This document provides information about Perthes' disease, including:
- It is characterized by avascular necrosis of the femoral head in children.
- Risk factors include being male and between ages 5-10 years old.
- Imaging studies like x-rays are used to diagnose and monitor the stages of avascular necrosis, fragmentation, ossification, and remodeling.
- Differential diagnosis depends on whether the condition is unilateral or bilateral.
- Treatment aims to prevent deformity through nonsurgical or surgical methods depending on the severity.
This document discusses fractures of the neck of the femur. It begins with an introduction and anatomy section describing the structure of the femoral neck. It then covers the classification, etiology, clinical presentation, diagnosis, treatment and complications of femoral neck fractures. Key points include that these fractures most commonly occur in the elderly due to falls, and treatment depends on the fracture type and patient age/health but may involve internal fixation, hemiarthroplasty or total hip replacement. Complications can include nonunion, avascular necrosis and osteoarthritis.
The document discusses developmental dysplasia of the hip (DDH), including: definitions; clinical detection from birth to 6 months using tests like Ortolani's and Barlow's; treatment from birth to 6 months using a Pavlik harness or closed reduction and hip spica casting; and treatment from 6 to 18 months also using closed reduction and hip spica casting, with the goal of obtaining and maintaining reduction without damaging the femoral head. Obstacles to reduction like hypertrophic soft tissues are also mentioned.
This document provides an overview of clubfoot (congenital talipes equinovarus), including:
1. The definition, incidence, causes, and typical deformities seen in clubfoot.
2. Evaluation methods like the Pirani scoring system and radiographic assessment.
3. Treatment approaches like the Ponseti method of serial casting and bracing, as well as surgical options like the McKay procedure when non-operative treatment fails.
4. Post-operative casting protocols and complications that can arise from treatment.
Perthes disease, also known as Legg-Calve-Perthes disease, is caused by impaired blood flow in the femoral head that leads to bone death in children aged 3-12 years old, causing deformity of the femoral head; it is more common in boys and whites and symptoms include limping and hip pain that varies depending on the stage of bone regeneration. Genetic factors and growth abnormalities play a role in its development.
Shoulder dislocations have been documented as far back as ancient Egypt. The most common type is anterior dislocation, which accounts for 60% of cases. Reduction techniques described include external rotation, scapular manipulation, Milch, Stimson, traction-countertraction, and Spaso. Post-reduction, most patients are immobilized for 3 weeks if under 30 or begin mobilization after 1 week if over 30. Recurrent dislocation is a major complication, seen in 50-90% of patients under 20.
This document provides information about Perthes' disease, including:
- It is characterized by avascular necrosis of the femoral head in children.
- Risk factors include being male and between ages 5-10 years old.
- Imaging studies like x-rays are used to diagnose and monitor the stages of avascular necrosis, fragmentation, ossification, and remodeling.
- Differential diagnosis depends on whether the condition is unilateral or bilateral.
- Treatment aims to prevent deformity through nonsurgical or surgical methods depending on the severity.
This document discusses fractures of the neck of the femur. It begins with an introduction and anatomy section describing the structure of the femoral neck. It then covers the classification, etiology, clinical presentation, diagnosis, treatment and complications of femoral neck fractures. Key points include that these fractures most commonly occur in the elderly due to falls, and treatment depends on the fracture type and patient age/health but may involve internal fixation, hemiarthroplasty or total hip replacement. Complications can include nonunion, avascular necrosis and osteoarthritis.
The document discusses developmental dysplasia of the hip (DDH), including: definitions; clinical detection from birth to 6 months using tests like Ortolani's and Barlow's; treatment from birth to 6 months using a Pavlik harness or closed reduction and hip spica casting; and treatment from 6 to 18 months also using closed reduction and hip spica casting, with the goal of obtaining and maintaining reduction without damaging the femoral head. Obstacles to reduction like hypertrophic soft tissues are also mentioned.
This document provides an overview of clubfoot (congenital talipes equinovarus), including:
1. The definition, incidence, causes, and typical deformities seen in clubfoot.
2. Evaluation methods like the Pirani scoring system and radiographic assessment.
3. Treatment approaches like the Ponseti method of serial casting and bracing, as well as surgical options like the McKay procedure when non-operative treatment fails.
4. Post-operative casting protocols and complications that can arise from treatment.
Perthes disease, also known as Legg-Calve-Perthes disease, is caused by impaired blood flow in the femoral head that leads to bone death in children aged 3-12 years old, causing deformity of the femoral head; it is more common in boys and whites and symptoms include limping and hip pain that varies depending on the stage of bone regeneration. Genetic factors and growth abnormalities play a role in its development.
Shoulder dislocations have been documented as far back as ancient Egypt. The most common type is anterior dislocation, which accounts for 60% of cases. Reduction techniques described include external rotation, scapular manipulation, Milch, Stimson, traction-countertraction, and Spaso. Post-reduction, most patients are immobilized for 3 weeks if under 30 or begin mobilization after 1 week if over 30. Recurrent dislocation is a major complication, seen in 50-90% of patients under 20.
This document provides information on slipped capital femoral epiphysis (SCFE), including:
- SCFE involves slippage of the femoral epiphysis posteriorly and inferiorly due to weakness of the growth plate.
- It most commonly affects obese adolescent boys and girls during periods of rapid growth.
- Clinical features include pain in the groin or knee and limited range of motion of the hip.
- Treatment involves closed or open reduction and internal fixation using pins or screws to stabilize the slip.
- The goals of treatment are to prevent further slippage and allow healing to occur without complications like avascular necrosis.
This document discusses neck of femur fractures (NOF), also known as hip fractures. It covers the epidemiology, risk factors, anatomy, classification, diagnosis, and treatment of NOF fractures. NOF fractures typically occur in elderly patients from low-energy falls and are associated with osteoporosis, while in younger patients they usually result from high-energy injuries. Treatment depends on factors like the patient's age, health, and fracture classification, and may involve closed or open reduction, fixation with screws or nails, or arthroplasty. Complications can include nonunion, osteonecrosis, fixation failure, dislocation, and increased mortality risk especially in older or less healthy patients.
supracondylar fracture humerus in childrenHardik Pawar
Supracondylar fractures of the humerus are the most common elbow injuries in children, making up approximately 60% of cases. They typically occur as a result of a fall onto an outstretched hand in children aged 5-7 years old. Radiographs are used to classify fractures as non-displaced (Type I), displaced with an intact posterior cortex (Type II), or completely displaced (Type III). Posteromedial displacement is more common than posterolateral. Physical examination focuses on evaluating neurovascular status and detecting any S-shaped deformity, with nerve injuries occurring in up to 16% of cases.
This document discusses genu valgum (knock knees) and genu varum (bowlegs). It defines the Q angle and normal ranges. Genu valgum can be physiological in children under 4 years old or pathological. Bilateral cases may be due to various conditions while unilateral cases are often due to trauma or injury. Evaluation involves physical exam and x-rays. Treatment depends on age but may include observation, bracing, hemiepiphysiodesis, or osteotomy. Genu varum is also normally physiological initially but becomes pathological after age 2. Causes in children and adults are discussed. Evaluation and treatment methods including bracing and surgery are outlined.
Ankle fractures are common injuries that require careful evaluation to identify bony and soft tissue damage. The ankle is a complex hinge joint supported by ligaments and the tibia, fibula, talus, and deltoid ligament. Classification systems like Lauge-Hansen and Weber are used to characterize fracture patterns and guide management, which may involve closed treatment for stable injuries or surgery to restore ankle anatomy and stability for unstable fractures. Radiographs are important for diagnosis but CT or MRI may be needed to fully evaluate injury extent.
