Grp 10, Sem 9.

2. Introduction Most notably, Ortolani , an Italian pediatrician in the early 1900s, evaluated, diagnosed, and began treating hip dysplasia. Galeazzi later reviewed more than 12,000 cases of DDH and reported the association between apparent shortening of the flexed femur and hip dislocation.  Typically, the term DDH is used in referring to patients who are born with dislocation or instability of the hip , which may then result in hip dysplasia.    More broadly, DDH may be defined simply as abnormal growth of the hip.

3. More specific terms are often used to describe the condition more precisely; these are defined as follows: Subluxation – Incomplete contact between the articular surfaces of the femoral head and acetabulum Dislocation – Complete loss of contact between the articular surface of the femoral head and acetabulum Instability – Ability to subluxate or dislocate the hip with passive manipulation Teratologic dislocation – Antenatal dislocation of the hip

4. Anatomy The anatomy of the dislocated hip, especially after several months, often includes formation of a ridge called the neolimbus . Closed reduction is often unsuccessful at a later date, secondary to various obstacles to reduction. These include adductor and psoas tendon contraction, ligamentous teres , a transverse acetabular ligament, and pulvinar and capsular constriction . With long-standing dislocations, interposition of the labrum can also interfere with reduction .

5. Epidemiology In Native Americans and Laplanders , the prevalence of hip dysplasia is much higher (nearly 25-50 cases per 1000 persons) than in other races, and the prevalence is very low in southern Chinese and black populations.   The frequency of hip dysplasia is 10 times higher in children whose parents had DDH than in those whose parents did not . Female sex, being the first-born child, and breech positioning are all associated with an increased prevalence of DDH.   Oligohydramnios is also reported to be associated with an increased prevalence of DDH.     The left hip is more commonly associated with DDH than the right hip, possibly because of the common intrauterine position of the left hip against the mother's sacrum, which forces it into an adducted position.    According to Barlow's study , more than 60% of newborns with hip instability became stable by age 1 week, and 88% became stable by age 2 months, leaving only 12% (of the 1 in 60 newborns, or 0.2% overall) with residual hip instability.

6. What are hip dysplasia symptoms ? The most common hip dysplasia symptoms include: Hip pain (usually in the front of your groin). Feeling like your hip is loose or unstable. Limping when you walk or move. Having legs that are different lengths. Babies born with hip dysplasia that aren’t old enough to walk yet may have different hip dysplasia symptoms, including: Having one leg that turns out (away from the center of their body) more than the other. Moving one leg less than the other. Uneven or wrinkled skin around their thighs and butt (buttocks). Ddx = Other musculoskeletal disorders of intrauterine malpositioning or crowding, such as metatarsus adductus and  torticollis , have been reported to be associated with DDH.   

7. In Infants, the Degree of Instability Can Be Described As: Dislocated and reducible (+ Ortolani ) Dislocated and irreducible (- Ortolani ) Dislocatable (+ Barlow) Subluxed (a hip with mild instability or laxity with a – Barlow maneuver ) Hip Dysplasia Presentations in the Infant 2 Months or Older After 2-3 months of age, the Ortolani test and Barlow maneuvers are less sensitive but several other physical exam findings become more apparent: Unilateral dysplasia presenting as asymmetric shortening on the side of the dislocation ( Galeazzi sign) The leg on the affected side may turn outward Tight hip adductors/decreased hip abduction Asymmetric thigh or gluteal folds The space between the legs may look wider than normal Hip Dysplasia Presentations in the Walking Child Mild hip flexion contractures from bilateral dysplasia may produce hyperlordosis in the lumbar spine and a waddling type gait Unilateral dislocations may produce a short leg gait and/or limp in the walking child On rare occasions, early exams and screenings will not detect a developing dysplasia of the acetabulum and the femoral head will slowly slide out and not be detected until walking age when a limp or short leg is identified. As pain is not common in children, keen observation is required or diagnosis may be missed. Hip Dysplasia Presentations in Preadolescents and Adolescents Presents with hip and leg pain which may be chronic and/or worsened by an injury If moderate to severe, can lead to degenerative hip disease and deformity if untreated Other Possible Late Presentations Late presentation growth disturbances Avascular necrosis Residual acetabular dysplasia or deformity

8. The Barlow Maneuver is done by guiding the hips into mild adduction and applying a slight forward pressure with the thumb. If the hip is unstable, the femoral head will slip over the posterior rim of the acetabulum , again producing a palpable sensation of subluxation or dislocation. Physical Examination

9. The Ortolani Test: The examiner’s hands are placed over the child’s knees with his/her thumbs on the medial thigh and the fingers placing a gentle upward stress on the lateral thigh and greater trochanter area. With slow abduction, a dislocated and reducible hip will reduce with a described palpable “clunk.”

