Congenital Hip Dysplasia PDF

3. CONGENITAL DYSPLASIA OF HIP JOINT - Hip Joint = Ball (femur head) and Socket (acetabulum – combo of 3 pelvic bones – ischium, ileum, pubis ) joint o Normally acetabulum develops perfectly around femur head - In the acetabulum there is a fossa where lig. Teres originates...

3. CONGENITAL DYSPLASIA OF HIP JOINT - Hip Joint = Ball (femur head) and Socket (acetabulum – combo of 3 pelvic bones – ischium, ileum, pubis ) joint o Normally acetabulum develops perfectly around femur head - In the acetabulum there is a fossa where lig. Teres originates and connects with Fovea capitis (on head of femur) and keeps the joint in place. - Also in the acetabulum there is a rim of cartilage = acetabular labrum and underneath it is the transverse ligament which fills in a notch of empty space. - There is a surrounding joint capsule (made up of 3 main ligaments = ileofemoral, pubofemoral, ischiofemoral ligs.)→ keeping femur in place as we walk and run - When the femur is not in the acetabulum, there is hypertrophy of Lig teres, acetabular labrum, transverse ligament making the acetabulum more ‘shallow’ and a poor fit for the femur head→ Subluxation or complete dislocation. - This condition is seen more commonly in girls and in 1st pregnancies of women as uterus is not able to dilate as much. ETIOPATHOGENESIS – Making Harmful Paragraphs generally lacklustre. 1. MECHANICAL THEORY- increased force on fetal thigh due to shortage of amniotic fluid in womb (uterine cavity is less expanded) along with sciatic position (pelvic joints bent proximally and knee-joints spread) lead to luxatio 2. HARMFUL FACTORS- IR, toxic substances, medication, avitaminosis, endocrine disease, metabolic and feeding disorders, infection, premature birth during pregnancy 3. PARALYTIC THEORY - adductor stronger then > abductor tone 4. GENETIC THEORY – affected parents are 10x more likely to have children with the same issue 5. LAX (LOOSE) JOINTS – more common in girls for hormonal reasons; runs in families PATHOANATOMY - JULIUS WOLF LAW– bone will adapt to pressure placed upon it and needs it for correct development of joint. Wrong pressure, e.g. increased, leads to increased trabeculation internally and increase cortical thickness externally; vice versa with lack of use or stress 1) LIGHT DYSPLASIA FORM – shallow acetabulum, light form of hypoplasia and ectopy of kernel of hip bone, valgus in neck-diaphyseal angle 2) SUBLUXATION – head of femur at edge of acetabulum (partially outside acetabulum) 3) LUXATION – The head of the femur is completely outside the acetabulum (Dislocation), in contact with iliac bone. o Joint capsule becomes like hourglass, narrowest part is obliterated forming a isthmus→ 2 cavities, one around the luxated head and another in gap left in acetabulum o The head of femur on ipsilateral side is smaller, resulting in muscular compensatory changes, due to difference in distance between places where muscles catch→ Hypotrophied muscles ▪ Changes become stronger as child starts to walk o “Neocotil” formation due luxation→ luxated head presses and forming new acetabulum o Types of Luxations ▪ Luxatio coxae iliaca ▪ Luxatio coxae supracotyloidea ▪ Luxatio coxae cotyloidea o Pelvic joint develops contractures DIAGNOSIS - Peter- Bade Symptom→ Asymmetrical folds of the hip skin→ either unilateral or bilateral - 1) Barlow’s Test- The legs are flexed at the hip and knee joints and then abducted, this creates clicks → out of joint. - 2) Ortolani Symptom- “leaping syndrome” → Newborn is put supine, hips at 90 and leg at 90-100. Gentle abduction→ feel “fitting click”; head drops out of acetabulum “dislocation click” - Palmen’s Test- used to test an “unstable subluxating joint” in newborn ~10 days old → done like barlow test but performed with greater adduction and extension and when pressing along longitudinal axis of hip it does not fully leave the acetabulum → it stretches the elastic capsule of joint and so you feel a “telescopic” springing and sliding movement without a click; and when releasing the head fits into the acetabulum without a click - Thomas’ Test- for diagnosing luxaio up to 2-3months of age → looks for flexional contracture of the pelvic joint. Pelvic bone is passively flexed until the hip reaches stomach and the spine is pressed on the table. Normally contracted m.iliopsoas of other joint is stretched and causes hip to lift 15-20, however luxated joint will not lift - Restricted abduction- Legs are flexed at the knee and pelvic joint 90 and abducted → normally knees should touch table board; abnormal- abduction with adductors stretched like string - Nelaton- Ombredane’s Measure- shows shortening more clearly → Child lies on back with symmetrically bent pelvic and knee joints at 90 → ruler placed on the knees → drops to the side affected - Savaruids measure- child goes from lying to sitting with knees stretched → ruler placed on heels to visual difference  - Loose joints- demonstrated by larger internal rotation of the dislocated joint: o Gurdon’s symptom- larger criss-crossing of limb in the opposite direction o Nove- Josserand’s symptom- abnormal flexibility of hip when pushed o Duputren’s symptom- pushing fixed hip proximally and distally, feel shortening and lengthening like a button - Putti’s symptom- in girls interlabial sulci is asymmetrical and points at the joint with the condition - Learning to walk late- delayed walking at 14-15 months X-RAY - Putti’s x-ray trinity o Abnormal/ slanting arch of the acetabulum o Delayed (4-6 months) forming (hypoplasia) of the epiphyseal nucleus of the hip head (femur head) o Ectopia of proximal end of hip bone (femur head) Facts by Prof Vladimirov Barlow→ unstable joint that can be luxated/ dislocated → head of hip is in acetabulum and can be put out and back into position Palmen→ unstable joint that can be subluxated/ partly dislocated/ head of the hip is in acetabulum and can partly be put out of joint Inborn dysplasia of pelvic joint diagnosed by echography directly after birth Externally provoked dysplasia due improper care or untreated unstable joint diagnosed by Sonography (3months) Retarded Dysplasia of pelvic joint after treatment of congenital and provoked subluxatio/ luxatio are due early trauma of dislocated head of the growing cartilage of the apophyse on acetabulum edge Congenital luxation developed during embryogenesis - diagnosed by sonography directly after birth Externally provoked sublaxtio- due improper swaddling of newborn and untreated unstable joint Retarded sublaxtio of pelvic joint after treatment of congenital and provoked subluxation are due to insufficient recuperation of the acetabulum and marked anteversion of the cervix of the hip → shows during puberty Typical congenital luxatio → Develops pre or perinatally; Marx-Ortolani test positive; muscles do not contract Provoked Luxation with healthy children having physiologically hyperlax connective tissue → all test- Marx-Ortolani, Barlow, Palmen show negative Clinical examination of Newborns-2months 1. Test of Thomas (by 2-3months) 2. Test of Barlow (by 10 days) 3. Test of Marx- Ortolani (by 10 days) 4. Test of Palmen- by 10 Days) 5. Sonography 6. Judging whether diapers are used correctly. Clinical examination of Babies 3-12months Peter bade symptoms Nelaton/ Savaruid measure prominent Limited abduction of pelvic joint with unilateral dislocation of external roation better visible Marked hyperlaxity (connective tissue not completlely developed)of pelvic joint Roser- Nelaton axillary lines Putti’s X-ray trinity and altered angle oh Hingelnreiner o New-borns – 27-30 o End of 1st year- 25 o 3rd yr- 20 o 14-15 yr- 10-12