This document discusses the history and management of clubfoot. It describes non-operative treatments from ancient times through modern methods like the Ponseti technique. The Ponseti method, developed in the 1940s, is now the standard first-line treatment as it is safe, effective, and decreases the need for surgery. It involves serial casting and manipulation to correct the deformity, often with a percutaneous Achilles tenotomy. Surgical treatment is reserved for resistant or recurrent cases, with approaches like the Turco or Cincinnati incisions. Postoperative care varies but often involves casting or K-wire fixation followed by exercises. Complications can include injury, infection, stiffness or over/undercorrection. Proper understanding of anatomy and
This document discusses shoulder dislocations, including the types, risk factors, signs and symptoms, treatment, and prognosis. It defines a shoulder dislocation as the separation of the humeral head from the scapula. The most common type is an anterior dislocation, accounting for 95% of cases. Risk factors include age and previous trauma. Signs and symptoms include loss of normal shoulder contour, pain, and decreased range of motion. Treatment involves reduction, immobilization, and physical therapy, while prognosis depends on age, with younger patients having a higher risk of recurrence.
This document discusses congenital talipes equino-varus (CTEV), also known as clubfoot. CTEV is a congenital deformity of the foot and ankle characterized by equinus, inversion, adduction and cavus. It occurs in about 1 in 1000 live births. The document describes the types and causes of CTEV, pathological changes, treatment methods including Ponseti technique and surgery, and long-term management with bracing. Non-operative treatment is usually attempted first using serial casting and manipulation techniques.
This document discusses fracture diseases that can result from prolonged immobilization following fracture treatment. The principal fracture diseases include musculoskeletal issues like muscle weakness, atrophy, soft tissue contractures, osteoporosis, and joint stiffness. Prolonged immobilization can also lead to cardiovascular complications such as increased heart rate, circulatory dysfunction, orthostatic hypotension, and venous thromboembolism. Prevention of these fracture diseases focuses on proper fixation, early and frequent mobilization, muscle stretching and contraction, range of motion exercises, use of leg stockings, anticoagulant drugs, and changing patient positioning regularly.
Isabelle, a 23-year-old woman, was in a high-speed motor vehicle accident where her car collided head-on with another vehicle going 90 km/hour. She experienced an airbag deployment and hit her head on the windshield and knees on the dashboard, resulting in a brief loss of consciousness. She was brought to the emergency department complaining of neck, knee, and hip pain. One injury that can occur in high-energy trauma like this is a hip dislocation, which will be the focus of the discussion. Hip dislocations are classified based on their location (posterior, anterior, central) and can have complications like avascular necrosis if not properly reduced. Closed reduction techniques like the Allis
Congenital hip dislocation (CHD) occurs when the femoral head spontaneously dislocates from the acetabulum before or shortly after birth. It is caused by hereditary joint laxity, maternal relaxin hormone exposure, or breech positioning in the womb. Clinically, CHD presents with leg length discrepancy, an abnormal gait, or limited hip movement. Treatment involves closed or open reduction of the femoral head and maintenance with casting or splinting, especially in younger patients. For older patients or those with severe deformity, acetabular reconstruction procedures like Salter's osteotomy may be needed. The goal is to achieve a stable reduction and encourage acetabular remodeling.
This document provides information on pelvic fractures, including:
- Pelvic fractures account for about 5% of skeletal injuries and most commonly occur in road traffic accidents.
- The pelvic ring is composed of the sacrum and two innominate bones joined by ligaments to provide stability.
- Pelvic fractures can result from lateral compression, anteroposterior compression, or vertical shear forces.
- Treatment may involve non-operative management for minor injuries or operative stabilization using external or internal fixation for more severe injuries.
This document discusses hip dislocations, including anatomy, classification, clinical features, imaging, treatment approaches, and complications. It describes the ball-and-socket anatomy of the hip joint and ligaments that provide stability. Hip dislocations are most commonly posterior or anterior, depending on the direction the femoral head is displaced from the acetabulum. Treatment involves closed or open reduction, sometimes along with fixation of any fractures. Complications can include myositis ossificans or avascular necrosis leading to osteoarthritis.
Slipped upper femoral epiphysis (SUFE) is a displacement of the proximal femoral growth plate in adolescents. Boys are more commonly affected than girls. Risk factors include obesity, delayed puberty, and unusually rapid growth. The weakened growth plate slips due to the stress of weight bearing. This causes the femoral head to displace forward and rotate externally. Complications can include avascular necrosis, chondrolysis, and deformities like coxa vara if not treated. Diagnosis is made through x-rays and imaging. Treatment ranges from pinning for minor slips to surgery to reposition the femoral head for severe slips.
Developmental dysplasia of the hip (DDH) is a spectrum of displacement of the femoral head from the acetabulum that can occur before, during, or after birth. It ranges from dysplasia to subluxation to frank dislocation. Risk factors include female sex, first born, family history, and breech position. Ultrasound and x-rays are used to classify the condition and guide management, which may include harness, closed reduction, or open reduction depending on the age of presentation and severity. The goal is to achieve a stable reduction and allow normal hip development.
Recurrent shoulder dislocation and managementAnshul Sethi
This document provides an overview of recurrent shoulder dislocations. It discusses the anatomy of the shoulder joint and its stabilizers. The glenohumeral ligaments, labrum, rotator cuff muscles, and negative intra-articular pressure provide static stability, while dynamic stability comes from the rotator cuff and scapulo-thoracic motion. Younger age, returning to collision sports, and bone defects increase risk of recurrence. Evaluation involves assessing range of motion, translation, and special tests like the anterior drawer and sulcus sign. History and physical exam help determine treatment which may include rehabilitation or surgery to address labral tears or bone loss.
This document discusses coxa vara, which is a hip deformity characterized by an abnormal decrease in the femoral neck-shaft angle. It classifies coxa vara as congenital, developmental, or acquired. Developmental coxa vara is the most common type and is caused by a primary cartilage defect in the femoral neck. Clinical features include limping and pain. Treatment involves corrective valgus osteotomies to restore the neck-shaft angle and relieve stress on the femoral physis. The document describes several techniques for valgus osteotomy including Pauwel's, Borden's, and subtrochanteric osteotomy. The goal of surgery is to stimulate healing of the femoral neck defect and restore normal
1) Tuberculosis of the knee joint is the third most common site of osteoarticular tuberculosis, accounting for around 10% of skeletal tuberculosis cases.
2) Initial pathology involves hematogenous spread to the synovium or subchondral bone, forming tubercles. Advanced cases involve erosion of joint surfaces and destruction of bones.
3) Clinical features include knee swelling, warmth, effusion, tenderness, and restricted painful movement. Advanced cases develop triple deformity of flexion, adduction, and internal rotation.
This document discusses developmental dysplasia of the hip (DDH), including its pathogenesis, clinical features at different ages, diagnostic imaging tools, and management approaches. DDH is a spectrum of hip disorders that can present from birth through childhood. Management involves both non-surgical and surgical techniques depending on the age of presentation and severity, with the goal of achieving and maintaining a stable, concentric reduction to allow normal hip development. Surgical options range from closed or open reduction to osteotomies to improve acetabular coverage. Careful long-term follow up is important to monitor for residual dysplasia or deformity.
Developmental dysplasia of the hip (DDH) refers to abnormal development of the hip joint during infancy. It ranges from mild hip instability to complete dislocation. Risk factors include breech positioning, family history, and neuromuscular disorders. Diagnosis is made through clinical examination and imaging studies like ultrasound and x-rays. Treatment depends on the severity and may include closed or open reduction and casting or bracing. Complications can include degenerative joint disease, leg length discrepancy, and back pain if left untreated.
This document provides information on slipped capital femoral epiphysis (SCFE), including:
- SCFE involves slippage of the femoral epiphysis posteriorly and inferiorly due to weakness of the growth plate.
- It most commonly affects obese adolescent boys and girls during periods of rapid growth.
- Clinical features include pain in the groin or knee and limited range of motion of the hip.
- Treatment involves closed or open reduction and internal fixation using pins or screws to stabilize the slip.
- The goals of treatment are to prevent further slippage and allow healing to occur without complications like avascular necrosis.
