cdh congenital dislocation of the hip mamoun kremli professor / consultant pediatric orthopedics...
TRANSCRIPT
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CDHCongenital Dislocation of the
Hip
Mamoun KremliProfessor / Consultant Pediatric Orthopedics
College of Medicine & King Khalid University Hospital
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CDH
• The most common disorder affecting the hip in children
• Spectrum of diseases/abnormalities of the hip with different etiologies, pathologies, and natural histories affecting the proximal femur and acetabulum
• Initial pathology is congenital, progresses if untreated.• Does not always result in dislocation.
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CDH
Definition• A progressive deformation of previously
normally formed structures during the embryonic period
NOT A malformation arising during the period of organogenesis
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CDHNomenclature
• CDH Congenital Dislocation of the Hip• DDH Developmental Dysplasia of the Hip• CDH Congenital Dysplasia of the Hip
• CHD Congenital Heart Disease !
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CDH Spectrum
• 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
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CDHIncidence
• Hip Instability at Birth : 0.5 – 1 % of infants
• Classic CDH : 0.1 % of infants
• Mild Dysplasia : Substantial
Contributing to adult Osteoarthritis
Up to 50 % of Hip Arthritis in Ladies
Have underlying hip dysplasia
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CDH
Incidence Area Incidence per 1000
Canadian Indians 188.5
Hungary 28.7
Uppsala, Sweden 20
USA Caucaseans
Blacks
15.5
4.9
Malmo, Sweden 2.18
Chinese, Hong Kong 0.1
Bantus, Africa 0.0 among (16678)
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CDH
Etiology
Multi-factorial
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CDH
Etiology
Physiologic Factors
Ligament Laxity :
Hormonal :
( Estrogen, Relaxin) Females
Familial hyper laxity :
mild - moderate - Ehler Danlos
ADD Picture of knee hyperextension
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CDH
Etiology
Genetic Factors• Gender : Female
Most studies:
Females > 4-6 X than males
• Twin studies:
Monozygotic 38 %
Dizygotic 3 % (similar to siblings)
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CDH
Etiology
Family Incidence and Genetic Counselling
Affected At risk Risk
One sibling Siblings 1 in 17
One parent Children 1 in 8
One parent, one sibling Children 1 in 3
2nd degree relative Nieces, nephews 1 in 100
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CDH
Etiology Mechanical Factors Prenatal : - Breech position - Oligohydramnious - Primigravida - Cong. Knee recurvatum/dislocation - Metatarsus adductus - Torticollis
Postnatal : - Swaddling / Strapping – Knees extended
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CDH
EtiologyMechanical Factors
• Breech Presentation :
Normally 2 –4 %
CDH 16 %
The Breech position In Utero Extended knees and flexed hips
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CDH
EtiologyEnvironmental & Mechanical Factors
• Swaddling / strapping ( Mihad ): Knees extended & Hips adducted
– Proven experimentally– Proven statistically
• American Indians.• Eskimos, and • Saudi Arabia
– Mechanics• Hip adduction and extension
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CDHPatients At Risk
• Positive Family History : increases risk 10X• A baby girl : increases risk 4-6 times• Breech Presentation : increases risk 5-10 X• Torticollis : CDH in 10-20 % cases• Foot Deformities : ( calcaneovalgus & metatarsus adductus) signs of intrauterine crowding• Knee Deformities : ( hyperextension & dislocation )
associated with Teratologic type
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CDH
Risk Factors
When Risk Factors Are Present• The infant should be examined repeatedly
• The hip should be imaged
( by U/S or X-ray )
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CDHNeonatal Examination
The infant should be quiet and comfortable
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CDHNeonatal Examination
LOOK :
•Wide perineum
( in bilateral )
•Lateralized contour
•External rotation attitude
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CDHNeonatal Examination
LOOK :• Asymmetric thigh
folds
anterior
posterior
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CDHClinical Examination
• Look :
Shortening ( not in neonates )
- Galeazzy sign
- in supine
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CDHNeonatal Examination
FEEL :
• Empty groin
• Weak Femoral pulse
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CDHNeonatal Examination
MOVE :• Hip instability
in early infancy• Limited hip abduction
in flexion - later
(careful in bilateral)
if <600 on both sides:
request imaging
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Cerebral palsy
Clinical AssessmentHip Flexion Deformity
SPECIAL :• Loss of fixed flexion
deformity of hips
( early infancy )• Normally FFD
newborn 28o
at 6 weeks 19o
at 6 months 7o
FFDNormal
No FFD?CDH
Thomas Test
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CDH
Neonatal ExaminationOrtolani
Feel a ClunkNot hear a click !
