CDH for students

CDH for students - CDH Congenital Dislocation of the Hip...

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Unformatted text preview: CDH Congenital Dislocation of the Hip Mamoun Kremli Professor / Consultant Pediatric Orthopedics College of Medicine & King Khalid University Hospital CDH • The most common disorder affecting the hip in children • Spectrum of diseases/abnormalities of the hip with different etiologies, pathologies, and natural histories affecting the proximal femur and acetabulum • Initial pathology is congenital, progresses if untreated. • Does not always result in dislocation. CDH Definition • A progressive deformation of previously normally formed structures during the embryonic period NOT A malformation arising during the period of organogenesis CDH Nomenclature • CDH Congenital Dislocation of the Hip • DDH Developmental Dysplasia of the Hip • CDH Congenital Dysplasia of the Hip • CHD Congenital Heart Disease ! CDH Spectrum • Teratologic Hip : Fixed dislocation Occurrs prenatally Often with other anomalies • Dislocated Hip : Completely out May or may not be reducible • Subluxated Hip : Only partially in • Unstable Hip : Femoral head can be dislocated • Acetabular Dysplasia : Shallow Acetabulu Head Subluxated or in place CDH Incidence • Hip Instability at Birth : 0.5 – 1 % of infants • Classic CDH : 0.1 % • Mild Dysplasia : Substantial of infants Contributing to adult Osteoarthritis Up to 50 % of Hip Arthritis in Ladies Have underlying hip dysplasia CDH Incidence Area Incidence per 1000 Canadian Indians Hungary Uppsala, Sweden USA Caucaseans Blacks 188.5 28.7 20 15.5 4.9 Malmo, Sweden Chinese, Hong Kong Bantus, Africa 2.18 0.1 0.0 among (16678) CDH Etiology Multi-factorial CDH Etiology Physiologic Factors Ligament Laxity : Hormonal : ( Estrogen, Relaxin) Females Familial hyper laxity : mild - moderate - Ehler Danlos ADD Picture of knee hyperextension CDH Etiology Genetic Factors • Gender : Female Most studies: Females > 4-6 X than males • Twin studies: Monozygotic 38 % Dizygotic 3 % (similar to siblings) CDH Etiology Family Incidence and Genetic Counselling Affected At risk Risk One sibling Siblings 1 in 17 One parent Children 1 in 8 One parent, one sibling Children 1 in 3 2nd degree relative Nieces, nephews 1 in 100 CDH Etiology Mechanical Factors Prenatal : - Breech position - Oligohydramnious - Primigravida - Cong. Knee recurvatum/dislocation - Metatarsus adductus - Torticollis Postnatal : - Swaddling / Strapping – Knees extended CDH Etiology Mechanical Factors • Breech Presentation : Normally 2 –4 % CDH 16 % The Breech position In Utero Extended knees and flexed hips CDH Etiology Environmental & Mechanical Factors • Swaddling / strapping ( Mihad ): Knees extended & Hips adducted – Proven experimentally – Proven statistically • American Indians. • Eskimos, and • Saudi Arabia – Mechanics • Hip adduction and extension CDH Patients At Risk • • • • • Positive Family History : increases risk 10X A baby girl : increases risk 4-6 times Breech Presentation : increases risk 5-10 X Torticollis : CDH in 10-20 % cases Foot Deformities : ( calcaneovalgus & metatarsus adductus) signs of intrauterine crowding • Knee Deformities : ( hyperextension & dislocation ) associated with Teratologic type CDH Risk Factors When Risk Factors Are Present • The infant should be examined repeatedly • The hip should be imaged ( by U/S or X-ray ) CDH Neonatal Examination The infant should be quiet and comfortable CDH Neonatal Examination LOOK : •External rotation attitude •Lateralized contour •Wide perineum ( in bilateral ) CDH Neonatal Examination posterior LOOK : • Asymmetric thigh folds anterio r CDH Clinical Examination • Look : Shortening ( not in neonates ) - in supine - Galeazzy sign CDH Neonatal Examination FEEL : • Empty groin • Weak Femoral pulse CDH Neonatal Examination MOVE : • Hip instability in early infancy • Limited hip abduction in flexion - later (careful in bilateral) if <600 on both sides: request imaging Cerebral palsy Clinical Assessment Hip Flexion Deformity SPECIAL : • Loss of fixed flexion deformity of hips ( early infancy ) • Normally FFD newborn 28o at 6 weeks 19o at 6 months 7o Thomas Test FFD Normal No FFD ?CDH CDH Neonatal Examination Ortolani Feel a Clunk Not hear a click ! CDH Neonatal Examination Barlow CDH Neonatal Examination Ortolani / Barlow clunk Ortolani Barlow CDH Neonatal Examination Ortolani / Barlow Ortolani Barlow CDH Neonatal Examination Hamstring Stretch Sign • Flex hip and knee 900 each. • Keep hip flexed and gradually extend the knee • Normally a resistance is felt towards the end of knee extension (caused by the hamstrings which are pulled from both ends) • In cases of CDH, no resistance is felt (when the hip is dislocated, the origin of the hamstrings are not pulled by hip flexion) CDH Neonatal Examination