This document discusses neck of femur fractures (NOF), also known as hip fractures. It covers the epidemiology, risk factors, anatomy, classification, diagnosis, and treatment of NOF fractures. NOF fractures typically occur in elderly patients from low-energy falls and are associated with osteoporosis, while in younger patients they usually result from high-energy injuries. Treatment depends on factors like the patient's age, health, and fracture classification, and may involve closed or open reduction, fixation with screws or nails, or arthroplasty. Complications can include nonunion, osteonecrosis, fixation failure, dislocation, and increased mortality risk especially in older or less healthy patients.
supracondylar fracture humerus in childrenHardik Pawar
Supracondylar fractures of the humerus are the most common elbow injuries in children, making up approximately 60% of cases. They typically occur as a result of a fall onto an outstretched hand in children aged 5-7 years old. Radiographs are used to classify fractures as non-displaced (Type I), displaced with an intact posterior cortex (Type II), or completely displaced (Type III). Posteromedial displacement is more common than posterolateral. Physical examination focuses on evaluating neurovascular status and detecting any S-shaped deformity, with nerve injuries occurring in up to 16% of cases.
This document discusses genu valgum (knock knees) and genu varum (bowlegs). It defines the Q angle and normal ranges. Genu valgum can be physiological in children under 4 years old or pathological. Bilateral cases may be due to various conditions while unilateral cases are often due to trauma or injury. Evaluation involves physical exam and x-rays. Treatment depends on age but may include observation, bracing, hemiepiphysiodesis, or osteotomy. Genu varum is also normally physiological initially but becomes pathological after age 2. Causes in children and adults are discussed. Evaluation and treatment methods including bracing and surgery are outlined.
Ankle fractures are common injuries that require careful evaluation to identify bony and soft tissue damage. The ankle is a complex hinge joint supported by ligaments and the tibia, fibula, talus, and deltoid ligament. Classification systems like Lauge-Hansen and Weber are used to characterize fracture patterns and guide management, which may involve closed treatment for stable injuries or surgery to restore ankle anatomy and stability for unstable fractures. Radiographs are important for diagnosis but CT or MRI may be needed to fully evaluate injury extent.
This document discusses the history and management of clubfoot. It describes non-operative treatments from ancient times through modern methods like the Ponseti technique. The Ponseti method, developed in the 1940s, is now the standard first-line treatment as it is safe, effective, and decreases the need for surgery. It involves serial casting and manipulation to correct the deformity, often with a percutaneous Achilles tenotomy. Surgical treatment is reserved for resistant or recurrent cases, with approaches like the Turco or Cincinnati incisions. Postoperative care varies but often involves casting or K-wire fixation followed by exercises. Complications can include injury, infection, stiffness or over/undercorrection. Proper understanding of anatomy and
This document discusses shoulder dislocations, including the types, risk factors, signs and symptoms, treatment, and prognosis. It defines a shoulder dislocation as the separation of the humeral head from the scapula. The most common type is an anterior dislocation, accounting for 95% of cases. Risk factors include age and previous trauma. Signs and symptoms include loss of normal shoulder contour, pain, and decreased range of motion. Treatment involves reduction, immobilization, and physical therapy, while prognosis depends on age, with younger patients having a higher risk of recurrence.
This document discusses congenital talipes equino-varus (CTEV), also known as clubfoot. CTEV is a congenital deformity of the foot and ankle characterized by equinus, inversion, adduction and cavus. It occurs in about 1 in 1000 live births. The document describes the types and causes of CTEV, pathological changes, treatment methods including Ponseti technique and surgery, and long-term management with bracing. Non-operative treatment is usually attempted first using serial casting and manipulation techniques.
This document discusses fracture diseases that can result from prolonged immobilization following fracture treatment. The principal fracture diseases include musculoskeletal issues like muscle weakness, atrophy, soft tissue contractures, osteoporosis, and joint stiffness. Prolonged immobilization can also lead to cardiovascular complications such as increased heart rate, circulatory dysfunction, orthostatic hypotension, and venous thromboembolism. Prevention of these fracture diseases focuses on proper fixation, early and frequent mobilization, muscle stretching and contraction, range of motion exercises, use of leg stockings, anticoagulant drugs, and changing patient positioning regularly.
Isabelle, a 23-year-old woman, was in a high-speed motor vehicle accident where her car collided head-on with another vehicle going 90 km/hour. She experienced an airbag deployment and hit her head on the windshield and knees on the dashboard, resulting in a brief loss of consciousness. She was brought to the emergency department complaining of neck, knee, and hip pain. One injury that can occur in high-energy trauma like this is a hip dislocation, which will be the focus of the discussion. Hip dislocations are classified based on their location (posterior, anterior, central) and can have complications like avascular necrosis if not properly reduced. Closed reduction techniques like the Allis
Congenital hip dislocation (CHD) occurs when the femoral head spontaneously dislocates from the acetabulum before or shortly after birth. It is caused by hereditary joint laxity, maternal relaxin hormone exposure, or breech positioning in the womb. Clinically, CHD presents with leg length discrepancy, an abnormal gait, or limited hip movement. Treatment involves closed or open reduction of the femoral head and maintenance with casting or splinting, especially in younger patients. For older patients or those with severe deformity, acetabular reconstruction procedures like Salter's osteotomy may be needed. The goal is to achieve a stable reduction and encourage acetabular remodeling.
This document provides information on pelvic fractures, including:
- Pelvic fractures account for about 5% of skeletal injuries and most commonly occur in road traffic accidents.
- The pelvic ring is composed of the sacrum and two innominate bones joined by ligaments to provide stability.
- Pelvic fractures can result from lateral compression, anteroposterior compression, or vertical shear forces.
- Treatment may involve non-operative management for minor injuries or operative stabilization using external or internal fixation for more severe injuries.
This document discusses hip dislocations, including anatomy, classification, clinical features, imaging, treatment approaches, and complications. It describes the ball-and-socket anatomy of the hip joint and ligaments that provide stability. Hip dislocations are most commonly posterior or anterior, depending on the direction the femoral head is displaced from the acetabulum. Treatment involves closed or open reduction, sometimes along with fixation of any fractures. Complications can include myositis ossificans or avascular necrosis leading to osteoarthritis.
Slipped upper femoral epiphysis (SUFE) is a displacement of the proximal femoral growth plate in adolescents. Boys are more commonly affected than girls. Risk factors include obesity, delayed puberty, and unusually rapid growth. The weakened growth plate slips due to the stress of weight bearing. This causes the femoral head to displace forward and rotate externally. Complications can include avascular necrosis, chondrolysis, and deformities like coxa vara if not treated. Diagnosis is made through x-rays and imaging. Treatment ranges from pinning for minor slips to surgery to reposition the femoral head for severe slips.
Developmental dysplasia of the hip (DDH) is a spectrum of displacement of the femoral head from the acetabulum that can occur before, during, or after birth. It ranges from dysplasia to subluxation to frank dislocation. Risk factors include female sex, first born, family history, and breech position. Ultrasound and x-rays are used to classify the condition and guide management, which may include harness, closed reduction, or open reduction depending on the age of presentation and severity. The goal is to achieve a stable reduction and allow normal hip development.
Recurrent shoulder dislocation and managementAnshul Sethi
This document provides an overview of recurrent shoulder dislocations. It discusses the anatomy of the shoulder joint and its stabilizers. The glenohumeral ligaments, labrum, rotator cuff muscles, and negative intra-articular pressure provide static stability, while dynamic stability comes from the rotator cuff and scapulo-thoracic motion. Younger age, returning to collision sports, and bone defects increase risk of recurrence. Evaluation involves assessing range of motion, translation, and special tests like the anterior drawer and sulcus sign. History and physical exam help determine treatment which may include rehabilitation or surgery to address labral tears or bone loss.
