Developmental Dysplasia of the Hip (DDH) PDF

# Common pediatric problumes ## Pr.Dr Elsayed Mohamady M. ## Prof. of orthopedic surgery ## Benha University # Developmental Dysplasia of the Hip (DDH) ## ANATOMY OF HIP JOINT - It is a multiaxial ball and socket joint designed for stability and weight bearing. - Movements at the joint include fl...

# Common pediatric problumes ## Pr.Dr Elsayed Mohamady M. ## Prof. of orthopedic surgery ## Benha University # Developmental Dysplasia of the Hip (DDH) ## ANATOMY OF HIP JOINT - It is a multiaxial ball and socket joint designed for stability and weight bearing. - Movements at the joint include flexion, extension, abduction, adduction, medial and lateral rotation, and circumduction. ## ARTICULAR SURFACES: - Head of femur articulates with acetabulum of hip bone to form hip joint. - Head of femur- more than 1½ a sphere, covered with hyaline cartilage. - Acetabulum- lunate shape -notch & fossa. - Except for the fovea, the head of the femur is also covered by hyaline cartilage. A diagram of the Hip Joint is shown, with the following parts labelled: - Synovial Fluid - Ligament and Joint Capsule - Articular Cartilage - Femoral Head - Synovial Membrane - Femur The same diagram is also shown with the following labels: - Acetabular labrum - Acetabular fossa - Lunate surface - Acetabular foramen - Obturator foramen - Transverse acetabular ligament - Pubis - Acetabular branch of obturator artery - Artery of ligament of head - Ligament of the femoral head - Obturator membrane - Ischial tuberosity - Synovial sleeve around ligament - Cut synovial membrane ## STABILITY OF HIP JOINT - Depth of acetabulum - Tension and strength of ligaments & surrounding muscles - Length & obliquity of the neck of femur - High degree of stability & mobility ## DDH - DDH is defined as partial or complete displacement of the femoral head from the acetabular cavity since birth. - It comprises a spectrum of disorders including acetabular dysplasia without displacement, subluxation and dislocation. - Incidence: Females affected 7 times more. - The left hip is more often affected than the right, B/L involvement in 1 in 5 cases. ## Theories of Etiology - GENETIC- hereditary predisposition- generalized joint laxity and shallow acetabula - HORMONAL – common in females, maternal relaxin, high E & P levels - aggravate laxity - INTRAUTERINE MALPOSITION: extended breech favour D/L- "packaging d/o" - POST NATAL FACTORS: uncommon in Asia and India ## CLINICAL FEATURES - Detected at birth or soon after when child starts walking. - Birth -Routine screening for suggestive signs in every newborns especially those at high risk. - Early childhood- Asymmetry of groin fold, click, limitation of movement. - Older child- peculiar gait, no pain. ## CLINICAL TESTS For infants: - Look for asymmerty of groin crease, limitation of movt or audible click. - Special tests include Barlow's and Ortolani's. <start_of_image> えい: - To assess DDH in neonate. - The Barlow maneuver identifes the unstable hip that is in a reduced position that the clinician can passively dislocate. - Here the hip is started reduced and the test will dislocate the hip. A diagram of the Barlow's Test is shown, with the following captions: - The examiner will flex the hip and knees to 90 degrees. - Mild pressure is then placed on the knee while directing the force posteriorly. - The maneuver is performed by bringing the thigh toward the midline (adducting the hip). - The femoral head will be pushed out of the socket. ## Ortolani Test - Ortolani maneuver is performed following Barlow's test to determine if the hip is actually dislocated. - Here the hip is started dislocated and the test will reduce the hip. A diagram of the Ortolani Test is shown, with the following captions: - The Ortolani test is performed by the examiner flexing the hips and knees to 90 degrees. - Pushing the thigh anterior. - Reduction is done by abduction of the hip and pushing the thigh anteriorly. - Reduction is done by abduction of the hip and pushing the thigh anterioly. - The test is positive if a palpable audible clunk is heard from the hip being reduced. ## For Older Child: - Limitation of hip abduction, limb short & ext rotated. - Higher buttock fold, asymmetrical thigh fold, lordosis of the lumbar spine. - Galeazzi's sign: Hips flexed to 70°,knees flexed-compare level -lowering on affected side. - Ortolani's may be +ve. - Trendelenberg's Test is +ve. - U/L D/L -trendelenberg gait. - B/L D/L- waddling gait. A diagram of a child with the following labels is shown: - Downward tilt of the pelvis on affected side - Positive Trendelenburg Gait - Apparent Short Femur - Unequal Knee Height - Positive Galeazzi Sign ## INVESTIGATIONS ### Radiological Imaging - Ultrasonography has replaced radiography for imaging hips in the newborn. Sequential assessment allows monitoring of the hip during a period of splintage. - Plain X-rays: X-ray examination is more useful after the first 6 months, and assessment is helped by drawing lines on the x-ray. ## X-ray findings: - Delayed appearance of ossification