2. hip

4. HISTORY Pain arising in the hip joint is felt in the groin, down the front of the thigh and, sometimes, in the knee; occasionally knee pain is the only symptom. Pain arising in the hip joint is felt in the groin, down the front of the thigh and, sometimes, in the knee; occasionally knee pain is the only symptom. Pain at the back of the hip is seldom from the joint: it usually derives from the lumbar spine. Pain at the back of the hip is seldom from the joint: it usually derives from the lumbar spine.

5. HISTORY Stiffness may cause difficulty with putting on socks sitting in a low chair. Stiffness may cause difficulty with putting on socks sitting in a low chair.

6. HISTORY Limp is common, and sometimes the patient complains that the leg is 'getting shorter'. Limp is common, and sometimes the patient complains that the leg is 'getting shorter'. walking distance may be curtailed or, reluctantly. the patient starts using a walking stick. walking distance may be curtailed or, reluctantly. the patient starts using a walking stick.

7. CLINICAL EXAMINATION

8. SIGNS WITH THE PATIENT UPRIGHT The gait is noted. The gait is noted. Antalgic gait. Or shortening (short-leg limp) or to Abductor weakness (Trendelenburg Lurch).

9. Friedrich Trendelenburg

10. The Trendelenburg test The patient is asked to stand, unassisted, on each leg in turn; while standing on one leg, he or she has to lift the other leg by bending the knee The patient is asked to stand, unassisted, on each leg in turn; while standing on one leg, he or she has to lift the other leg by bending the knee

11. Normally Normally the weight-bearing hip is held stable by the abductors and the pelvis rises on the unsupported side. the weight-bearing hip is held stable by the abductors and the pelvis rises on the unsupported side.

12. if the hip is unstable, or very painful, the pelvis drops on the unsupported side. if the hip is unstable, or very painful, the pelvis drops on the unsupported side.

13. is found in Dislocation or subluxation of the hip. Dislocation or subluxation of the hip. Weakness of the abductors. Weakness of the abductors. Shortening of the femoral neck. Shortening of the femoral neck. Painful disorder of the hip. Painful disorder of the hip. A positive Trendelenburg test

14. SIGNS WITH THE PATIENT LYING SUPINE

15. Look if one leg seems to be shorter than the other. be shorter than the other. Look for scars or sinuses, Look for scars or sinuses, swelling or wasting and any obvious deformity or swelling or wasting and any obvious deformity or malposition of one of the limbs. malposition of one of the limbs. (In babies) Asymmetry of skin creases may be important. Asymmetry of skin creases may be important.

17. Feel Bone Contour are felt when leveling the pelvis and judging the height of the greater trochanters. Bone Contour are felt when leveling the pelvis and judging the height of the greater trochanters.

18. Move The assessment of hip movements is difficult because any limitation can easily be obscured by movement of the pelvis. The assessment of hip movements is difficult because any limitation can easily be obscured by movement of the pelvis.

19. Hip Range of Motion FLEXION FLEXION

20. EXTENSION

21. Internal Rotation Internal Rotation

22. External Rotation

23. Adduction

24. Abduction

25. SIGNS WITH THE PATIENT LYING PRONE

26. THE DIAGNOSTIC CALENDAR Hip disorders are characteristically seen in certain well-defined age groups. Hip disorders are characteristically seen in certain well-defined age groups.

27. Age of onset Age years Age years birth birth 10-20 10-20 0-5 0-5 5-10 5-10 Adults Adults Probable diagnosis Developmental dysplasia. Infections. Perthes' disease. Slipped epiphysis. Arthritis.

29. Historical review FOR DDH

30. Dupuytren – Paris (1800’s) Dissected DDH specimens. Dissected DDH specimens. he did not think condition could be treated. he did not think condition could be treated.

31. Paletta – Milan – 1820 First anatomic description of congenitally dislocated hip First anatomic description of congenitally dislocated hip (15 day old boy –Bilateral DDH).

32. Diagnosing DDH Early La Damanay – Rennes – 1908. La Damanay – Rennes – 1908.

33. Ortolani – Italy – 1937.

34. Normal Growth and Development Embryologically the acetabulum, femoral head develop from the same primitive mesenchymal cells cleft develops in precartilaginous cells at 7th week and this defines both structures 11wk hip joint fully formed. Embryologically the acetabulum, femoral head develop from the same primitive mesenchymal cells cleft develops in precartilaginous cells at 7th week and this defines both structures 11wk hip joint fully formed.

35. femoral head deeply seated in acetabulum by surface tension of synovial fluid and very difficult to dislocate. femoral head deeply seated in acetabulum by surface tension of synovial fluid and very difficult to dislocate. in DDH this shape and tension is abnormal in addition to capsular laxity. in DDH this shape and tension is abnormal in addition to capsular laxity.

37. The condition formerly known as congenital dislocation of the hip and now called developmental dysplasia of the hip ( DDH ). The condition formerly known as congenital dislocation of the hip and now called developmental dysplasia of the hip ( DDH ).WHY?