This document discusses coxa vara, which is a hip deformity characterized by an abnormal decrease in the femoral neck-shaft angle. It classifies coxa vara as congenital, developmental, or acquired. Developmental coxa vara is the most common type and is caused by a primary cartilage defect in the femoral neck. Clinical features include limping and pain. Treatment involves corrective valgus osteotomies to restore the neck-shaft angle and relieve stress on the femoral physis. The document describes several techniques for valgus osteotomy including Pauwel's, Borden's, and subtrochanteric osteotomy. The goal of surgery is to stimulate healing of the femoral neck defect and restore normal
1) Tuberculosis of the knee joint is the third most common site of osteoarticular tuberculosis, accounting for around 10% of skeletal tuberculosis cases.
2) Initial pathology involves hematogenous spread to the synovium or subchondral bone, forming tubercles. Advanced cases involve erosion of joint surfaces and destruction of bones.
3) Clinical features include knee swelling, warmth, effusion, tenderness, and restricted painful movement. Advanced cases develop triple deformity of flexion, adduction, and internal rotation.
This document discusses developmental dysplasia of the hip (DDH), including its pathogenesis, clinical features at different ages, diagnostic imaging tools, and management approaches. DDH is a spectrum of hip disorders that can present from birth through childhood. Management involves both non-surgical and surgical techniques depending on the age of presentation and severity, with the goal of achieving and maintaining a stable, concentric reduction to allow normal hip development. Surgical options range from closed or open reduction to osteotomies to improve acetabular coverage. Careful long-term follow up is important to monitor for residual dysplasia or deformity.
Developmental dysplasia of the hip (DDH) refers to abnormal development of the hip joint during infancy. It ranges from mild hip instability to complete dislocation. Risk factors include breech positioning, family history, and neuromuscular disorders. Diagnosis is made through clinical examination and imaging studies like ultrasound and x-rays. Treatment depends on the severity and may include closed or open reduction and casting or bracing. Complications can include degenerative joint disease, leg length discrepancy, and back pain if left untreated.
Developmental Dysplasia of the Hip and Ultrasoundhungnguyenthien
Developmental dysplasia of the hip (DDH) refers to a spectrum of hip abnormalities ranging from mild dysplasia to frank dislocation. Risk factors include breech presentation and family history. Diagnosis involves a thorough physical exam including Ortolani's and Barlow's maneuvers in infants, with ultrasound used for further evaluation. Treatment depends on severity but may involve bracing or surgical reduction and stabilization of the hip.
This document provides an overview of developmental dysplasia of the hip (DDH), including its normal development, etiology, epidemiology, diagnosis, treatment, and complications. Key points include: DDH can range from mild dysplasia to frank dislocation and is more common in females. Clinical diagnosis involves the Ortolani and Barlow maneuvers while imaging includes x-rays and ultrasound. Treatment depends on the grade of DDH and may involve closed or open reduction along with bracing or splinting. Complications can include avascular necrosis and osteoarthritis if left untreated.
This document discusses developmental dysplasia of the hip (DDH), which refers to dysplasia of the hip joint that develops during fetal life or infancy. It can range from shallow acetabulum to complete hip dislocation. DDH is more common in females and risk factors include breech presentation and family history. Treatment depends on age, with Pavlik harness used in infants under 6 months and hip spica casting for older infants and children under 2 years. The goal of treatment is to reduce the femoral head in the acetabulum and allow normal hip joint development.
A 7-month-old girl was referred to an orthopedic surgeon after her pediatrician noticed asymmetric skin folds in her upper thighs during a vaccination appointment. Upon examination, the orthopedic surgeon found palpable hip instability, unequal leg lengths, and limited abduction on the left side. An ultrasound confirmed a diagnosis of developmental dysplasia of the hip. Treatment options included abduction splints, hip spica casting, or reduction procedures.
This document outlines 3 personas - Vivek, a millennial college senior who often loses things and wants to find lost items; Meghan, a student who studies in various locations including local coffee shops and is active on social media; and Todd Goodall, Preetom Chakraborty, and Ryan Barna, listed without descriptions.
El documento describe los subsistemas que integran la seguridad social en Venezuela. Estos incluyen el subsistema de pensiones, salud, paro forzoso y capacitación laboral, vivienda y política habitacional, y recreación. Cada subsistema tiene un objetivo específico como proveer pensiones, atención médica, protección temporal por terminación laboral, acceso a vivienda, y promover programas recreacionales. Los subsistemas están constituidos por diferentes fondos y regímenes financieros para alcanzar sus objetivos de manera sostenible.
1) There are 33 vertebrae in the spine, but due to fusion only 26 are functional. The vertebrae are divided into 7 cervical, 12 thoracic, and 5 lumbar vertebrae.
2) Degenerative disc disease is the most common cause of lower back pain. It involves the gradual drying out and loss of the intervertebral disc's ability to function as a shock absorber. This transfer of stress can lead to further degeneration of surrounding structures like facet joints.
3) Stages of disc degeneration include disc bulge, annular tears, and disc herniation which can be protruded, extruded, or sequestrated as it progresses. Identification of the specific
Developmental dysplasia of the hip (DDH) is a condition where the femoral head has an abnormal relationship with the acetabulum. The document discusses the normal development of the hip joint, pathoanatomy and clinical presentation of DDH, as well as methods of diagnosis including imaging and treatment options depending on the age of presentation. Treatment in infants less than 6 months involves the Pavlik harness to obtain and maintain reduction of the hip to allow for normal development.
Developmental dysplasia of the hip (DDH) refers to a spectrum of hip abnormalities ranging from shallowness of the hip socket to dislocation of the femoral head. It was previously known as congenital dislocation of the hip but the term developmental dysplasia is now preferred as it can develop after birth. Left untreated, DDH can cause limping, leg length discrepancies, and hip arthritis. Treatment depends on the child's age and severity of dysplasia, ranging from splinting or bracing for mild cases to osteotomy surgery for more advanced cases. Early diagnosis before walking begins is important to allow for effective nonsurgical treatment.
This document discusses developmental dysplasia of the hip (DDH), also known as congenital hip dysplasia. DDH ranges from shallow acetabulum to complete hip dislocation. It is more common in females and breech babies. Clinical signs include leg length discrepancy, limited hip abduction, and Trendelenberg gait. Ultrasound is the best initial imaging method, using the alpha and beta angles to assess acetabular depth and femoral head position. X-rays become more useful after age 4-7 months as ossification centers appear. Early diagnosis and treatment are important to prevent long-term complications of DDH like osteoarthritis.
Developmental dysplasia of the hip (DDH) is a partial or complete displacement of the femoral head from the acetabular cavity present since birth. Risk factors include being female, a first born, or having a family history. Clinical features in infants include positive Ortolani's and Barlow's tests, while features in older children and adults include a waddling gait, limb length discrepancy, and decreased hip range of motion. Radiographs are used to assess parameters like the acetabular index and femoral head position to diagnose and monitor DDH at various stages.
This document discusses developmental dysplasia of the hip (DDH), also known as congenital hip dysplasia. DDH ranges from shallow acetabulum to complete hip dislocation. Risk factors include breech presentation and family history. Diagnosis involves clinical tests like Barlow and Ortolani in newborns and ultrasound or x-ray in older infants. Treatment depends on age and includes Pavlik harness in newborns, closed or open reduction and casting in infants, and osteotomies if needed in older children. Complications can include avascular necrosis. Proper screening and treatment can prevent long term issues from untreated DDH.
Developmental dysplasia of the hip (DDH) is a spectrum of hip dysplasia that ranges from shallow acetabulum to subluxation to complete dislocation. It is more common in females and affects the left hip more often than the right. Risk factors include breech birth position, torticollis, and a family history. Symptoms may include leg length discrepancy, uneven skin folds, limping, or limited mobility. Diagnosis involves clinical examination including Ortolani's and Barlow's maneuvers as well as imaging like ultrasound and x-rays. Treatment options include use of a Pavlik harness or von Rosen splint for younger infants or surgical reduction and spica casting for older children.