10. How Is Hip Dysplasia Evaluated ? Children under 6 months of age : Beyond clinical screening exams, US (ultrasound) is the preferred technique. Though US screening of all infants is not advised, infants with identified risk factors or questionable exams should be routinely screened. With a normal exam, screening US should be delayed until at least 4-6 weeks, when hip maturation improves exam specificity. US is also used to document reduction and follow the improvement or maturity of a dysplastic hip following treatment.

11. This is the Graf classification - short version. The alpha-angle, which is a measurement of the bony roof of the acetabulum , mainly determines the hip type. Actually, for classification purposes the beta angle is only used to differentiate between type Ia and Ib (both normal hips) and between type IIc and type D)

12. Children 6 months of age or older: Plain radiographic evaluation is used. On an AP radiograph, lines which localize the femoral head in relationship to the acetabulum -- Hilgenreiner’s , Perkin’s, and the acetabular index--can be drawn and measured. The proximal femoral metaphysis should lie medial to Perkin’s line, within the inner and lower quadrant of the resulting grid. In the dysplastic hip, the normal acetabular index (around 25 to 27 degrees) is increased. Other findings include disruption of Shenton’s line, delay in epiphyseal ossification and/or a widened or delayed “teardrop” appearance. Plain radiographs and measurements are also used to follow hip development and maturation

13. Treatment Birth to 6 months : Immature, stable hips ( Barlow negative ) that become normal do not need treatment . Hips that are Barlow positive at birth may also become stable in the first 3 weeks of life; therefore, treatment may be delayed. In both cases, close follow-up and routine physical exams are required, plus a later US to document normal hip stability and development. With an unstable, Ortolani positive hip , early treatment is required. Reduced hips are positioned in flexion and mild abduction to stimulate normal joint development, most commonly performed via the Pavlik harness , a dynamic brace which positions the thighs to allow and maintain hip reduction. Infants are followed bi-weekly for strap adjustment. Progress is monitored and reduction verified with subsequent US evaluations. Pavlik treatment continues until US parameters have normalized and the hip stabilized on exam, on average 2-3 months later. Follow-up through skeletal maturity is then emphasized. 6 months to 1-2 years :  Children who present at this time or fail to stabilize with the Pavlik harness require genera anesthesia , followed by closed or open hip reduction and spica casting. Over 2 years of age :  Older children may require extensive open surgical reductions with possible femoral and pelvic osteotomies (cutting and realigning the bones), followed by a spica cast . In a skeletally mature teenager or young adult , a procedure called  periacetabular osteotomy ( PAO ) is done. In a PAO, portions of the pelvis are cut in order to reposition the acetabulum so that it gives better coverage to the femoral head. This surgery has great potential to prevent or delay hip arthritis, especially if it is performed prior to irreversible cartilage injury, such as a torn labrum .

14. Prognosis Overall , the prognosis for children treated for hip dysplasia is very good, especially if the dysplasia is managed with closed treatment. If closed treatment is unsuccessful and open reduction is needed, the outcome may be less favorable   , although the short-term outcome appears to be satisfactory. If secondary procedures are needed to obtain reduction, then the overall outcome is significantly worse. In this study, the rate of osteonecrosis was higher in the bilateral group, but this difference was explained by older age at surgery and a greater degree of hip dislocation before surgery.   The authors concluded that the clinical outcomes after surgery of the children with bilateral hip dislocations were worse mainly because of asymmetric outcomes.

15. References https:// emedicine.medscape.com/article/1248135-overview https://www.nationwidechildrens.org/conditions/hip-dysplasia#:~:text=The%20Ortolani%20Test%3A%20The%20examiner's,a%20described%20palpable%20%E2%80%9Cclunk.% E2%80%9D https:// www.hss.edu/condition-list_hip-dysplasia.asp https:// www.pennmedicine.org/for-patients-and-visitors/patient-information/conditions-treated-a-to-z/hip-dysplasia https:// radiologyassistant.nl/pediatrics/hip/developmental-dysplasia-of-the-hip-ultrasound