38. Frank dislocation during the neonatal period; Subluxation (partial displacement) Frank dislocation during the neonatal period; Subluxation (partial displacement) Shallow acetabulum (acetabular dysplasia) without actual displacement. dislocatable.dislocation. DDH Comprises a spectrum of disorders :

39. Incidence of neonatal hip

40. instability is 5-20 per 1000 live births. instability is 5-20 per 1000 live births. however, most of these hips stabilize spontaneously. Re-examination 3 weeks after birth the incidence of instability is only 1 or 2 per 1000 infants. Re-examination 3 weeks after birth the incidence of instability is only 1 or 2 per 1000 infants.

41. Girls are much more commonly affected than boys, The ratio being about 7: l. Girls are much more commonly affected than boys, The ratio being about 7: l. The left hip is more often affected than the right. The left hip is more often affected than the right. in 1 in 5 cases the condition is bilateral in 1 in 5 cases the condition is bilateral

42. Risk Factors

43. 80% Female 80% Female First born children First born children Family history Family history 6% one affected child. 12% one affected parent. 12% one affected parent. 36% one child + one parent) 36% one child + one parent)

44. Oligohydramnios.

45. Breech (sustained hamstring forces). Breech (sustained hamstring forces).

46. Swaddling cultures.

48. Left 60 % (left occiput ant), Left 60 % (left occiput ant), Right 20%. both 20%

49. Torticollis

51. Or foot deformity

52. Aetiology and pathogenesis

53. Genetic factors Genetic factors must be important, for DDH tends to run in families and even in entire populations (e. g, along the northern. must be important, for DDH tends to run in families and even in entire populations (e. g, along the northern.

54. Hormonal changes in late pregnancy may aggravate ligamentous laxity in the infant. in late pregnancy may aggravate ligamentous laxity in the infant.

55. Intrauterine malposition especially a breech position with extended legs, would favor dislocation. especially a breech position with extended legs, would favor dislocation.

56. Postnatal factors Postnatal factors play a particular in maintaining any tendency to instability.

57. Clinical features

58. The ideal, still unrealized, is to diagnose every case at birth. The ideal, still unrealized, is to diagnose every case at birth. When there is a family history of congenital dislocation, and with breech presentations (presence of risk factors). When there is a family history of congenital dislocation, and with breech presentations (presence of risk factors). For this reason, every newborn child should be examined for signs of hip instability. For this reason, every newborn child should be examined for signs of hip instability.

59. Neonatal diagnosis

60. There are several ways of testing for instability. There are several ways of testing for instability. Ortolani’s test Ortolani’s test

61. the baby's thighs are held with the thumbs medially and the fingers resting on the greater trochanters; the baby's thighs are held with the thumbs medially and the fingers resting on the greater trochanters; the hips are flexed to 90 degrees and gently abducted. the hips are flexed to 90 degrees and gently abducted. Normally there is smooth abduction to almost 90 degrees. Normally there is smooth abduction to almost 90 degrees.

63. Barlow's test

64. In DDH the movement is usually impeded, but if pressure is applied to the greater trochanter. In DDH the movement is usually impeded, but if pressure is applied to the greater trochanter. there is a soft 'clunk' as the dislocation reduces, and then the hip abducts fully (the 'jerk of entry'). there is a soft 'clunk' as the dislocation reduces, and then the hip abducts fully (the 'jerk of entry').

65. Barlow ’ s Provocative test

66. Performed in a similar manner but here the examiner's thumb is placed in the groin and, by grasping the upper thigh, an attempt is made to lever the femoral head in and out of the acetabulum during abduction and adduction.

68. If the femoral head normally in the reduced position, can be made to slip out of the socket and back in again. If the femoral head normally in the reduced position, can be made to slip out of the socket and back in again. the hip is classed as 'dislocatable' (i.e. unstable). the hip is classed as 'dislocatable' (i.e. unstable).

69. INVESTIGATIONS IN EARLY INFANCY

70. Every hip with signs of instability – however slight - should be examined by ultrasonography. Every hip with signs of instability – however slight - should be examined by ultrasonography. This provides a dynamic assessment of the shape of the cartilaginous socket and the position of the femoral head This provides a dynamic assessment of the shape of the cartilaginous socket and the position of the femoral head

75. Late features

76. Ideally, all children should be examined again at 6 months. Ideally, all children should be examined again at 6 months. 12 months. 12 months. and 18 months of age, so as to be sure that late-appearing signs of DDH are not missed.

77. With unilateral dislocation. With unilateral dislocation. are asymmetrical creases. are asymmetrical creases. the hip does not abduct fully. the hip does not abduct fully. the leg is slightly short and rotated internally. the leg is slightly short and rotated internally.

