Pediatric Hip

1. Pediatric Hip Dr. Fadel Naim Orthopedic Surgeon IUG

3. Developmental Dysplasia of the Hip ( DDH )

4. The main aim of this presentation is to: • emphasize the importance of the early identification of DDH • The earlier an abnormality of the infant hip is detected, the simpler and more effective the treatment will be

5. Developmental Dysplasia of the Hip (DDH) • DDH is a term used to describe a spectrum of abnormalities affecting the relationship of the femoral head to the acetabulum. • an immature hip • a hip with mild acetabular dysplasia • a hip that is dislocatable • a hip that is subluxated • a hip that is frankly dislocated.

6. Teratologic Hip : Fixed dislocation Occurrs prenatally Often with other anomalies • Dislocated Hip : Completely out May or may not be reducible • Subluxated Hip : Only partially in • Unstable Hip : Femoral head can be dislocated • Acetabular Dysplasia : Shallow Acetabulu Head Subluxated or in place

7. Epidemiology • 1 in 100 newborns examined have evidence of instability ( positive Barlow or Ortolani) • 1 in 1000 live births true dislocation • most detectable at birth in nursery • 60% stabilize in 1st week and 88% stabilize in first 2 months without treatment remaining 12% true dislocations and persist without treatment

8. Risk Factors associated with DDH • Breech Presentation • Family History of DDH (especially if in parent or sibling) • Female Baby (DDH is 4 X likely to occur in a female infant) • Postnatal Positioning

9. Risk Factors associated with DDH • Breech Presentation • Family History of DDH (especially if in parent or sibling) • Female Baby (DDH is 4 X likely to occur in a female infant) • Postnatal Positioning

10. Risk Factors associated with DDH • decreased intrauterine space • Large Baby (>4kg) • Overdue > 42 weeks • Oligohydramnios • Associated with Plagiocephaly, Torticollis and foot deformities • First born baby or multiple pregnancies

11. PHYSICAL EXAMINATION • The reliability of physical examination changes as the child grows, therefore examination techniques vary depending on the age of the child.

12. Diagnosis • Clinical risk factors • Physical exam • Ortolani Test • Barlow Test

13. Neonatal ExaminationOrtolani (reduction test) Feel a Clunk Not hear a click !

14. Neonatal ExaminationBarlow (stress test)

15. Ortolani and Barlow tests are accurate within the first 48 hours of birth and then become increasingly less accurate. • Thus Hip examination ideally should be performed within 48 hours • After 3 months of age, the Ortolani and Barlow tests may be unreliable • therefore additional means of examination, used in combination with the Ortolani and Barlow tests, are necessary

16. Older Infants (> 3 months of age) • restricted abduction at the hips • leg length discrepancy • asymmetrical thigh and gluteal skin folds

17. Restricted Abduction At The Hips • The most sensitive sign associated with DDH in the older infant. • The examination should be performed gradually and may need to be repeated a number of times • Normal range of motion at the hip is abduction to 60˚ or more, with range less than this suggestive of DDH.

18. Leg Length Discrepancy • Total leg length discrepancy should be assessed in prone with hips and knees extended • assessing for leg length discrepancy using the Galeazzi Test.

19. Asymmetrical Skin Folds • Asymmetrical skin folds alone do not constitute a diagnosis of DDH • However this information can be used in combination with other physical signs during assessment.

20. Bilateral Dislocation • Diagnosis more diffecult • Abduction may be decreased symmetrically with bilateral dislocations. • Galeazzi Test may be negative in bilateral dislocations • There may be no asymmetrical skin folds

21. Klisic test • An imaginary line between anterior superior iliac spine and great trochanter should point towards or above the umbilicus. • If dislocated will point below

22. Late Signs • In children who are walking • a limp may be present • the child may toe-walk on the affected side. • If DDH is present in both hips • increased lumbar lordosis • prominent buttocks • a waddling gait

23. Ultrasound • Morphologic and dynamic assessment • Indications controversial due to high levels of over-diagnosis • Currently not recommended as a routine screening tool other than in high risk patients

25. Ultrasound

26. Ultrasound Femoral head Abductors Ilium

27. Ultrasound Femoral head Abductors Ilium

28. Ultrasound Femoral head Abductors Ilium

29. Ultrasound Graf’s alpha angle >60 = normal *line w/ ilium bisects head 50/50

30. If the child is 6 weeks to 5 months of age, Ultrasound (US) is generally the most appropriate imaging technique • If the child is 5 months or greater, X-ray is generally the most appropriate imaging technique • Between 4 and 6 months, US and X-ray are equally effective diagnostic tools

31. Radiography

32. Radiographs Summary • Femoral head appears 4 - 7 months • Shenton’s line • Perkin’s and Hilgenreiner’s lines • Inferomedial quadrant • Acetabular index • Normal < 30 (Weintroub et al)

33. Radiography

34. Radiological Diagnosis X-ray findings • Delayed appearance of ossific nucleus • Small ossific nucleus • Dysplastic acetabulum • Proximal displacement of femur • Increased acetabular index ( n=27, >30-35 dysplasia) • Disruption Shenton line

35. Radiography

36. Radiography

37. Radiography in out

38. Radiography 39o 27o

39. Imaging

40. Imaging

41. Imaging

42. Imaging

43. Imaging

44. Imaging

45. Imaging < 30 wnl

46. Imaging

47. Imaging

48. Imaging

49. Imaging

50. Treatment Options • Age of patient at presentation • Family factors • Reducibility of hip • Stability after reduction • Amount of acetabular dysplasia