Pediatric Hip Dysplasia and Dislocation= note

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Questions and Answers

What anatomical structure is MOST affected in acetabular dysplasia?

  • Femoral neck
  • Femoral head
  • Acetabulum (correct)
  • Greater trochanter

Up to what age should you examine a baby to catch late hip dislocations?

  • 6 months
  • 15-24 months (correct)
  • 5 years
  • 3 years

What is the MOST common hip disorder in children?

  • Transient synovitis
  • Legg-Calvé-Perth disease
  • Slipped capital femoral epiphysis
  • Hip dysplasia/dislocation (correct)

Which term is now preferred over "congenital hip dysplasia"?

<p>Developmental hip dysplasia (D)</p>
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Which of the following BEST describes a subluxatable hip?

<p>The hip is in the acetabulum but can be partially dislocated manually. (D)</p>
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In the context of hip dysplasia, what does a 'reducible' hip refer to?

<p>A hip that can be manually moved back into the joint. (D)</p>
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In hip dysplasia, what does 'irreducible' refer to?

<p>A hip that cannot be manually relocated into the acetabulum. (C)</p>
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What is the approximate incidence of hip dysplasia at birth?

<p>1 in 100 births (B)</p>
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Which of the following is TRUE regarding the etiology of hip dysplasia?

<p>The etiology is not definitively known but likely involves a combination of genetic, hormonal, and mechanical factors. (B)</p>
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Which of the following is a known risk factor for developmental dysplasia of the hip (DDH)?

<p>Breech presentation (B)</p>
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What percentage of deliveries are breech?

<p>4% (C)</p>
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How do the quadriceps muscles contribute to hip dysplasia?

<p>They pull the hip upwards and laterally. (A)</p>
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What is the typical ratio of occurrence of hip dysplasia in girls compared to boys?

<p>4:1 (D)</p>
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Following the description of muscle action leading to hip dysplasia, which direction is the hip MOST likely to slip?

<p>Up, out, and laterally (A)</p>
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True or False: It is important to get X-rays to diagnose hip dysplasia.

<p>False (A)</p>
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What is the MOST reliable method for diagnosing hip dysplasia?

<p>Clinical examination (D)</p>
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Which sign is associated with dislocation?

<p>Telescoping sign (B)</p>
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What indicates dislocation based on symmetry of skin folds?

<p>More folds on the affected side indicate dislocation (D)</p>
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What does a positive Ortolani test indicate?

<p>A dislocated hip that is reducible (B)</p>
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What combination of findings are expected in a normal neonate?

<p>Negative Ortolani's, Barlow's, and Palmen's tests (B)</p>
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What is the correct order of maneuvers when examining a neonate for hip dysplasia?

<p>Ortolani's then Barlow's (D)</p>
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When does the abduction test become more reliable?

<p>When the provocative tests become less reliable (B)</p>
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If one or both hips become dislocated at or around birth, a predictable series of changes occur. What is the first change?

<p>The fatty plug (called the pulvinar) which lies within the acetabulum begins to hypertrophy (D)</p>
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What is the term for the finding of a shortened femur in hip dislocation?

<p>Galeazzi's sign (D)</p>
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What does the Hilgenreiner line measure?

<p>Transverse line through the triradiate cartilages (D)</p>
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What is the MOST commonly used treatment modality in the US for hip dysplasia in the neonatal period?

<p>Pavlik harness (D)</p>
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What does the Pavlik Harness do?

<p>Allows the baby's own movements to reduce the dislocation (D)</p>
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Why does extreme abduction increase risk for avascular necrosis in DDH?

<p>It applies pressure to the medial femoral circumflex artery. (A)</p>
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In the von Rosen view, how are the hips positioned during radiography?

<p>Abducted and internally rotated (A)</p>
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Which of the following statements accurately describes Shenton's line in the context of hip radiography?

<p>It is a smooth curve from the obturator foramen to the femoral metaphysis and interruption suggests dislocation. (C)</p>
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Which condition requires fixing the proximal femur?

<p>High inclination angle (A)</p>
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What does the Y-Line measure?

<p>Transverse line through the triradiate cartilages (B)</p>
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A newborn displays a positive Barlow test. What is the MOST appropriate next step in management?

<p>Application of a Pavlik harness (A)</p>
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In the context of DDH, what is the significance of the iliopsoas tendon?

<p>It can become an obstacle to reduction by passing between acetabulum and femoral head. (A)</p>
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A 6-month-old infant presents with limited hip abduction on the left side. Ortolani and Barlow tests are negative. Which of the following is the MOST appropriate next step?

<p>Radiographic evaluation (AP pelvis and frog-leg lateral views). (D)</p>
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A 3-month-old infant is being treated with a Pavlik harness for DDH. At a follow-up appointment, the physician notes persistent hip subluxation on examination and imaging. What is the MOST appropriate next step?

<p>Consider closed reduction with hip spica casting. (D)</p>
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A 1-year-old child presents with a painless limp. Radiographs reveal unilateral hip dislocation with a shallow acetabulum and femoral head ossification delay. What is the MOST appropriate management strategy?