78. Galleazi sign flex both hips and one side shows apparent femoral shortening Galleazi sign flex both hips and one side shows apparent femoral shortening

79. Bilateral dislocation is more difficult to detect because there is no asymmetry and the characteristic waddling gait may be mistaken. Bilateral dislocation is more difficult to detect because there is no asymmetry and the characteristic waddling gait may be mistaken.

80. Perineal gap is abnormally wide and abduction is limited.

81. hyperlordosis in bilateral cases

82. Investigations in late DDH For diagnosis

83. X-ray examination is helpful in older children. is helpful in older children. The ossific centre of the femoral head is underdeveloped, and from its position it may be apparent that the head is displaced upwards and outwards The ossific centre of the femoral head is underdeveloped, and from its position it may be apparent that the head is displaced upwards and outwards

84. Plain Radiographs Hilgengreiner’s line is across the triradiate cartilage. Hilgengreiner’s line is across the triradiate cartilage. Perkins line is vertical along the lateral border of the acetabulum. Perkins line is vertical along the lateral border of the acetabulum. Shenton’s line. Shenton’s line.

86. Acetabular index is the angle between the acetabulum and hilgenreiner’s line Acetabular index is the angle between the acetabulum and hilgenreiner’s line It should be less than 30 degrees in a newborn It should be less than 30 degrees in a newborn

87. X-ray findings Delayed appearance of ossific nucleus Delayed appearance of ossific nucleus Small ossific nucleus Small ossific nucleus Dysplastic acetabulum Dysplastic acetabulum Proximal Proximal displacement of femur The Limping Child: Age 1 – 3 DDH

88. TREATMENT

89. Treatment under 6 months of age The simplest and safest policy is to regard all infants with a positive Ortolanis or Barlow test as DDH. The simplest and safest policy is to regard all infants with a positive Ortolanis or Barlow test as DDH. SO SO

90. Nurse them in double napkins. Nurse them in double napkins. or with an abduction pillow between the legs for the first 6 weeks. or with an abduction pillow between the legs for the first 6 weeks.

91. those with persistent instability are treated by more formal abduction splintage until the hip is stable. those with persistent instability are treated by more formal abduction splintage until the hip is stable. and x-ray shows that the Acetabular roof is developing satisfactorily (usually 3-6 months). and x-ray shows that the Acetabular roof is developing satisfactorily (usually 3-6 months).

92. Splintage

93. Arnold Pavlik 1902-1962

94. Pavlik ’ s Father – Harness Maker

95. Pavlik and his Harness 1946 –Pavlik introduces his leather harness : Czech Ortho Society, Prague 1946 –Pavlik introduces his leather harness : Czech Ortho Society, Prague

96. Modern Day Pavlik – San Diego

97. Treatment of persistent dislocation; 6 months to 6 years

98. If, after early treatment, the hip is still incompletely reduced, If, after early treatment, the hip is still incompletely reduced, or if the child presents late with a 'missed' dislocation, or if the child presents late with a 'missed' dislocation, the hip must be reduced and held reduced until acetabular development is satisfactory this done by the hip must be reduced and held reduced until acetabular development is satisfactory this done by

99. Closed reduction

100. Manipulation under anaesthesia carries a high risk of femoral head necrosis. Manipulation under anaesthesia carries a high risk of femoral head necrosis. To minimize this risk. To minimize this risk. reduction must be gradual traction is applied to both legs, preferably on a vertical frame, and abduction is gradually increased until, by 3 weeks by gallows traction, reduction must be gradual traction is applied to both legs, preferably on a vertical frame, and abduction is gradually increased until, by 3 weeks by gallows traction,

102. to over come. to over come.

103. A vascular necrosis

104. Then

105. Splintage

106. If concentrically reduced, the hips (both) are held in a plaster spica at 60 degrees of flexion, 40 degrees of abduction and 20 degrees of internal rotation. If concentrically reduced, the hips (both) are held in a plaster spica at 60 degrees of flexion, 40 degrees of abduction and 20 degrees of internal rotation. After 6 weeks, the plaster is replaced by a splint that prevents adduction but allows movement. After 6 weeks, the plaster is replaced by a splint that prevents adduction but allows movement.

109. If FAILED

110. Open reduction at any stage, concentric reduction has not been achieved by conservative methods. at any stage, concentric reduction has not been achieved by conservative methods.

111. open operation is needed.

112. Treatment after the age of 6 years

113. For unilateral dislocation

114. operative reduction is still feasible. operative reduction is still feasible. it may be necessary to combine this with corrective osteotomy of the femur or innominate osteotomy of the pelvis. it may be necessary to combine this with corrective osteotomy of the femur or innominate osteotomy of the pelvis.

118. With bilateral dislocation

119. the deformity is symmetrical and therefore less noticeable; Therefore, most surgeons avoid operation unless pain or deformity is unusually severe. the deformity is symmetrical and therefore less noticeable; Therefore, most surgeons avoid operation unless pain or deformity is unusually severe.

120. ALGORITHM FOR TREATMENT OF DDH

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