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CDH C ONGENITAL D ISLOCATION OF THE H IP

Dr. ABDULMONEM ALSIDDIKY , MD , SSCO. Assistant Professor & Consultant pediatric Ortho.& Spinal Deformities KSU,KKUH Riyadh , Saudi Arabia . CDH C ONGENITAL D ISLOCATION OF THE H IP. Nomenclature. CDH : Congenital Dislocation of the Hip

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CDH C ONGENITAL D ISLOCATION OF THE H IP

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  1. Dr. ABDULMONEM ALSIDDIKY , MD , SSCO. Assistant Professor & Consultant pediatric Ortho.& Spinal Deformities KSU,KKUH Riyadh , Saudi Arabia CDHCONGENITALDISLOCATION OF THE HIP

  2. Nomenclature • CDH :Congenital Dislocation of the Hip • DDH :Developmental Dysplasia of the Hip

  3. NORMAL PELVIS

  4. Normal hip Dislocated hip

  5. Patterns of disease • Dislocated • Dislocatable • Sublaxated • Acetabular dysplasia

  6. Radiology • After 6 months: reliable

  7. Causes (multi factorial) Unknown • Hormonal • Relaxin, oxytocin • Familial • Lig.laxity diseases • Genetics • Female 4 X male --- twins 40% • Mechanical • Pre natal • Post natal

  8. Mechanical causes • Pre natal • Breach , oligohydrominus , primigravida , twins • (torticollis , metatarsus adductus ) • Post natal • Swaddling , strapping

  9. Infants at risk • Positive family history: 10X • A baby girl: 4-6 X • Breach presentation: 5-10 X • Torticollis: CDH in 10-20% of cases • Foot deformities: • Calcaneo-valgus and metatarsus adductus • Knee deformities: • hyperextension and dislocation

  10. Infants at risk When risk factors are present • The infant should be reviewed • Clinically • radiologically

  11. Clinical examination • The infant should be • quiet • comfortable

  12. Look: • External rotation • Lateralized contour • Shortening • Asymmetrical skin folds • Anterior – posterior

  13. Move • Limited abduction

  14. Special test • Galiazzi • Ortolani , Barlow test • Trendelenburgh sign • Limping ( waddling gait if bilateral)

  15. Special test Galiazzi test

  16. Special test Ortolani test

  17. Special test Barlow test

  18. Special test Trendelenburgh sign

  19. Screening programs • Clinical screening proven to be effective • Performed by trained personnel • Must be dynamic • Repeated with periodic examination • U/S screening is controversial

  20. Investigations • 0-3 months U/S • > 3months X-ray pelvis AP + abduction

  21. U/S Screening • Incidence of hip stability declines rapidly to 50% within the first week of neonatal life. • Better to delay U/S screening

  22. U/S - Problems • Too sensitive: • Detects a lot of hip abnormalities, most of which would develop normally if left alone • Operator-dependant

  23. Radiology • Early infancy: not reliable

  24. Radiology • After 2-3 months: more reliable

  25. Radiology • After 2-3 months: more reliable 39o 27o

  26. Radiology • After 2-3 months: more reliable Von Rosen view in out in out out in

  27. Radiology • After 2-3 months: more reliable out in

  28. Radiology • After 6 months: reliable

  29. Radiology • After 6 months: reliable

  30. Treatment - Aims • Obtain concentric reduction • Maintain concentric reduction • In a non-traumatic fashion • Without disrupting the blood supply to femoral head

  31. Treatment • Method depends on age • The earlier started, the easier it is • The earlier started, the better the results are • Should be detected EARLY

  32. Treatment • Birth – 6m • Pavlik harness or hip spica • 6-12 m: • Closed reduction under GA and hip spica • 12 - 18 m: • Open reduction • 18 – 24 m: • Open reduction and Acetabuloplasty • 2-8 years: • Open reduction, Acetabuloplasty, and femoral shortening • Above 8 years: • Open reduction, Acetabuloplasty cutting all three pelvic bones, and femoral shortening

  33. Treatment: Neonatal hip instability • Most resolve spontaneously • Can initially wait • Avoid adduction swaddle • Apply double diapers – to bring back!! • See at 2weeks of age

  34. Treatment: Neonatal hip instability Unstable at 2 weeks: • Double / Triple diapers: inadequate • Gives illusion that patient is “in treatment” while wasting valuable time

  35. Treatment: Neonatal hip instability Unstable at 2 weeks: • Pavlik Harness • Dynamic, effective, safe

  36. Treatment: 6-12 m • Initially non-operative closed reduction UGA and immobilization in hip spica cast • Position: • Avoid sever abduction • Avoid frog position • Must obtain stable concentric reduction, otherwise needs surgery

  37. Treatment: 6-12 m • Possibly closed reduction • Stable and concentric reduction • Possibly open reduction • Unstable or un-concentric reduction • Arthrography-guided

  38. Treatment: 6-12 m • Arthrography-guided Closed Reduction

  39. Treatment: 6-12 m Arthrography-guided Closed Reduction Acceptable Too lateralized

  40. Treatment: 18-24 m • Open reduction – surgery • Possibly: Acetabuloplasty

  41. Treatment: Above 2 years • Open reduction, and • Acetabuloplasty, and • Femoral shortening

  42. Acetabuloplasties • Many types

  43. Treatment • Birth – 6m • Pavlik harness or hip spica • 6-12 m: • Closed reduction under GA and hip spica • 12 - 18 m: • Open reduction • 18 – 24 m: • Open reduction and Acetabuloplasty • 2-8 years: • Open reduction, Acetabuloplasty, and femoral shortening • Above 8 years: • Open reduction, Acetabuloplasty cutting all three pelvic bones, and femoral shortening

  44. CDH - Summary • Complex multi-factorial, endemic disease • Health education and Drs. awareness • Screening programs are needed • Learning proper examination methods • Identify at risk groups • Efficient referral system • Proper management by specialized Drs

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