<p>Open reduction with femoral shortening Osteotomy (B)</p>
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Which of the following accurately reflects the impact of age on treatment outcomes of developmental dysplasia of the hip (DDH)?

<p>Earlier treatment is associated with better outcomes, with success inversely related to age. (B)</p>
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Hip dysplasia and dislocation are uncommon in children.

<p>False (B)</p>
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What term is used to describe hips that are unstable and manually dislocatable?

<p>Dislocatable</p>
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A femoral head that is out and NOT able to be reduced is considered ______.

<p>irreducible</p>
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Match the following hip conditions with their descriptions:

<p>Acetabular Dysplasia = Shallow acetabulum that cannot appropriately contain the femoral head. Subluxed Hip = Partial hip dislocation. Dislocatable Hip = Unstable hips that are manually dislocatable. Reducible Hip = Femoral heads are out but can be reduced by maneuvers.</p>
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Which of the following is NOT a risk factor for developmental dysplasia of the hip (DDH)?

<p>Being male (B)</p>
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Breech presentation increases the risk of hip dysplasia due to the in utero position.

<p>True (A)</p>
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In breech presentations, what position are the knees and hips typically in, predisposing the infant to hip dysplasia?

<p>Knees hyperextended, hips hyperextended (D)</p>
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The typical in-utero position of knees and hips is ______, with feet crossed and around the buttocks.

<p>flexion</p>
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Which muscle group contributes to upward, outward, and lateral slipping of the hip due to contracture in hip flexion?

<p>Quadriceps musculature (A)</p>
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In the context of hip dysplasia, relying solely on X-rays is preferable to clinical examination due to its higher accuracy.

<p>False (B)</p>
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Which clinical finding is MOST reliable for indicating hip dislocation in infants?

<p>Asymmetry of hip abduction (D)</p>
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What is the name of the sign used to describe the ability to displace a mobile proximal femur in a dislocated hip?

<p>Telescoping sign</p>
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A positive Ortolani's test indicates a dislocated hip that is ______.

<p>reducible</p>
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A normal neonate should have positive Ortolani's, Barlow's, and Palmen's tests.

<p>False (B)</p>
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After 8 weeks of age, which test becomes more reliable than provocative tests like Ortolani and Barlow for assessing hip stability?

<p>Abduction test (C)</p>
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What is the fatty plug that impedes the relocation of the femoral head within the acetabulum called?

<p>Pulvinar (C)</p>
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What is the name of the line used as reference for Perkin's line and measurement of the acetabular angle?

<p>Y-line</p>
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In the context of a von Rosen view X-ray, the AP of the pelvis is taken while the examiner internally rotates the hips ______ degrees.

<p>25</p>
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Flashcards

Early Hip Dysplasia Treatment

Early treatment of hip dysplasia is typically successful.

Unstable pediatric hip

Problems in the acetabulum; continuum where mild=undetectable to severe=dislocated.

Subluxatable Hip

The femoral head can be manually pushed into partial dislocation but returns to its original position when pressure is released.

Dislocatable Hip

Unstable hips that can be manually dislocated using maneuvers like Barlow's test.

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Irreducible Dislocation

Femoral head cannot be reduced.

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Etiology of Hip Dysplasia

Females, genetic factors, hormonal influences, and mechanical factors (e.g., breech position).

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Breech Presentation Risk

Flexion of knees and hips with feet crossed around the buttocks is normal and safe. Breech positions with hyperextended knees and hyperflexed hips increase risk.

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Effect of Hip Flexion Muscles

Quadriceps, iliopsoas, hamstrings, and adductors pull the hip up, out, and laterally when flexed.

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Gender and Laterality

DDH is more common amongst females (4:1) and unilateral left hip is more common.

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Associated Conditions

Clubfoot (talipes equinovarus), equinus of ankle, and varus of TN

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Family History Risk

2x-3x increased risk in families, particularly in females, so pay more attention to hip dysplasia in female infants with a family history.

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Teratologic Form DDH

In the late 1st to 2nd trimester typically due to abnormal joint formation and muscle movement.

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Typical or Idiopathic DDH

More common hip dysplasia, diagnosed perinatally or later.

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Symmetry in Skin Folds

Affected side shows more skin folds indicating a shift.

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Femoral Head Position

The femoral head drops down and posterior causing the limb to shorten.

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Telescoping Sign

Done to identify a dislocated mobile proximal femur.

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Ortolani's Test

Always superior and posterior dislocated. (+) indicates a clunk when abducting and lifting.

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Barlow's Test

Provocative test. (+) indicates being able to dislocate the hip by adducting and pushing down.

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Normal Neonate Tests

A normal neonate should have negative Ortolani's, Barlow's, and Palmen's tests

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Barlow's Precedence

If Barlow's was done first with a dislocation, the Ortolani test will be negative.

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Abduction Test

Decreased abduction on the affected side

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Changes After Dislocation

Decreased likelihood of relocation, especially after six weeks.