This document provides information on developmental dysplasia of the hip (DDH). It discusses the definition, causes, incidence, clinical findings, pathology, diagnosis through imaging like ultrasound and X-rays, and treatment approaches for different age groups from newborns to older children. Key tests like Barlow, Ortolani and imaging classifications including Graf are outlined. The main treatment mentioned is use of Pavlik harness for young infants, while older infants may require traction and closed reduction or open reduction if closed fails.
This document discusses development dysplasia of the hip (DDH), including its presentation, risk factors, diagnosis, natural history, and treatment. DDH includes a spectrum of disorders like subluxation, dislocation, and acetabular dysplasia. Risk factors include breech presentation, female sex, and family history. Clinical examination involves assessing range of motion and stability tests. Radiographs and ultrasound are used for diagnosis. Without treatment, DDH can progress to osteoarthritis, but early detection and treatment can help prevent long-term issues.
Developmental dysplasia of the hip (DDH) is a condition where the hip joint is not properly formed or does not properly develop during fetal life or infancy. It ranges from shallow hip sockets to partial or complete dislocation of the hip joint. The goals of treatment are to reduce the femoral head into the acetabulum and maintain a concentric reduction to allow for normal hip development. Treatment depends on the age of presentation and severity, and may include use of a Pavlik harness, hip spica cast, closed or open surgical reduction, and osteotomies. Early diagnosis and treatment generally lead to better outcomes.
Developmental dysplasia of the hip (DDH) is a condition where the hip joint is not properly formed or does not properly develop during fetal life or infancy. It ranges from shallow hip sockets to partial or complete dislocation of the hip joint. The goals of treatment are to reduce the femoral head into the acetabulum and maintain a concentric reduction to allow for normal hip development. Treatment depends on the age of presentation and severity, and may include use of a Pavlik harness, hip spica cast, closed or open surgical reduction, and osteotomies. Early diagnosis and treatment generally lead to better outcomes.
Developmental Dysplasia of Hip final.pptxsudarshan731
This document provides information on Developmental Dysplasia of the Hip (DDH), including its definition, risk factors, diagnosis, and management approaches. DDH is a spectrum of abnormalities where the hip joint does not properly form during development before or after birth. Risk factors include breech positioning and female sex. Diagnosis involves clinical examination and imaging like ultrasound and x-rays. Management is based on age and severity, ranging from harness treatment in infants, to closed or open reduction and casting in older children, and osteotomies or salvage procedures in older children and adults. The goal is early diagnosis and treatment to reduce dislocation and prevent complications like avascular necrosis.
Developmental dysplasia of the hip (DDH) is a spectrum of abnormalities including hip dysplasia, subluxation, and dislocation caused by capsular laxity and mechanical factors during development. DDH is most common in females and the left hip. Risk factors include being firstborn, breech position, and family history. Presentation depends on age, ranging from asymptomatic in newborns to Trendelenburg gait in older children. Treatment options include non-operative methods like Pavlik harness for infants or closed reduction and spica casting for older infants, and operative methods like open reduction and osteotomies for older children with residual dysplasia.
1. Developmental dysplasia of the hip (DDH) refers to dysplasia or dislocation of the hip joint that develops during fetal life or infancy. It can range from shallow acetabulum to partial or complete dislocation.
2. Risk factors include female sex, breech presentation, family history, and swaddling practices that restrict hip movement. Screening involves clinical examination and ultrasound of newborns and infants.
3. Treatment depends on age and severity but aims to reduce the femoral head and maintain the reduction to allow for normal hip development. Options include Pavlik harness, hip spica casting, and surgery.
1. Developmental dysplasia of the hip (DDH) refers to dysplasia or dislocation of the hip joint that develops during fetal life or infancy. It can range from shallow acetabulum to partial or complete dislocation.
2. Risk factors include female sex, breech presentation, family history, and swaddling practices that restrict hip movement. Screening involves clinical tests and ultrasound imaging to detect abnormalities.
3. Treatment depends on age and severity but generally aims to reduce the femoral head and maintain the reduction through devices like Pavlik harness or hip spica casting. Surgical intervention may be needed for older patients or failed non-surgical treatment.
1. Developmental dysplasia of the hip (DDH) refers to dysplasia or dislocation of the hip joint that develops during fetal life or infancy. It can range from shallow acetabulum to partial or complete dislocation.
2. Risk factors include female sex, breech presentation, family history, and swaddling practices that restrict hip movement. Screening involves clinical examination and ultrasound of newborns and infants.
3. Treatment depends on age and severity but aims to reduce the femoral head and maintain the reduction to allow for normal hip development. Options include Pavlik harness, hip spica casting, and surgery.
This document discusses developmental dysplasia of the hip (DDH). It defines DDH and explains how it occurs due to ligamentous laxity and breech positioning. Risk factors include female sex, family history, and oligohydramnios. DDH can present as a dysplastic, subluxated, or dislocated hip. Diagnosis is made through clinical examination and imaging like ultrasound and x-rays. Treatment depends on age and may include Pavlik harness, closed or open reduction, and hip spica casting. Complications include failure of reduction or avascular necrosis.
This document discusses developmental dysplasia of the hip (DDH). It begins by defining DDH and providing epidemiological data on incidence. It then covers normal hip development, risk factors, clinical presentation, imaging findings, and management approaches. For newborns, treatment focuses on stabilizing unstable hips or reducing dislocated hips using a Pavlik harness, which places the hips in flexion and abduction. The success rate of the Pavlik harness in newborns is reported to be 85-95%.
Developmental dysplasia of the hip is a spectrum of disorders affecting the development of the hip joint that can present from birth to 18 months of age. It has genetic, hormonal, and positioning factors that can affect proper formation of the acetabulum and coverage of the femoral head. Clinical signs include limited abduction, a positive Galeazzi sign, and the femoral head being displaced in the Klisic test for older children. Treatment may involve harnessing or closed reduction depending on the stability and reducibility of the hip.
developmental dyspepsia of the hip is the most common pediatric hip problem. often occurs in first born female baby, in left side more than right side in cases of breech presentation. it may be bilateral in 20% of cases.
This document discusses developmental dysplasia of the hip (DDH), including its etiology, presentation, diagnosis and treatment. Key points include:
- DDH is a spectrum of hip disorders presenting at different ages, including subluxation, acetabular dysplasia and dislocation.
- Risk factors include ligamentous laxity, breech positioning, and postnatal positioning with hips in extension.
- Clinical diagnosis involves the Ortolani and Barlow tests for instability in infants. Imaging includes ultrasound and x-rays.
- Left untreated, DDH can progress from instability to dislocation and eventual osteoarthritis. Treatment aims to prevent this progression.
Developmental dysplasia of the hip (DDH) is a spectrum of hip disorders that can occur from conception to skeletal maturity. It most commonly affects females and risk factors include genetic predisposition, breech positioning, and hormonal influences. Clinical features include limb asymmetry and limited hip movement. Diagnosis involves clinical tests and imaging like ultrasound or X-rays. Management depends on age, with splinting often used for young infants and closed or open reduction with spica casting for older children. Complications can include limping, osteoarthritis, or avascular necrosis if left untreated.
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Devlopmental dysplasia of hip(DDH) by DR.NAVEEN RATHOR
1. Developmental Dysplasia of the
Hip
Dr.NAVEEN RATHOR
(RESIDENT DOCTOR)
DEPT. OF ORTHOPEDICS
RNT MEDICAL COLLEGE
UDAIPUR
2. • Definition
• Dysplasia of the hip that develop during
fetal life or in infancy.
• It ranges from dysplasia of the acetabulum
(shallow acetabulum) to subluxation of the
joint to complete dislocation.
• The old name was ‘‘congenital dysplasia of
the hip (CDH).’’ The name has changed to
indicate that not all cases are present at
birth and that some cases can develop later
on during infancy and childhood
3. Developmental Dysplasia of the
Hip
1. Complete hip dislocation.
2. Partial hip subluxation.
3. Hip dysplasia (incomplete development).
4.Dislocatable hip
4. Dysplasia: radiographic finding of increased
obliquity and loss of concavity of the
acetabulum, with an intact Shenton's
line(deficient development of
acetabulum)
Subluxation: femoral head is in partial contact
with the acetabulum
Dislocation:femoral head is not in contact with
the acetabulum
5. Incidence
• Most newborn screening studies suggest that
some degree of hip instability can be detected in
1/100 to 1/250 babies, actual dislocated or
dislocatable hips are much less common, being
found in 1-1.5 of 1000 live births.