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CDH
Neonatal ExaminationBarlow
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CDHNeonatal Examination
Ortolani / Barlow
clunk
Ortolani Barlow
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CDHNeonatal Examination
Ortolani / Barlow
Ortolani Barlow
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CDHNeonatal Examination
Hamstring Stretch Sign• Flex hip and knee 900 each.• Keep hip flexed and gradually extend the knee• Normally a resistance is felt towards the end of
knee extension (caused by the hamstrings which are pulled from both
ends)
• In cases of CDH, no resistance is felt (when the hip is dislocated, the origin of the hamstrings are
not pulled by hip flexion)
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CDHNeonatal Examination
Hamstring Stretch Sign
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CDHClinical Examination
• Neonate (up to 2-3 months) : - Instability/ Ortolani-Barlow - Thomas test
• Infant ( > 2-3 months) : - Limited abduction - Shortening ( Galeazzi ) - Hamstring stretch sign
• Toddler : - Limited abduction - Shortening ( Galeazzi ) - Hamstring stretch sign
• Walking : - Trendelenburgh - Hamstring stretch sign
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CDHClinical Examination
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CDHClinical Examination
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CDH
Clinical ExaminationThe Walking Child
• Trendelenburgh: unilateral / bilateral (waddling)
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CDHScreening Program
• Clinical screening proven to be effective
• Performed by Trained personnel
• Must be DYNAMIC
with periodic examination till walking
• Adjunctive use of U/S controversial
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CDHUltrasound Screening
• Incidence of hip instability declines rapidly to 50 % within the first week of neonatal life
• Better to delay U/S screening
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CDHUltrasound Screening
• Early U/S screening not recommended
• Delayed U/S screening :
- Older than 6 weeks
- Those at risk only - by
History
Clinical exam
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CDH
Ultrasound Referral
• If hip normal : no need
• If hip clearly unstable : no need
• If suspicious : U/S appropriate
• If at risk factors : U/S appropriate
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CDHUltrasound
• Too sensitive
detects a lot of hip anomalies most of which would develop normally
• Operator dependant
Static Vs Dynamic
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CDH
Radiography
• Early infancy : not reliable• By 2-3 months of age : reliable
AP view - neutral position
- draw reference lines
- acetabular index - in early infancy
< 30o : normal
30o – 40o : questionable
> 40o : abnormal
Von Rosen view : 45o abduction
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CDHRadiography
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CDHRadiography
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CDHRadiography
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CDHRadiography
Von Rosen view
in out
in out
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CDHRadiography
27o 39o
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CDHRadiography
in out
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CDH
Treatment
Aims
• Obtain and Maintain concentric reduction
• In an Atruamatic fashion
• Without disrupting the blood supply
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CDH
Treatment• Method depends on Age
• The earlier started, the easier the treatment
• The earlier started, the better the results
• Should be detected EARLY
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CDH
Treatment• Birth to 6 months : Pavlik harness or hip spica cast• 6 months – 12 months : closed reduction UGA and hip spica casts• 12 months – 18 months : possible closed / possible open reduction• Above 18 months : open reduction and ? Acetabuloplasty• Above 2 years : open reduction,acetabulplasty, and femoral osteotomy• Above 8 years : open reduction,acetabulplasty cutting three bones, and femoral
osteotomy
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CDHTreatment
Hip instability in the neonatal period
Most resolve spontaneously• Observation
• Pavlik harness
• Double /triple diapers ??