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Iliopsoas position

Iliopsoas tendon passes anterior to the interval between the acetabulum and displaced femoral head.

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Galeazzi's Sign

Identifies a shortened femur in hip dislocation.

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Trendelenburg Sign

Standing on dislocated limb will cause the pelvis to drop on the unaffected side.

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Pseudoacetabulum on XR

Hips have been out for a long time-sign of long standing dislocations.

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Von Rosen View

AP of the pelvis with the baby supine abducting the hips.

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Hilgenreiner line (Y line)

Horizontal line that passes through the triadiate cartilages.

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Acetabular Index

Tells how deep or shallow the acetabulum is

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Perkin's Line

Line from lateral most portion of ossified acetabulum that divides the acetabulum into quadrants.

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Shenton's Line

Continuous curve from obturator foramen to metaphysis.

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Size of Femoral Ossific Nucleus

Hip dysplasia/dislocation of the hip causes delay in endochondral ossification

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Syndromic Association with Hip Dysplasia

Synonymous with Caudal regression

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Vertical Talus

Ankle in max equinus, heel is down but foot is not.

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Spasticity

Increased tone, ankle clonus, increased reflexivity.

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Complications of Surgical tx

Avascular necrosis of the femoral head

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Neonatal period

Pavlik Harness --> GOLD STANDARD

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Pavlik Harness position

Keeps the hips flexed at about 110°-115° and prevents adduction

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Avascular necrosis

Can apply pressure to medial femoral circumflex aa

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Structures Preventing Reduction

Inverted limbus, pulvinar, ligamentum teres femoris

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Hip Dysplasia/Dislocation Prevalence

Hip dysplasia and dislocation are the most common hip disorder in children.

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Developmental Hip Dysplasia

Modern terms for describing hip instability, focusing on the dynamic and progressive nature of the condition.

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Incidence of Dysplasia

Occurs in 0.5%-1% of births but few proceed to dislocation.

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Symmetry in Motion

An exam looking for symmetrical abduction in flexion, active and passive motion, limitations imply hip issues.

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Order of Exam Maneuvers

Assess for dislocation, subluxation, or stability following reduction to guide the treatment.

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Provocative Test Limitations

Reliability of provocative tests decline, re-examine at 6 weeks if risk factors are present.

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Iliac Angle

More ossified portion of Ala of ilium to triradiate cartilage.

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Hilgenreiner Line

Used in 4-6 month olds. A line that is good for diagnosing this age group.

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Study Notes

New Information: Case Studies

  • Overview of specific patient cases related to hip dysplasia and dislocation.

Patient #1

  • A 4-year-old female.
  • X-ray shows the femoral head is out of place.
  • A false acetabulum developed because the femoral head was out of place for an extended period.
  • The problem involves fixing the proximal femur to reduce the high inclination angle and performing an osteotomy of the pelvis.
  • A significant problem is with the osteotomy of the pelvis; dropping the acetabulum down can lead to good superior coverage but poor posterior coverage, resulting in a risk of falling out..
  • It was necessary to shorten the femur to get the femoral head into the acetabulum.

Patient #2

  • The chief complaint is flat feet.
  • X-ray shows the right femoral head is out of place.
  • Dislocation occurred a long time ago, either congenitally or around age 1.
  • Pelvic osteotomy is required to reduce the acetabular index.
  • Examination reveals possible Trendelenburg sign due to weakness, a negative Gower sign, and full symmetrical abduction

Patient #3

  • A boy with Down syndrome.
  • Collagen is poor, resulting in very lax/loose joints.
  • Palmen, telescoping, and Barlows tests are positive (+).
  • The left hip is dysplastic.
  • Down syndrome often involves a small angle of inclination, resulting in limited posterior coverage, increasing the risk of posterior dislocation.
  • He requires an osteotomy.

Patient #4

  • A 9-year-old female.
  • Cavus foot with left hip pain.
  • Family history of Charcot-Marie-Tooth disease.
  • Hip dysplasia/dislocation occurs in about 20% of the population with CMT.
  • All CMT patients get a screening hip x-ray for hip dysplasia and dislocation.
  • Lateral instability is present.
  • She has genu valgum, which shows no correlation with coxa varum.
  • She has a subluxed left hip and a possible right hip subluxation.

Patient #5

  • Older girl
  • Subluxed R hip
  • Acetabulum is dysplastic on L and subluxed on R

Patient #6

  • If false acetabulum, it means the hip has been out a long time
  • Hips are out, acetabulum is low, and the femoral head is high→ false acetabulum is very deep-been out a long time therefore teratological dislocation (something is wrong w/ the muscle)
  • L hip dislocated

Patient #7

  • 9 mo old female
  • Asymmetry of the ossific nucleus.
  • The hip is out, dislocated, and has been so for a long time.
  • Abduction x-ray shows:
    • Left side dislocation
    • Decreased abduction
    • Shallow acetabulum
    • Pseudoacetabulum
    • A line from the metaphysis does not enter the triradiate cartilage

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