• There is marked geographic and racial variation in
the incidence of DDH.
• More inidence of DDH IN Sweden,Yugoslavia and
Canada.
6. Etiology
• A positive family history for DDH is found in
12-33% of affected patients.
• DDH is more common among female patients
(80%). This is thought to be due to the greater
susceptibility of female fetuses to maternal
hormones such as relaxin, which increases
ligamentous laxity
• Primigravida.
• Breech presentation(2-3%).
• Oligohydramnios ,primi gravida and large baby
( crowding phenomenon ).
• Adduction and Extension postnatally.
8. • The left hip is the most commonly affected hip
• In the most common fetal position, this is the hip
that is usually forced into adduction against the
mother’s sacrum.
• Girls are affected 5 times more than boys.
9. • Types:
• DDH is classified into two major groups :
• Typical and teratologic .
• Typical DDH occurs in otherwise normal patients
or those without defined syndromes or genetic
conditions.
• Teratologic hip dislocations usually have
identifiable causes such as arthrogyposis or a
genetic syndrome and occur before birth.
15. Neonatal Presentation
Exam one hip at a time
Baby must be quiet
Barlow’s sign: provocative maneuver
Ortolani’s sign: reduces hip
Other signs not helpful in newborn
16. CLINICAL FINDINGS
• IN NEWBORNS
• Usually asymptomatic and must be screened
by special maneuvers
• 1) Barlow test.
It is a provocative test that attempts to
dislocate an unstable hip.
- Flexion ,adduction, posteriorly.
- “Clunk”
17. The Barlow test for developmental dislocation of the hip in a neonate.A, With the infant
supine, the examiner holds both of the child's knees and gently adducts one hip and
pushes posteriorly.B, When the examination is positive, the examiner will feel the
femoral head make a small jump (arrow) out of the acetabulum (Barlow's sign). When
the pressure is released, the head is felt to slip back into place.
18. • 2) Ortolani test
It is a maneuver to reduce a recently
dislocated hip.
• Flexion, abduction, anteriorly.
• We can`t use X-rays because the
acetabulum and proximal femur are
cartilaginous and wont be shown on X-ray.
• US is the best method to Dx.
19. The Ortolani test for developmental dislocation of the hip in a
neonate.A, The examiner holds the infant's knees and
gently abducts the hip while lifting up on the greater trochanter with
two fingers.B, When the test is positive, the dislocated femoral head
will fall back into the acetabulum (arrow) with a palpable (but not
audible) “clunk” as the hip is abducted (Ortolani's sign). When the hip is
adducted, the examiner will feel the head redislocate posteriorly.
20. Clinical Manifestations
• In infants:
• As the baby enters the 2nd and 3rd
months of life, the soft tissues begin to
tighten and the Ortolani and Barlow tests
are no longer reliable.
• Shortening of the thigh, the Galeazzi
sign , is best appreciated by placing both
hips in 90 degrees of flexion and
comparing the height of the knees,
looking for asymmetry
21. • The most diagnostic sign is Ortolani’s
limitation of abduction.
• Abduction less than 60 degrees is almost
diagnostic.
• X-rays after the age of 3 months can be
helpful esp. after the appearance of the
ossific nucleus of the femoral head
• US is 100% diagnostic.
22. Infant Presentation
Skin fold asymmetry
Limited hip abduction
Unequal femoral lengths (Galeazzi’s sign)
(Flex both hips and one side shows apparent
femoral shortening)
27. After Walking Age
Trendelenberg gait
Leg length discrepancy
Increased lumbar lordosis in Bilateral
dislocation
–Klisic test positive
28. The examiner places the middle finger over the greater trochanter, and the
index finger on the anterior superior iliac spine.A, With a normal hip, an
imaginary line drawn between the two fingers points to the umbilicus.B, When
the hip is dislocated, the trochanter is elevated and the line projects halfway
between the umbilicus and the pubis.
31. Which hip dysplasia
pain?
•Complete dislocation with
no false acetabulum:
NO
•Complete dislocation with
false acetabulum:
YES
•Subluxation:
YES
32. • All neonates should have a clinical
examination for hip instability
• Risk factors :
– breech presentation
– family history
– torticollis
– oligohydramnios
– metatarsus adductus
USG SCREENING
SCREENING..!!
33. Imaging
• X-rays
– Femoral head ossification center
• 4 -7 months
• Ultrasound
• CT
• MRI
• Arthrograms
– Open vs closed reduction
34. Radiograph
• It is not reliable in early stages of DDH but new born
screening may reveal severe acetabular dysplasia or
teratological dislocation.
• as child grows soft tissue become contracted and
radiographs become more helpful in diagnosis.
• Most common used lines of reference are vertical
line of Perkins and horizontal line of Hilgenreiner,
both used to assess the position of femoral head.
35. Von Rosen view
• In this view both hips are Abducted,
Internally Rotated and Extended.
• Line is drawn along femoral shaft, which
intersect acetabulum.
• In dislocated hip, it crosses above the
acetabulum.
36. Von rosen view
AP X-ray: hip in 45°abduction and IR describes the longitudinal
relationship between long axis of femur and acetabulum
37. X-ray
Horizontal line of Hilgenreiner:
drawn between upper ends of tri-radiate
cartilage of the acetabulum.
Vertical line of perkins:
drawn from the lateral edge of the acetabulum
vertical to horizontal line.
4 quadrants:
Normal hip: the ossification center of the femoral
hip lower medial quadrant.
Dislocated hip: upper lateral quadrant.
38. Perkin line is through lateral margin
of acetabulum
• While hilgenreiner line is through triradiate
cartilage.
• Shenton line is curved line that begins at
lesser trochanter, goes upto femoral neck, and
connect with line along inner margin of pubis.
• In normal hip, medial beak of femoral
metaphysis lies in lower inner quadrant
produced by junction of Perkin and hilgenreiner
lines.
39. RADIOGRAPHY…!!
Dimensions H and D are measured to quantify proximal
and lateral displacement of the hip and are most useful
when the head is not ossified.
Acetabular index and the medial gap
40. X-ray
Acetabular index:
angle between horizontal line of
hilgenreiner and the line between the two
edges of the acetabulum.
normal hip 20º30
dilocated or dysplastic hip ≥ 30º
Shenton’s line:
semicircle between femoral neck and
upper arm of obturator foramen, in
dislocated hip this line is broken.
42. The acetabular index is the angle between a line drawn along the margin of the
acetabulum and Hilgenreiner's line; it averages 27.5 degrees in normal newborns
and decreases with age.
• Acetabular Index
44. Centre –Edge angle
• It is useful to measure hip position.
• It is formed at the junction of Perkin line
with line that connects lateral margin of
acetabulum to the center of femoral head.
• In children 6-13 yr. old, >19 degree is
considered normal.
• In children >=14 yr. old, >25 degree is
considered normal.
45. Centre – Edge Angle of Wilberg…!!
6 – 13 years >19 degrees
>14 years > 25 degrees
46. Acetabular tear drop
• It is seen in AP radiograph of pelvis.
• Formed by several lines ,
• Derived from – wall of acetabulum laterally,
• Wall of lesser pelvis medially,
• Curved line inferiorly and
• Acetabular notch.
• In normal hip it appears between 6-24 months
of age.
48. Tear drop
AP X-ray
Lateral:wall of
acetabulum
Medial:lesser pelvis
Inferior :acetabular
notch
Appears between 6-23
mo
[delayed in DDH]
49. It significans is in the pronosis.
• Hips in which teardrop appears within 6
months of reduction have better outcome
than in which it appears late.
• 4 types have been noted:-
• Open , closed , crossed and reversed.