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CDH
Treatment
Hip instability in the neonatal period
Double / Triple Diapers• Often inadequate : therefore inappropriate• Gives illusion patient is in “treatment” while
wasting valuable time• Most hip instability improves spontaneously in
early infancy , giving this ineffective management credit
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CDH
Treatment
Birth – 6 months
Hip instability (dislocatable)
Established dislocation (reducible)
• Should be actively treated until hip is normal clinically and radiographically
• Pavlik harness
• Hip Spica Cast
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CDH
Treatment
Birth – 6 monthsPavlik harness
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CDH
Treatment
Birth – 6 months
Other Devices - Frejka pillow - Craig
- Von Rosen splint Soft abduction splints: Not good enough
Rigid abduction splints: Risk AVN
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• Initially non operative – closed reduction• Reduction under anesthesia and immobilization in hip
spica cast• Position: Human
Avoid severe abduction
Avoid Frog position
• Must be stable and concentrically reduced otherwise needs open reduction
CDHTreatment
6 – 12 months
Better Picture
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CDH
Treatment
12 – 18 months
• Possibly closed reduction !!
when hip stable and concentrically reduced• Probably open reduction
when hip unstable or not concentrically reduced• Arthrography guided:
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CDHTreatment
ArthrographyClosed Reduction
Too lateralized Acceptable
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CDHTreatment
Above 18 months
• Open reduction
? and acetabulplasty
? And femoral shortening – if high
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CDHTreatment
Above 3 years
• Open reduction
• And acetabulplasty
• And femoral shortening
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Redirectional Acetabuloplasty
Salter’s
Add Picture with K wires
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Pemberton’s
Need for a lot of improvement in coverNeed for a lot of improvement in cover
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Triple Steel
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CDH
When Not to Treat ?!Bilateral High Posterior Dislocation
good function – not painful
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CDH
When Not to Treat !
الدواِء� بعضِ من وخيٌرالداِء�
Painful stiff left hip Painful stiff right hip in adduction
![Page 65: CDH Congenital Dislocation of the Hip Mamoun Kremli Professor / Consultant Pediatric Orthopedics College of Medicine & King Khalid University Hospital](https://reader037.vdocuments.mx/reader037/viewer/2022102719/56649e2b5503460f94b192bc/html5/thumbnails/65.jpg)
CDH
When Not to Treat !
الدواِء� بعضِ من وخيٌرالداِء�
Painful right hip & ankylosed left hip
![Page 66: CDH Congenital Dislocation of the Hip Mamoun Kremli Professor / Consultant Pediatric Orthopedics College of Medicine & King Khalid University Hospital](https://reader037.vdocuments.mx/reader037/viewer/2022102719/56649e2b5503460f94b192bc/html5/thumbnails/66.jpg)
CDH
Summary
• Complex multi-factorial, endemic– treatable.• Dr’s awareness and health education.• Screening programs are needed.• Learning proper examination methods.• Identify at-risk groups.
– repeat examination & imaging.
• Efficient referral system.• Proper management in referral centers.
![Page 67: CDH Congenital Dislocation of the Hip Mamoun Kremli Professor / Consultant Pediatric Orthopedics College of Medicine & King Khalid University Hospital](https://reader037.vdocuments.mx/reader037/viewer/2022102719/56649e2b5503460f94b192bc/html5/thumbnails/67.jpg)
![Page 68: CDH Congenital Dislocation of the Hip Mamoun Kremli Professor / Consultant Pediatric Orthopedics College of Medicine & King Khalid University Hospital](https://reader037.vdocuments.mx/reader037/viewer/2022102719/56649e2b5503460f94b192bc/html5/thumbnails/68.jpg)