center of head of femur. - Retarded development of ossification center. - Sloping acetabulum. - Lateral and upward displacement of ossification centre of femoral head. - A break in Shenton's line. Several x-ray images are shown, with the following labels indicated: - Perkins Line - UO - UI - LO - LI - Hilginreiner's line - Perkins line - Shenton's line Another x-ray image is shown with the following labels: - Normal - CDH - Acetabular Index - Hilgenreiner Line - Shenton Line - rkins Line - Disrupted Shenton Line - Perkins Line The final two x-ray images are shown with the following labels: - 36уг - 11/04 - (a) - 43 Tr - 6/01 - (b) - 20° - 45° ## MANAGEMENT OF DDH - Aim is to achieve reduction of the head into the acetabulum and maintain it until the hip becomes clinically stable and a "round" acetabulum covers the head. - Most cases closed reduction possible, else open reduction done. ## Birth to 6m: Where facilities for ultrasound scanning are available, all newborn infants at risk are examined by USG. 1. If hip is reduced and has a normal cartilaginous outline, no treatment is required, observe for 3-6m. 2. If acetabular dysplasia or hip instability, the hip is splinted in a position of flexion and abduction and USG done at intervals. ## Splintage - Splintage The object of splintage is to hold the hips somewhat flexed and abducted maintainence of reduction). - Von Rosen's splint is an H-shaped splint. - The Pavlik harness is more difficult to apply but gives the child more freedom while still maintaining position. 3 golden rules of splintage are: - the hip must be properly reduced before it is splinted; - extreme positions must be avoided; - the hips should be able to move. Four images are shown: - Two images of babies in various splints. - Two x-ray images of a child in different positions after treatment. ## If ultrasound is not available: nurse them in double napkins or an abduction pillow for the first 6 weeks and observe for first 6m for devpt of acetabular roof. ## Persistent Dislocation : 6-18m - The hip must be reduced – preferably by closed methods but if necessary by operation – and held reduced until acetabular development is satisfactory. - Closed reduction : suitable after 3m and is performed under G/A with an arthrogram to confirm a concentric reduction. - Failure to achieve concentric reduction should lead to abandoning this method in favour of an operative approach at approximately 1 year of age. ## Splintage - Held in a plaster spica at 60 degrees of flexion, 40 degrees of abduction and 20 degrees of internal rotation. - After 6 weeks the spica is changed & stability assessed. - If satisfactory, spica retained for 6w, then abduction splint for 6m. - If concentric reduction is not achieved, open operation is done. ## The psoas tendon is divided; obstructing tissues are removed and the hip is reduced. - It is usually stable in 60 degrees of flexion, 40 degrees of abduction and 20 degrees of internal rotation. A spica is applied and the hip is splinted. ## Persistent Dislocation 18m to 4y: - In older children, arthrography and OR preffered over CR. - Traction: help to loosen the tissues and bring the femoral head down opposite the acetabulum. - Arthrography: anatomy of hip, degree of acetabular dysplasia. - Acetabular reconstruction procedures- If there is marked acetabular dysplasia, either a. - Pericapsular reconstruction of the acetabular roof (Pemberton's operation). - An innominate (Salter) osteotomy. ## Salter's osteotomy Osteotomy of iliac bone, so that acetabulum becomes more horizontal and covers the head. ## Chiari's Osteotomy: Iliac bone transversly divided avobe acetabulum & medially displaced for additional depth. ## Pemberton's osteotomy: The roof is deflected over the femoral head. A diagram of the three types of osteotomies is shown: - Salter's osteotomy - Chiari's osteotomy - Pemberton's osteotomy - Normal ## Splintage - After operation, the hip is held in a plaster spica for 3 months and then left unsupported. ## D/L in children >4yr: - U/L D/L in the child over 8 years often leaves the child with a mobile hip and little pain. This justifies non-intervention, though the child must accept the fact that gait is distinctly abnormal. - B/L D/L the deformity -waddling gait – is symmetrical and therefore not so noticeable; - Operation avoided unless the hip is painful or deformity unusually severe. ## COMPLICATIONS - Failed reduction: The acetabulum remains undeveloped, the femoral head may be deformed, the neck is usually anteverted and the capsule is thickened and adherent. - AVN: ischaemia of the immature femoral head. It may occur at any age and any stage of treatment and is probably due to vascular injury or obstruction d/t forceful reduction and hip splintage in abduction. ## To avoid AVN - Traction should be gentle and in the neutral position; - Soft-tissue release (adductor tenotomy) should precede closed reduction; - If difficulty is anticipated open reduction is preferable. ## Persistent D/L in Adults: - If disability is severe enough - total joint replacement. # THANK YOU