• Also be describe as U- or V- shaped.
• V- shaped associated with poor outcome.
50. DIAGNOSIS
• 1. ULTRA SOUND
• In the Graf technique, the transducer is placed
over the greater trochanter, which allows
visualization of the ilium, the bony acetabulum,
the labrum, and the femoral epiphysis
• The angle formed by the line of the ilium and a
line tangential to the boney roof of the
acetabulum is termed the α angle and represents
the depth of the acetabulum.
• Values > 60 degrees are considered normal, and
those < 60 degrees imply acetabular dysplasia.
51. • The β angle is formed by a line drawn tangential
to the labrum and the line of the ilium; this
represents the cartilaginous roof of the
acetabulum.
• A normal β angle is < 55 degrees, as the femoral
head subluxates, the β angle increases.
55. • In DDH , alpha angle decreases and beta
angle increases, depending upon femoral
head subluxation.
• Depending upon alpha angle measurment
he proposed a classification system
57. MRI
• It gives excellent anatomical visualization of
infant hip.
• Kashiwagi and associates proposed
classification of hips with DDH.
• Group 1 hips had sharp acetabular rim, all
were reducible with Pavlik hareness.
• Group 2 hips had a rounded acetabular rim and
almost all are reducible with Pavlik hareness.
58. Group 3 hips have inverted
acetabular rim, and none was
reducible with hareness.
• MRI findings includes :-
• Widening of iliac bone,
• Lateral drift of superior and posterior
portions of acetabular floor,
• Overgrowth of acetabular cartilage,
• Convexity of posterior portion of cartilage.
59. Treatment
• Is divided in 5 age – related groups
• 1) newborn ( birth to 6 months old )
• 2) infant ( 6 to 18 months old )
• 3) toddler ( 18 to 36 months old )
• 4) child ( 3 to 8 yrs. Old )
• 5) adolescent and young adult ( > 8 yrs.
Old )
60. Treatment Options
• Age of patient at presentation
• Family factors
• Reducibility of hip
• Stability after reduction
• Amount of acetabular dysplasia
61. Management of DDH – Guidelines
0 to 6 months
Pavliks Harness
6 to 18 months 18 to 36 months 3 to 8 years
Traction
Closed reduction
Hip spica
Open reduction
Pri. open
reduction
Pelvic osteotomy
Pri, open
reduction with
Femoral
shortening
6 weeks no
reduction
Arthrography
No reduction >1/3rd head
visible
62. Birth to Six Months
• Triple-diaper technique
– Prevents hip adduction
– “Success” no different in some
untreated hips
• Pavilk harness (1944)
– Experienced staff*
– Very successful
– Allows free movement within
confines of restraints
*posterior straps for preventing add. NOT producing abd.
63. • Pavlik harness :- is used in first 6 months ,
shows excellent result in t/t of DDH.
• It is dynamic flexion-abduction orthosis.
• c/I in children who are crawling or fixed soft
tissue contracture, or teratological dislocation
present.
• After application, radiograph is taken and
confirm the reduction. Hip is placed in flexion
of 110 and abduction to occur by gravity itself .
64. Birth to Six Months
• Pavlik harness
– Indications
• Fully reducible hip*
• Child not attempting to stand
• Family
• Close regular follow-up (every 1-2 weeks)
• For imaging and adjustments
• Duration
• Childs age at hip stability + 3 months
65. APPLYING PAVLIK HARNESS..!!
A:The chest halter is applied. The shoulder straps on the halter should cross in the back.
B:The leg stirrup straps are applied
C:The attachment for the anterior (flexor) stirrup straps should be located at the anterior
axillary line
D:posterior (abduction) stirrup straps should be attached over the scapula. The
position should be set to hold the hip in 90° of flexion with the posterior straps limiting
adductionto prevent dislocation.
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
JBJS:VOLUME 85-A OCTOBER 2003
66. How long pavlik harness should be
continued
• After closed reduction and application of
pavlik hareness. Patient is follow up in every
1-2 weeks.
• At this time, hip stability is checked.
• Pavlik hareness is discontinued 6 weeks
after clinically hip stability is obtained.
• To weaning of up to 2 hrs. per week until
brace is worn at night time.
67. Persistent dislocation of hip
• May be present after application of pavlik
hareness , 4 basic pattern is observed
• Superior, inferior , lateral and posterior.
• If present following manuvre should be done
• Superior – additional flexion is required,
• Inferior – flexion should be decreased,
• Lateral – closed observation to see for direction
of femoral neck towards triradiate cartilage.
68. Head may be gradually reduce and
dock into the acetabulum.
Persistent posterior dislocation is difficult to
treat. As tight hip adductor muscle are
present.
If any of this persistent dislocation present for
more than 3 to 6 weeks, pavlik hareness
should be discontinued.
t/t includes closed or open reduction and
casting.
69. Pavlik Harness
• Failures
– Poor parent compliance
– Improper use by the physician
• Inadequate initial reduction
• Failure to recognize persistent dislocation
– Viere et al 1990
• Bilateral dislocation
• Absent Ortolani’s sign
• > 7weeks of age
70. Pavlik Harness
• Complications
– Avascular necrosis
• Forced hip abduction
• Safe zone (abd/adduction and flexion/extension)
– Femoral nerve palsy
• Hyperflexion
*Be aware of Pavlik Harness Disease
*Follow until skeletal maturity
71. Other splint
• Ilfeld and von rosen splint have high rate of
success with fewer complication but not
superior to pavlik hareness.
• Frejka pillow and triple diaper are not used
because of high rate of AVN.
72.
73.
74. Treatment:1 month – 6 months
4 weeks
Pavlik harness:1st choice
Continued till achieving stability
no reduction
discontinued
Reduced
Continue for 6 more weeks
Appearance of the notch predicts
better development of acetabulum
75. Treatment:6 months-2 years
AIM: obtain & maintain concentric
reduction without damaging femoral
head
Closed/open reduction
Pre op traction ????
Femoral shortening &Innominate
osteotomy may be needed
76. Traction…!!
Pre-reduction traction was considered essential to
reduce the incidence of AVN and to enable the
surgeon to obtain a closed reduction
Salter et al 1969
Gage & winter 1972
Morel et al 1975
Langenskiold & Paavilainen 2000
“The need for traction has been challenged by a
number of studies showing that hips can be safely
reduced without preliminary traction”
Weinstein & Ponsetti 1979
Kahle et al 1990
Quinn et al 1994
Current reccomendation: No traction
77. Closed Reduction…!!
Stable: if leg could be adducted 30° from max
abduction & extend to below 90°
Unstable: if wide abduction or more than 10 or 15
degrees of internal rotation is required to maintain
reduction
Never keep the limb in
wide Abduction or >15°IR AVN
79. Ramsey “zone of safety”…!!
Wide zone of safety
Moderate zone of safety
Narrow zone of safety
Ramsey PL, Lasser S, MacEwen GD: Congenital dislocation of the hip: Use of the Pavlik harness
in the child during the first six months of life. J Bone Joint Surg Am 1976; 58:1000
80. ARTHOGRAPHY…!!
• An arthrogram obtained at the time of reduction is very
helpful for evaluating the depth and stability of the
reduction
• Width of the medial dye pool to asses lateralisation
Good < 5mm
Fair 5-6 mm
Poor > 6mm
81. Post reduction ..!!
Cast in human position
6 weeks
Examination under GA
Stability assessment
Stable ,reduced Doubtful reduction
,unstable
Arthogram
Cast in human position6 weeks
3rd cast for
6 weeks &
discontinue
Abduction splinting
for 6 weeks
OR
Open Reduction
82. Open Reduction…!!
• Unable to achieve closed
reduction
• Widening of the joint
space
• Unstable reductions
• Loss of reduction on
follow up
• Advanced age
83. Open reduction can be performed by
• Anterior
• Anteromedial
• Medial approach
• Anterior approach :- pathology in the
anterior and lateral aspect of hip can be
easily reached and pelvic osteotomy can be
easily performed.