Hamstring Stretch Sign CDH Clinical Examination • Neonate (up to 2-3 months) : - Instability/ Ortolani-Barlow - Thomas test • Infant ( > 2-3 months) : - Limited abduction - Shortening ( Galeazzi ) - Hamstring stretch sign • Toddler : - Limited abduction - Shortening ( Galeazzi ) - Hamstring stretch sign • Walking : - Trendelenburgh - Hamstring stretch sign CDH Clinical Examination CDH Clinical Examination CDH Clinical Examination The Walking Child • Trendelenburgh: unilateral / bilateral (waddling) CDH Screening Program • Clinical screening proven to be effective • Performed by Trained personnel • Must be DYNAMIC with periodic examination till walking • Adjunctive use of U/S controversial CDH Ultrasound Screening • Incidence of hip instability declines rapidly to 50 % within the first week of neonatal life • Better to delay U/S screening CDH Ultrasound Screening • Early U/S screening not recommended • Delayed U/S screening : - Older than 6 weeks - Those at risk only - by History Clinical exam CDH Ultrasound Referral • If hip normal : no need • If hip clearly unstable : no need • If suspicious : U/S appropriate • If at risk factors : U/S appropriate CDH Ultrasound • Too sensitive detects a lot of hip anomalies most of which would develop normally • Operator dependant Static Vs Dynamic CDH Radiography • Early infancy : not reliable • By 2-3 months of age : reliable AP view - neutral position - draw reference lines - acetabular index - in early infancy < 30o : normal 30o – 40o : questionable > 40o : abnormal Von Rosen view : 45o abduction CDH Radiography CDH Radiography CDH Radiography CDH Radiography in out in out Von Rosen view CDH Radiography 27o 39o CDH Radiography in out CDH Treatment Aims • Obtain and Maintain concentric reduction • In an Atruamatic fashion • Without disrupting the blood supply CDH Treatment • Method depends on Age • The earlier started, the easier the treatment • The earlier started, the better the results • Should be detected EARLY CDH Treatment • Birth to 6 months : Pavlik harness or hip spica cast • 6 months – 12 months : closed reduction UGA and hip spica casts • 12 months – 18 months : possible closed / possible open reduction • Above 18 months : open reduction and ? Acetabuloplasty • Above 2 years : open reduction,acetabulplasty, and femoral osteotomy • Above 8 years : open reduction,acetabulplasty cutting three bones, and femoral osteotomy CDH Treatment Hip instability in the neonatal period Most resolve spontaneously • Observation • Pavlik harness • Double /triple diapers ?? CDH Treatment Hip instability in the neonatal period Double / Triple Diapers • Often inadequate : therefore inappropriate • Gives illusion patient is in “treatment” while wasting valuable time • Most hip instability improves spontaneously in early infancy , giving this ineffective management credit CDH Treatment Birth – 6 months Hip instability (dislocatable) Established dislocation (reducible) • Should be actively treated until hip is normal clinically and radiographically • Pavlik harness • Hip Spica Cast CDH Treatment Birth 6 months Pavlik harness CDH Treatment Birth – 6 months Other Devices - Frejka pillow - Craig - Von Rosen splint Soft abduction splints: Not good enough Rigid abduction splints: Risk AVN CDH Treatment 6 – 12 months • Initially non operative – closed reduction • Reduction under anesthesia and immobilization in hip spica cast • Position: Human Avoid severe abduction Avoid Frog position • Must be stable and concentrically reduced otherwise needs open reduction Better Picture CDH Treatment 12 – 18 months • Possibly closed reduction !! when hip stable and concentrically reduced • Probably open reduction when hip unstable or not concentrically reduced • Arthrography guided: CDH Treatment Arthrography Closed Reduction Too lateralized Acceptable CDH Treatment Above 18 months • Open reduction ? and acetabulplasty ? And femoral shortening – if high CDH Treatment Above 3 years • Open reduction • And acetabulplasty • And femoral shortening Redirectional Acetabuloplasty Salter’s Add Picture with K wires Pemberton’s Need for a lot of improvement in cover Triple Steel CDH When Not to Treat ?! Bilateral High Posterior Dislocation good function – not painful CDH When Not to Treat ! ‫وخير من بعض الدواء‬ ِ ِ ٌ ُ‫الداء‬ Painful stiff left hip Painful stiff right hip in adduction CDH When Not to Treat ! ‫وخير من بعض الدواء‬ ِ ِ ٌ ُ‫الداء‬ Painful right hip & ankylosed left hip CDH Summary • • • • • Complex multi-factorial, endemic– treatable. Dr’s awareness and health education. Screening programs are needed. Learning proper examination methods. Identify at-risk groups. – repeat examination & imaging. • Efficient referral system. • Proper management in referral centers. ...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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