84. Approach…!
Medial
• Minimal dissection
• Obstructions
encountered directly
BUT..
• Limited view
• Pelvic osteotomy not
possible
• No capsulorrhaphy
Anterior
• Better exposure
• Capsulorrhaphy
• Pelvic osteotomy
possible
BUT..
• Blood loss
• iliac crest apophysis and
abductors damage
• Stiffness of hip
85. Medial approach ;- interval between
iliopsoas and pectineus
• Medial circumflex vessel at higher risk.
98. 2 Years of Age and Older
• For child 2 -3 years of age, during open reduction
acetabular coverage if insufficient warrants
reorientation osteotomy
• If coxa valga with excessive anteversion, VDRO
may be done.
• Children > 3 years usually need an acetabular
procedure
Femoral shortening is essential part of it’s
management. In past , child is put on skeletal
traction but result of shortening are better and
morbidity is less.
99. Open Reduction with Femoral
Shortening..!
• Pressure leads to risk of AVN
• Better results than preoperative traction in older
children with less morbidity
When to do??
• Anticipated increased pressure on reduced femur head
• Recommended in child > 2yrs.
• distract the joint few millimeter per operatively
• Judge the tightness of soft tissues after reduction
• irreducible dislocation
100. How much shortening?
• Pre op: bottom of the femoral head to the floor of the
acetabulum (a to b)
• amount of overlap is noted after osteotomy
• Tension of the soft tissue
• Derotation usually combined
leaving 15 to 20 degrees of
anteversion
101. Open Reduction with Femoral
Shortening..!
Subtrochanteric cut
Overlap method to determine the
amount to shorten the femur.
Internal fixation with an
appropriate blade-plate
104. Salter Single Innominate
•Age –18 months –6 years
•Requires concentrically reduced hip
–Open reduction at same time is possible
–Iliopsoas and adductor tenotomies often
required
•Covers antero-later alacetabular deficiency
–Up to 15 degree of acetabular index corrected
105. Salter Osteotomy..!!
Osteotomy: transverse & perpendicular to ilaic axis from just
above AIIS to sciatic notch
Symphysis pubis :a flexible hinge for acetabular redirection to
cover anterolateral insuffiency in a concentrically reduced
hip
Appropriate for children of 2-8 years
Before 2 yrs >8 yrs
Iliac wings too small symphysis pubis
to support graft less mobile
106. Salter
•Anterior approach to acetabulum
–Exposing inner and outer ilium
–Expose hip capsule if reduction needed
–Transverse osteotomy is done just above acetabulum
• Sciatic notch to Ant.Inf.iliac Spine
–Rotate on pubic symphysis in antero-lateral direction
–Hold correction with bone graft wedge & K-wires
115. Peri-acetabular Ostetomies
• Provide greater correction of acetabular index
• Reduce volume of hip joint
• Possibility of growth disturbances
Types
– Pemberton’s
– Dial (Eppright)
– Wagner
– Dega’s
– Ganz osteotomy (Bernese)
116. Pemberton Acetabuloplasty
•Age –18 months –10 years
•Requires reduced hip
•Decreases acetabular volume
–Remodeling of acetabulum required
•Corrects >15 degree of Acetabular index
•Reduces antero-lateral acetabular defects
–Cuts altered to cover more anteriorly or laterally
117. Pemberton
•Anterior Approach -Exposure as for Salter
–Cut inner and outer table with small osteotome
– osteotomy 1cm above AIIS, staying 1 cm above
capsule
–Do not cut through to sciatic notch
–Lever through the cut until coverage is acceptable
•(Levers on tri-radiate cartilage)
–Hold correction with bone graft wedge
119. Dega Acetabuloplasty
•Similar to Pemberton
•Larger posterior hinge
–Hinges on horizontal tri-radiate limb
•Less inner table osteotomized for more lateral
coverage
(More inner table –more anterior coverage)
120. Dega osteotomy (transiliac)
This is incomplete transiliac osteotomy ,
involves osteotomy of anterior and middle
portion of inner cortex of ilium , leaving a
intact hinge posteriorly consisting of intact
posteromedial iliac cortex and sciatic notch.
At this osteotomy site , bone graft is placed.
125. Dega osteotomy..!
Intact postero-medial cortical
hinge
If more anterior coverage desired ,inner cortex cut more
If more lateral coverage desired, inner cortex cut less
126. Dega osteotomy..!
JAN S. GRUDZIAK & W. TIMOTHY WARD :THE JOURNAL OF BONE & JOINT SURGERY · JBJS.ORG VOLUME 83-A · NUMBER 6 · JUNE 2001
A larger graft is inserted anteriorly. The posterior graft should be
smaller in order not to loosen the anterior graft.
127. GANZ osteotomy..!
Larger corrections all directions(correction not
limited by sacro-pelvic ligaments)
Blood supply preserved
Shape of true pelvis unaltered
Technically demanding
128. Steel Triple Innominate
Osteotomy
•Age –Skeletally mature
•Requires congruent hip joint
•Divides ilium, ischium and superior ramus
–Acetabulum is rotationally free
–Indicated when other osteotomies not
possible
•Rotates to cover any acetabular defect
129. Steel
•Multiple incision technique
–Posteriorly between gluteus and hamstrings
•Allows osteotomy of ischium
–Anteriorly freeing medial attachments
•Allows Salter and superior ramus osteotomy
–Rotate acetabulum as desired
•Avoid externally rotating
–Bone graft wedge is fixed as per Salter type
130. Steel triple innominate osteotomy
• Ischium, superior pubic ramus and ilium
superior to acetabulum all are divided and
acetabulum is repositioned and stabilized by
bone graft and pins.
131.
132. Salvage or Shelf procedures
• Chiari and Staheli osteotomies
– Requires capsular metaplasia
– Pain is the main indication
– Used in Treatment of chronic hip pain in
adolescents
133. Staheli Shelf Procedure
•Age –older child to skeletal maturity
•Salvage operation
•Indicated for non-concentric hips
•Augments supero-lateral deficency
–Slotted bone graft placed over capsule
deepening the acetablum
134. Staheli
•Anterior approach is used with outer wall exposure only
–Identify superior acetabular edge
–Create slot 1cm deep along edge in cephlad angle
–Remove 1 cm cortical strips from outer table
•Insert into slot, cutting at desired lateral overhang
•2nd layer inserted lengthwise
•Use remaining to fill in above slot edge
–Hold in place with reflected fascia and adductors
137. Chiari Medial Displacement
•Age –skeletally mature
•Salvage operation only
–Used when no other osteotomy possible
–Possible with subluxed hip
•Covers well laterally
–Anterior and posterior augmentation may be
necessary
•May be useful in other conditions
–Coxamagna, OA in dysplasichips
138. •Anterior approach –as per Salter
–Identify superior extent of capsule
–Cut from AIIS to notch following capsule
curve
•Angle osteotome10-20ocephlad
–Displace distal fragment medially 50-100%
•Ensure complete head coverage
•Leg abduction, hinges on pubic symphysis
147. Complications of Treatment
• Worst complication is disturbance of
growth in proximal femur including the
epiphysis and physeal plate
• commonly referred to as AVN however, no
pathology to confirm this
• may be due to vascular insults to epiphysis
or physeal plate or pressure injury
• occurrs only in patients that have been
treated and may be seen in opposite
normal hip
148. Necrosis of Femoral Head
• Extremes of position in abduction ( greater 60
degrees ) and abduction with internal
rotation
• compression on medial circumflex artery as
passes the iliopsoas tendon and compression of
the terminal branch between lateral neck and
acetabulum
• “ frog leg position “ uniformly results in
proximal growth disturbance
150. • extreme position can also cause pressure
necrosis onf epiphyseal cartilage and
physeal plate
• severin method can obtain reduction but
very high incidence of necrosis
• multiple classification systems with Salter
most popular
151. DDH: THR
does not solve all ills!
Right:
painless
Left:
severe pain